NCG030440 DMR SW (5)

STORMWATER DISCIIARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCC030000
CERTIFICATE OF COVERAGE NO.'NCGO3 7 V6
FACILITY NAME Ti mv,c61cd - Tc
PERSON COLLECTING SAMPLES
CERTInED LABORATOA11 PAC_ Lab #
Lab #
Part A: Specific Monitoring Requirements.
DA t
lit j
:Benchmark .7
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SAMPLES. COLLECTED DURING CALENDAR YEAR:
(This moulturilig rep' —
ort is due at the Division 11f) later than 30 days froxii
the dat6 the facilit-Y receives tl . ic scut
�g results from the laboratory.)
COUNTY
PHONE No.
PLEASE SIGN ON THE REVERSE
-78144
Note:
If
you report sampled value• fii excess of the b eclmiaj �
value, or outside he b�ncehmarc range for PH,re General ttex
t.
E 0
R E C E i VIE
Did this facility perform Velucle Maintenance Activities using more than 55 gallons of new
(if yes, complete Part B) w Motor Oil Per month?yes 11
- FEB 2 9 2016
Part B. Vehicle Maintenance Activit Al 21torlit,
. . . . . . . . . . . . . . . , Requirellients
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Note: If you report a sampled value in excess of die benchmark value, or outside, We bei 9SjPL17aq3A9jN J01 1djeo@8 ujnle;u Ij 919
See General Pernlit text. ef}or
STORM EVENT CHARACTERISTICS:
Date — 1/4—A—Mrst event sainpled)'
Total Event Precipitation (inches): r -S
Date (list each additional event sampled this reporting period,
Total Event Precipitation (inches): *—
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CENTRAL FILES
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Total Toxic Organics sampling is applicable only for diose facilities which perforin metal finishing operations; tntutufacture semiconductors, manufacture electronic crystals or
manufacture cathode ray tubes. For purposes of this permit the definition of Total Toxic Organics is that definition contacted in the FPA Effluent Guidelines for the facility subject
to the requirenreiit to sample (formctal finishing' use tlte.defiiiition as founid.in 40 GIR 4331 l; .for semiconductor inaziufacture use flic'dclinition as fotind0 CFR 469.12; for
in 4
electronic crystal manufacture use the `derutition!as found in 40 CFR 469.22; iuid'for cathode ray tube manufacture use the definition found in 40 CFR 4 id in69.3 4.
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan Wray request that DWQ waive inouitorim
management plan shall include a list of the total toxic arganie compoutnds used and the other elements listed im the General Pernut. For those facilities g Of ltallowed soxic � h a waivsolvent die
discharger shall sign the following certification statement:
"Based upon my inquiry of tine persona or persons directly responsible for managing compliance with tine perintit niotutoring 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 stonnwater or areas which are exposed to rainfall or stormwater
runoff has occurred since filing tine last discharge monitoring report. I further certify that this facility is iuplennentiig die all the provisions of tine solvent management
plan included in the StorMwater Pollution Prevention Plan."
Name //(Print name)
Title (Print tntic)
(Siggpai 9 (Date)
"I certify, under penalty of law, that this document and all attachments were prepared under city direction of -
supervision in accordance with a systein designed to assure that qualified personnel properly gather and evaluate the
information subniitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the inforination subiWtted 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, includin
the possibility o%fines and imprisonment for lailowing violations." g
(Si -ure f Permittee) t e)
S WU-24 5-102107