NCG080212 DMR SW

Semi-annual Stormwater Discharge Monitoring Resort
.for North Carolina Division of Water Quality General Permit No. NCG080000
(� f C 19 h 1
Date submitted
CERTIFICATE OF COVERRE NO. NQG^0'8 d Q SAMPLE COLLECTION YEAR
FACILITY NAME k :L G7V C& — an ` SAMPLE PERIODan June QA f'y-Dec
COUNTY �t a, or Monthly'_ (month)
PERSON COLLECTING SAMPLE G DISCHARGING TO CLASS ❑ORW ❑HQW JRTrout ❑PNA
LABORATORY C— C, 6 Lab Cert, g ❑Zero -flow ❑Water Supply ❑SA
Comments on sample collection or analysis: _ ❑Other
Part A: Vehicle Maintenance Areas Monitoring Requirements
DEC �� PLEASE REMEMBER TO SIGN ON THE REVERSE 4
nV%-R1
® ���� E] No discharge this period'
A
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _, yes _no
(if yes, report your analytical results In the table Immediately below)
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals
1 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
SWU-250
last revised October 25, 2012
Page 1 of 2
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1 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
SWU-250
last revised October 25, 2012
Page 1 of 2

STORM EVENT CHARACCrERiSTICS:
Date 0J(first event sampled)
Total Event Precipitation (inches):
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Note: If you report a sample value In excess of the benchmark, you must Implement Tler 1, Tier 2, or Wer 3 responses. See General Permit text
FOR PART AAND PART MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
• 2 EXCEEDANCES INA ROW FOR THE SAME PARAMETER ATTHE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an avidin/ and one coov of this DMR includfna all '7110 Discharge" reports within 30 days of receipt of the lab remb for at end of manitorina period in
the arse of NO Dfscharae" reoorts) to.
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFI[eIN 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 thering the information, the Information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that
the a significant p Ides for ubmitting false information, Including the possibility of fines and imprisonment for knowing violations."
/z����
(Signature of Permittee) (Date)
Additional copies of this form may be downloaded at: ham://13ortal.ncdenr are_/web/w-/ws/su/npdessw#t b 4
SWU-250 last revised October 25, 2012
Page 2 of 2