NCG130067_2024 DMR_20241104

( Co /1 4)
Division � A �`'`��'
NCDEQ on nergy, Mineral and Land Resources
Stormwater Discharge MonitoringReport P ort (DMR) Form for NCG130000
Non-metal Waste and Scrap
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copyof the DMR
to the appropriate DEMLR Regional Office.
.
Certificate of Coverage No. NCG1 C 1
Person Collecting Samples:s• M /Ttc. ( 4r
Facilit
Name: Q10, dye Prof �f
Laboratory Nam • ct,ff.p4
Facility County: gcc4.,;,_ _At 5L �C) L , G-
Cowa Laboratory Cert. No.: DU (ft i i • r #.Discharge during this period: 'Yes fl 110 (if no, skip to signature and date)
Has your facility 'mplemented mandatory Tier response actions for any benchmark exceedances? Yes fl No
If so, which Tie 0II, or III)? 7c ,- /
Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
Parameter T--
Code _ Parameter Outfall i Outfall Z Outfall I Outfall 9 Outfall f
•
N/A Receiving Stream Class C G C
C C
N/A Date Sample Collected MM/DD/YYYY 09 / 2 71A(021( .................------ -4
it ,
46529 24-Hour Rainfall in inches t/
)
pH in standard units (6.0 — 9.0 FW,
004004 *6.8-8.5 SW) • �. G cp c ii/ SP: 7
00340
Chemical Oxygen Demand (COD) in
mg/L (120) çø
K
3 3 i
00552 Non-Polar Oil & Grease in mg/L (15) OiA AdA : PilA ‘ /J/A N/A ,
C0530 TSS in mg/L (100 or 501 / IC c - c e)7• ,( c;s2 -ar ,
NCOIL New Motor/Hydraulic Oil Usage in
gal/month CS (
Notes (optional):
"I certify by my signature below, 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
aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for
knowing violations."
Z" ;"Zr /7" / ' e2 V
Signature of Permittee or Delegated Authorized Individual Date
it (A)Fy tA ic"-Jf Colos-k 5 0 ,ccr 57 ij
Email AddeEss Phone Number

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG130000
Non-metal Waste and Scrap
Click here for instructions
.
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report 1DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG13 Person Collecting Samples:
Facility Name: Laboratory Name:
Facility County: Laboratory Cert. No.:
Discharge during this period: (=1 Yes D No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions for any benchmark exceedances? LI Yes LI No
If so, which Tier (I, II, or III)?
Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
Parameter
Code Parameter Outfall Outfall7 artfeit I
N/A Receiving Stream Class
4 * C- . .4\ C
N/A Date Sample Collected MM/DD/YYYY , (9/42 /./X1 y . r ---,
46529 24-Hour Rainfall in inches iti . 1
00400 pH in standard units (6.0 — 9.0 FW,
C6.8-8.5 SW) - -
00340 Chemical Oxygen Demand (COD) in
mg/L (120) I S 2 I
00552 Non-Polar Oil & Grease in mg/L (15) ,A, II / , Aff-A
C0530 TSS in mg/L (100 or 501 <2 . C . C- 1
NCOIL New Motor/Hydraulic Oil Usage in
_ gal/month �5 �f , ,,)
Notes (optional):
"I certify by my signature below, 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
aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for
knowing violations."
_______71 //-1— 9
Signature of Permittee or Delegated Authorized Individual Date
"ft, cid il
/1(.1 d _ w. Ix
Email Ad ress Phone Number