NCG140288 DMR SW

STORM.WATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
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CERTIFICATE OFCOV M E NO.. G ' Z
FACILITY NAME!' �JlV
PERSON COLLECTING SANE . L
CERTIFIED LABORATORY `�G `Lab #
Lab #
OPTIONAL INFO:
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD: ❑ July -December &anuary-June
COUNTY
PHONE NO. ��/
ADD TO LISTSERVE? YES ❑NO EMAIL: cK" z; k1
DISCHARGING TOC SS []SA ❑HQW []PNA'0TraI1it ther G
rart'h: azurmwaFer monmzormg Kequwrements
v
1 I JJ iF'k�}'T 4�1j, �' j
Ari _, IjljVo, P s t% ��f d , w
a
y,� ,�
,''t1, Tier 2
pH {
A Event Total
TSS 4. nthly #ofMonths.in�Tier
��� Duration Rainfall
(minutes) (ink t S
AP 2g
TV-
DWR S
I
FiLpA
N
if "NO FLOW" or "NO
DISCHARGE, Enter "NO
FLOW" or. "NO DISCHARGE"for each
outfall hA.rA. Ple'ase.maka eura to marle
tha a2mniga nario%A �k^ue
-- - .....r., r ........ ........ .
2 If a value is in excess'of;the;bench mark,.or outslde.th'e 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,conse6 ive sami Ies.are.below.the benchmark or wlthln.the benchmark range.
a TSS benchmark vaiues ere;100 mg/I, except;when discharging to:QRW,; HQW; Trout, and PNA waters where they are 50 mg/I,.
° For each sampled measurable storm event..thetotal. 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
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Part B: Vehicle Maintpnanr a AMutfv Unn1#-^rin& Dam.
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NAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANYONE OUTFALL (INCLUDING VEHICLE MAINTENANCE),?
HAVE YOU CONTACTED THE REGION? YES NOE]'
REGIONAL OFFICE CONTACT NAME:
III case Or - ivo Now”) toe'—.,.:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service, Center
Raleigh, North Carolina 27699-1617
YES ❑ N0�
"I certify, under penalty;bf law, tihat 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 gatMeringthe information, the information submitted is, to.the best of my knowledge and belief, true, accurate, and complete. I
am awar here are -significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee) (Date)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
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