NCG140250 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG14 D Z 5 ti
FACILITY NAME: I ( 3
PERSON COLLECTING SAMPLES IL%f 14 AMC :4,P
CERTIFIED LABORATORY PAG-&! Lab #
Lab III -
OPTIONAL
OPTIONAL INFO:
SAMPLE COLLECTION YEAR: Z a 116
SAMPLING PERIOD: ❑ July -December January -June
COUNTY 6(01-n 5 1e
PHONE NO,( G I Og
ADD TO LISTSERVE? OYES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout ❑Other
Part A: D[OrrOWaLCr W10mrU11916 -41— c—
Date Sample
Collected
Outfall No. (mo/dd/yr OR
NO FLOW)'
.1—
PH
(Standard
Units)
TSS
(mg/L)
Event Total
.
Duration Rainfall
(minutes) (in)
In Tier 2
Monthly # of Months in Tier
2
Monitoring? 25ampling
(y/n)
6-9
100
Z/411b
61 z
H.I
9D. z
1 If"NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE- Tor each outtall here. Piease mdKe sure io n.d­ 111c o0111Pio pe .,.. aOVO.
2If a value is In excess of the benchmark, or outside the 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 consecutive samples are below the benchmark or within the benchmark range.
a T55 benchmark values are 100 mg/I, except when discharging to ORW, HOW, Trout, and PNA waters where they are 50 mg/l.
For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
Permit Date: 7/1/2011-60/30/2015 I Last Revised 7/13/11
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oma.• n. %1 MA. A..•i.:,•., eA....it—l— 112o,.,6—o,.« fnr foriiki— —ino � rr vat of now motor nil /month –averaeed over a calendar vear
Outfall Date Sample
No. Collected
(mo/dd/yr)
pH
(Standard
Units)
TPH using method
1660 SGT -HEM
(mg/L)
Total Suspended Event
Solids Duration
(mg/L) (minutes)
Total New Motor Oil In Tier 2 # of Months
Rainfall' Usage Monthly in Tier 2
(in) (gal/month) Monitoring? Sampline
[y/n)
I
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDEN AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ffl'
HAVE YOU CONTACTED THE REGION? YES [:]NO
REGIONAL OFFICE CONTACT NAME:
Mail Orieinal 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 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 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.
am aware that ere are significant penalties for submitting false information, including the possibility of fi es and imprisonment for knowing violations."
3 a 6
(Sign at f P ittee) ! (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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