NCG140112 DMR SW (2)

- STORMWA TER -DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NC6140000
CERTIFICATE OF COWRAGE
jNo. NCG14D _L _L 3
FACILITY NAME: /�i�'�GY1�t.�e G.� /%"Pd&
PERSON COLLECTING SAMPLES jCgr'16S .ay/'a."
CERTIFIED LABORATORY4il,��Lab # 10
OPTIONAL INFO: lab #
Part A: Stormwater Monitnrinn ae..,�.e......_
SAMPLE COLLECTION YEAR: R019,
SAMPLING PERIOD: July -December ❑
COUNTY /?4/'4-N
PHONE NO. Qaj j! Z - I
ADD TO LISTSERVE? ❑YES ®NO EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW /
' If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to
2 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or 1
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark rang
3 TSS benchmark values are 100 mg/I, except when discharging to ORW, HQW, Trout, and PNA waters where they are!
a For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain go
Permit Dat e:7/1/2011-60/30/2015 %
RECEIVED
DEC 04 2015
nuary-JuneCENTRAL FILES
DWR SECTION
[]Trout
'rk the sample period above.
2 responses in the General Permit. Tier 2
mg/I.
Last Revised 7/13/11
Page 1 of/2

Part B: Vehicle Maintenance Activitv Monitoring Requirements for facilities using > 55 gal of new motor oil/monin —
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)?
HAVE YOU CONTACTED THE REGION? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail Ori final and one co of this DMR includin all "No Flow" & "No Dischar
in case of "No Flow") to: e" re orts within 30 da sof recei t i
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
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquin
those person irectly responsible for gathering the information, the information submitted is, to the best of.'
am aware there a si nificant penalties for submitting false information, including the possibility of fine
v►.
(Sig ature of Permittee) ®=,
Permit Date: 7/1/2011-60/30/2015 (Date)
a calendar
YES 'Q NOX
supervision in accordance with a system designed to
of the person or persons who manage the system, or
ly knowledge and belief, true, accurate, and complete.
and imprisonment for knowing violations."
If
Last Revised 7/13/11
Page 2 of 2