NCG140296 DMR SW (2)

4C
STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. N�T�4
FACILITY NAME: ,
PERSON COLLECTING SAMPLES A16eCE P fry 3 r.
CERTIFIED LABORATORY Lab # %D
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: 20/S
SAMPLING !�RIOD: ;�dluly-December ❑ January -June
COUNTY I++
PHONE NO. (Z ++
'1 j/(p- 7 Q
ADD TO LISTSERVE? ❑YES EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA []Trout ❑Other
Outfall No.
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)
pH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total 4
Rainfall
(in)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in Tier
2 Sampling2
-
-
6-9
1002'
-
-
-
-
CIA11.1 2
7eZ
424o
i7 0
2
6,0
970
nci
v
Fr`
nj_AVR
IC
If "NO FLOW" or "NO
DISCHARGE. Enter "NO
FLOW" or "NO DISCHARGE" for each outfall here. Please make sure to mark the samnle nerind ahnve.
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, HOW, Trout, and PNA waters where they are 50 mg/I.
4 For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
Zs
N
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 1 of 2

1_
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
(mo/dd/yr)1
pH
(Standard
Units)
TPH using method
1664A SGT -HEM
(mg/L)
Total Suspended
Solids
(mg/L)
Event
Duration
(minutes)
Total
a
Rainfall
(in)
New Motor Oil
Usage
(gal/month)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months
in Tier 2
Z
Sampling
6-9
15
100 ,
-
-
-
-
-
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEI)ENCE5 AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO
HAVE YOU CONTACTED THE REGION? YES ❑ N
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 monitoring period
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 personsVe
ly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete
wa
am are the are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
/In E.i , v 7 -) -
(Sig a r Permittee) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2

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READY MIX CONCRETE (FARMVILLE)
MR. RICKIE GRAY
P.O. BOX 877
GREENVILLE ,NC 27834
PARAMETERS
PH (not to be used for reporting)
Total Suspended Residue, mg/l
001 Analysis Method
Discharge Date Analyst Code
7.3 09/25/15 KKF 4500HB-00
<2.6 09/28/15 MLH 2540D-97
ID#: 1090
DATE COLLECTED: 09/24/15
DATE REPORTED : 09/29/15
REVIEWED BY:A -