NCG140106 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
,
GENERAL PERMIT NO. NC3140000
1
1
CERTIFICATE OF COVERAGE NO. NCG14 0 1
FACILITY NAME:
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY Lab #
1 Lab #
OPTIONAL INFO:
,
Zoos
SAMPLE COLLECTION YEAR: .
SAMPLING PERIOD:�July-December ❑ January -June
COUNTY �.IP.aVG
PHONE NO. (Zszi �I X7"1- 53s 6
ADD TO LISTSERVE? []YES ❑NO EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW ❑PNA ❑Trout ❑Other
Part A: 5tormwater lvtont[onng nequuemeAu-
1Date Sample
Collected pH TSS
Outfall No. {Standard
mo/cld/yr OR (mg/L)
( Units)
NO FLOW)'
Event Total o
Duration Rainfall
(minutes) (in)
In Tier 2
Monthly # of Months in Tier
z
Monitoring? 2 Sampling
{y/n)
tN ti`
AI 0 4 2016
n t C
�11p
11
11
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u
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ni_....,...,...i,,. � ., +.....orL
fhn
a comnla nanri ahAVe
' If " NO FLd1W° or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE Tor each ouun ahere, rnease Mane au. u, r•— -• -- --- -
2 If a value isinexcess oflthe benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/1, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I.
`For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
NN E
Last Revised 7/13/11
Permit Date: 7/1/2011-60�/30/2015
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•
Part R: Vehicle Maintenance Activitv Monitoring Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year.
Outfall
No.
pH
Date Sample
(Standard
Collectedi Units)
(mo/dd/yr)
6-9
TPH using method
1664A SGT -HEM
(mg/L)
is
Total Suspended Event
Solids Duration
(mg/L) (minutes)
100 ' -
Total New Motor Oil In Tier 2 # of Months
a Monthly
Rainfall Usage " in Tier 2
(in) (gal/month) Monitoring? Sampling2
(y/n)
- - -
I
i
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copy of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at end of monitoring period
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified pers nnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those p r ons ' e I sp ible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete,
am'a th a re ificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
of
Permit Date: 7/1/2011-60/30/2015
(Date)
Last Revised 7/13/11
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