NCG210396 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO)
MONIT .
GENERAL PERMIT NO NCG210000 PLES COLLECTED DIRING CALENDAR YEAR: QO\FJ
CERTIFICATE OF COVERAGE NO. NCG21®31®Q ( is niffing report is due at the Division no later than 30 days from
pAA 6 trLEslity gceives the sampling results from the laboratory.)
FACILITY NAME hr Sark, C71ON COUNTY
PERSON COLLECTING SAMPLES WPHONENO.(_9o?,F9-3G;r-?
CERTIFIED LABORATORY Lab #_ 94
C'IM, s Lab # PLEASE SIGN ON THE REVERSE 4
Part A: S ecific Monitoring Re uirements'
Outfall Date
No. Sample -Collected,
mo/dd/ r
Total. Rainfall,
inches.` `,
=00530:,
T6tALSuspe'nded Solids,
m
00400'
pH;.
Standard units
00340
Chemical'Oxygen=Demand'(COD),
m
Benchmark*
-
100'
Within 6:0 = 9:0 ..
120
1 111 Va
r
\
1115,�.in
1,
1
1i
i
5,3
11
*Note: 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.
'Monitoring is required only if the facility stores exposed piles of sawdust, wood chips, bark, mulch, or other similar material on site for longer than seven (7) days.
A facility that does not retain exposed (either exposed to incident precipitation or exposed to stormwater run on) piles of sawdust, wood chips, bark, mulch, or other similar material on
site for more than seven (7) days before removing the material is not required to monitor for the parameters in Table 1 of the General Permit. If at any time the material is not removed
within this time frame, the facility must begin analytical monitoring immediately. (Reminder: This condition does not exempt any facility from qualitative monitoring of SDOs.)
If the facility removes such materials within seven days to meet the monitoring exemption, the Permittee shall record and maintain in the facility's SPPP a log which documents, at a
minimum, the dates when material is generated and removed, how removed, and by whom. The log must be sufficient to establish that no materials were exposed for longer than seven
days. For record-keeping purposes, the Permittee may also maintain in the SPPP this form with the signed certification below:
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement for analytical monitoring, I certify that to the
best of my knowledge and belief, no piles of sawdust, wood chips, bark, mulch or other similar materials were stored exposed (either to incident precipitation or to
stormwater run on) for longer than seven (7) days before removal since filing the last discharge monitoring report."
Name (Print name)
Title (Print title)
(Signature)
(Date)
�R SWU-245-110408
Page 1 of 2-

DID THIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH, ON
AVERAG7No
HE CALENDAR YEAR?:.
El Yes.(If yes, complete. Part B)
Part B: Vehicle MamtenanceActivity Monitoring Requirements
Outfall Date
No. Sample Collected,
mo/dd/yr
00400
00556
00530
Total Rainfall, New Motor Oil Usage, pH, Oil and Grease;
inches :Annual average gal/mo Standard'. units - mg/L,
'Total Suspended Solids, -
mg/L
Benchmark* -
- - 6.0`9.0
30-..160
'
*Note: If you report a value in excess of the benchmark value, or outside the benchmark range (for pH) you must implement Tier 1 or Tier 2 responses in the General Permit.
Mail original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED IN PARTS A AND/OR B:,
"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. I am aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations."
(Signature of
o Sr3j x015
(Date)
SWU-245-110408
Page 2 of 2