NCG140423 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO),- Semi -Annual MONITORING FORM .;
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 ®� Z SAMPLE COLLECTION YEAR: IS
FACILITY NAME: � SAMPLING PERIOD: [�uly-December ❑January -June
PERSON COLLECTINGS MPLES A1_- COUNTY
CERTIFIED LABORATORY Lab # PHONE NO. (�3l�) 191,e4-
Lab
9/o4Lab # ADD TO LISTSERVE7 DYES ❑NO EMAIL: ^
OPTIONAL INFO: -DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout Other.y
Part A: Stormwater Monitoring Requirements
Date Sample
IJICollected
PH
Event
TSS
In Tier 2
Total Monthl .# of Months n'Tier
a' Y
Outfall No . , m /dd/y :1
( o r0R
(Starid'rd
( g/�) . Duration
m
Ftamfall Monitoring? 2 Sampling?
Units
(minutes)
(m)
(Y/n)
NO FLOW)
AM FIOW.
6-92
100 -
m EIVED
CENTF AL FILES
r< . N
'if "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISLHAKUL" Tor eacn ounan nere. riease maKe sure --
2 If a value is in excess of the 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/I, except when discharging to ORW, HOW, 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.
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 1 of 2

Y gal g - . .. r year.
Part B: Vehicle Maintenance Activit Monitoring Requirements for facilities using > 55 al of new motor of mont — avers a over a ca -
HAS YOUR FACILITY HAD 4 OR MORE,BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES [J NO 1!��
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 personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am awar t there are si nificant penalties for submitting false information, including the possibility 9f fines pd imprisonment for knowing violations."
_ I S
( ure of Perini ) ( te)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2
p H
TPy using'method
Total°Suspended
Event Total
New Motor Oil:
It:of Months
Monthly
;Outfall ..:
Date Sample..'(Standard."
`
"' _ " ;:`
1664A SGT HEM,,.
So lids
Duration :, :.' Ramfall4
Usage
. m Tier 2
Monitoring? z
No
Collected ,
Units)
(mg/L)
(mg/L)
(minutes) (m)
(gal/month)
Sampling
lY/n)
(mo/dd/yr)r
100Z
HAS YOUR FACILITY HAD 4 OR MORE,BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES [J NO 1!��
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 personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am awar t there are si nificant penalties for submitting false information, including the possibility 9f fines pd imprisonment for knowing violations."
_ I S
( ure of Perini ) ( te)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2