NCG030440 DMR SW (3)

GENERAL PERMIT NO. NCG030000
CERTIFICATE OF COVERAGE NO. NCG03
STORMWATER DISCh,,&GE OUTFALL (SDO)
MONITORING DEPORT
6WL)
FACILITY NAME PAAC,, -77-- /Ij
PERSON COLLECTING SAMPLES zrbl��
CERTIFIED LABORATORY tab #
2A C- e- __-Lab N
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Part A: Specific Monitoring Requirements,
SAMPLES COLLECTED DURING CALENDAR YEAR: '�6/3
(This monitoring report is due at the. Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY —
.PHONE NO. (VD �11K/
PLEASE. SIGN ON THE REVERSE -)
j -11 Qu .. F v. "I GALAZ;00 UL LU-, bundurtauk vaiue, or outside we benclimark range for pH, you must implement Tier I or -Tier 2,responses.
See General Permit text.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? yes --n-o'
(if yes, complete Part B)
PIN
RECEIVELJ
Part B: Vehicle Maintenance Activity Monito : rinfy Rp.aidremprik
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j -11 Qu .. F v. "I GALAZ;00 UL LU-, bundurtauk vaiue, or outside we benclimark range for pH, you must implement Tier I or -Tier 2,responses.
See General Permit text.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? yes --n-o'
(if yes, complete Part B)
PIN
RECEIVELJ
Part B: Vehicle Maintenance Activity Monito : rinfy Rp.aidremprik
0
U
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%
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Note: If ou
J IF samp e va ue m excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier I or Tier 2 responses.
See General Permit text.
STORM EVENT CHARACTERISTICS:
Date &-6,-8 (first event sampled)
Total Event Precipitation (inches):
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
'Mail Original and one copy to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SWU-245-102107
Page I of 2

Total Toxic Organics sampling -is applicable only for those facilities which perform metal finishing operations, manufacture semiconductors, manufacture electronic crystals, or
manufacture cathode ray tubes. For 'purposes of this permit the definition of Total Toxic Organics is that definition contained in die EPA Effluent Guidelines for the facility subject
to the requirement to sample (for metal finishing use the definition as found in 40 CFR 433.11; for semiconductor manufacture use the definition as found in 40 CFR 469.12; for
electronic crystal manufacture use the definition as found in 40 CFR•469.22; and for cathode ray tube manufacture use the definition found in 40 CFR 469.31).
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that.DWQ waive monitoring of total toxic organics. The solvent
management plan sliall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the
discharger shall sign the following certification statement: ,
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I
certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or stormwater
runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing the all the provisions of the solvent management
plan included in the.Stormwater Pollution Prevention Plan."
Name (Print name)
Garbe,,
Title (Print title) -
(Signature)', -
(Date)
"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. T am aware that -there are significant penalties for submitting false information, including
the possibili f fines and imprisonment for knowing. violations."
(Si a re of P r •ttee) (Da )
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