NCG140002 DMR SW

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. NCG141)-
FACILITY NAME: -_,CPi> T _r -
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY P G Lf' Lab # (4 (a
OPTIONAL INFO:
1 It "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.
Lab #
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD: 0 July -December ❑ January -June
COUNTY lr4p, ;h
PHONE NO. (� q14 , z 1<r l
ADD TO LISTSERVE? []YES ®NO EMAIL:
DISCHARGING TO'CLASS: ❑SA ❑HQW ❑PNA ❑Trout
cb,,,_IxLCS-6
IVSD
2C+5
FILES
:TION
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO1
HAVE YOU CONTACTED THE REGION? YES ❑ NO Fj
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 persons pifectly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am awarLtt y are signi 'cant pe alties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signatumittee) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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