NCG140032 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
_ GENERAL -PERMIT N0. NCG140000...
CERTIFICATE OF COVERAGE NO NCG140 =_
. .. .SAMPLE COLLECTION
— —`�'- SAMPLING PERIOD: [� July December } ❑ January June
FACILITYNAMt""' 1'vI� c1' I�'Y1l;i(�� r.
COUNTY � �w� � ..,
.
PERSON COLLECTING SAMPLES; PHONE NO. (70 ) �r S — /5
CERTIFIED LABORATORY )'� f ? Lab # X5`7
Lab # ADD TO LISTSERVE? ]YES WNO EMAIL:
OPTIONAL INFO:
DISCHARGING TO CLASS: []SA❑HQW ❑PNA []Trout Other CG
Part A: Stormwater•Monitoring Requirements
Date Sample` In Tier 2
PH Event Total Monthl # of Months in Tier
Collected - TSS a Y
Outfall, No (Standard Duration Rainfall z
(mo/dd/yr OR (mg/L) r a :`s Momtoringat
s1: Umts)� (minutes) ., (m)
NO, FLOW) n)
nit
6 9z 100z
r t
60
13
61 ZCi
CENTRAL.FM:S
DWR TIO
If NO FLOW" or NO DISCHARGE, Enter NO FLOW' or NO DISCHARGE for each outfall here. Please make. sure to mark the sample period above
2 If a value is in excess''bf the benchmark,.or out the -benchmark range (forepH), ,you musf implement the Tier 1 or Tier 2 responses in the. General Permit. Tier 2
Monthly samplin j.s' 11 be done until,lconsecutivesamples;are below the benchmark or w,ithin0e benchmark range.:
TSS benchmark`values'are 100 mg/I, except when discharging to ORW HQW, Trout,. and;PNA waters, ere they are;50{mg/I.
4 For each sampled measurable storm event the totallprecipitation 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

Part B: Vehicle Maintpwinrp Artivity Mnnitnrina Pon nirnev 4n F.,r F ­;M:. , rr __1
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
o:Division of Water Quality-
Attn: DWQCentral.F•iles.,
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify; under pe"salty 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 nor persons who..manage the system, or
those persons directly responsible forgathering the information, the information submitted is, -to the best of my. knowledge and belief, true, accurate, and complete. I
am awarethatthere re signi ' nt p nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of P rmittee)'
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2
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:month
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fir
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
o:Division of Water Quality-
Attn: DWQCentral.F•iles.,
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify; under pe"salty 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 nor persons who..manage the system, or
those persons directly responsible forgathering the information, the information submitted is, -to the best of my. knowledge and belief, true, accurate, and complete. I
am awarethatthere re signi ' nt p nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of P rmittee)'
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2