NCG020003 DMR WW

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — WASTEWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year a,01;
*Report ALL WASTEWATER monitoring data on this form (include "No Flow"/"No Discharge" and Limit Violations) from
the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG02
RECEIVED
Facility Name: // y7e r
County: Lee FEB2016
Phone Number: 60 Total no. of o ijIgWVit%EL
Certified Laboratory ENCO %4b; Lab # PWQ-16 DWR SECTION
Lab #
Wastewater (WW) Discharge Outfall No. Q_
Is this an industrial sand mine (See 40 CFR §436 Subpart D)?
Yes ❑
No
Does this outfall discharge WW to SA waters?
Yes ❑
No [✓(
Does this outfall discharge WW to S13 or PNA waters?
Yes ❑
No [�
Does this outfall discharge WW to HQW or ORW waters?
Yes ❑
No [✓�
If so, what is the 7Q10 flow rate? or Tidally influenced waters,
7Q10 not available ❑
Does this outfall discharge WW to Trout (Tr) designated waters?
Yes ❑
No 0
Were there any limit violations in the calendar year?
Yes ❑
No R1
Permit Date 10/1/2015 — 9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCG02 Q a❑©❑,
CERTIFICATION
"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 aware that there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Required by 40 CFR § 122.221
Signature
Date `a./
Mail Annual Summary Wastewater DMR to the NCDEQ Central Office:
Note the address is correct - Central Files is housed in DWR (not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 10/1/2015 — 9/30/2020
Last Revised 10-2-2015