NCG140159 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCC3140000
CERTIFICATE OF COVERAGE NO. NCG14 ' / r 9
FACILITY NAME: P r h C Ir
PERSON COLLECTING SAMPLES Ldd r Y,k
CERTIFIED LABORATORY f- S Lab # /,LV 1(A
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: a U J1
SAMPLING PERIOD: ❑ July -December January -June
COUNTY J h 1/ �►/
PHONE NO.
ADD TO LISTSERVE? ❑YES 2hO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ZTrout []Other.
Outfall No,
Date Sample
Collected.
(mo/dd/yr OR
NO FLOW)1
pH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total
RainfallA
(in)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in Tier
2 Sampling2
-
-'
6-92
1002,3
-
-
-
-
RECEIN
CENTRAL
1 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.
2 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, HQW, Trout, and PNA waters where they are 50 mg/I.
° For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
M
015
ILES
'ICON
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year.
Outfall,
No.
Date Sample
"'' . 'Collected :'
1
(mo/dd/yr)
pH
(Standard_
Units) :.
TPH, using method
1664ASGT-HEM
(mg/L),
Total Suspended
-Solids M �:
(mg/L)
Event
Duration,
(minutes)
Total
a
Rainfall. .
(in)
New Motor Oil
Usage
-
(gal/month)
In Tier 2
Monthly
-
Monitoring?
(y/n),
# of Months,
'inTier'2'
2
Sampling.
6-92
15Z
1002,3.
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑
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 monitorine Deriod
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 tF"e are signifiga f penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(k� 3,/ a
(Signature of r e) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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