NCG140111 DMR SW (3)

s. _ -STORM-WATER DISCHARGE=OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF-COVERAGE'NO. NCG1401 I !
FACILITY NAME Te41✓'iffi;ee44 ;Co^col4 * Ci► GT'�
PERSON COLLECTING -SAMPLES -R -i4% i6air,
CERTIFIED LABORATORY&VjXA4PW.& ' Zwr. Lab # �Q
Lab #
OPTIONAL INFO:
SAMPLE COLLECTION YEAR: 0?01(,r
SAMPLING PERIOD: ❑ July -December January -June
COUNTY 0A3kine
PHONE NO. (2)�'i 3 -
ADD TO LISTSERVE? []YES 610 EMAIL:
DISCHARGING TO CLASS: []SA ❑HQW ❑PNA []Trout ❑Other
Part A: biormwater monitoring Kequwrements
. Date Sample
rpH
Event
Total
`In Tier 2'
f# '
Collected
Outfall No..
(Standard,".
TSS ,�
Duration
4
Rainfall
MontHly
of Months in Tier
2 -
(mo/dd/yr OR
Units)
(mg/L).
(minutes) :
(in)
Monitoriog?
2 Sampling,
NO FLOW)
(Y/n') .
6-9 `..-- .
;-'. =100 '.
? i` - 1
11. s
I 11 1
�2 ya
1 t
1 /V
1 W1.4
' If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the sample period above.
z If 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.
3 TSS 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 Last Revised 7/13/11
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Part B: Vehicle Maintenance
uirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NOM
HAVE YOU CONTACTED THE REGION? YES ❑ NO
REGIONAL OFFICE CONTACT NAME:
Mail Original 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 person rectly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I
am aware there a ificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Si ature of Permittee) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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