NCG210414 DMR SW (2)

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STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO_ NCG210000
CERTIFICATE OF COVERAGE NO. Nr "'
FACILITY NAME i -J (:� i� P_,o S .
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY Lab #
Lab #
Part A: Specific Monitoring Requirements'
SAMPLES COLLECTED DURING CALENDAR YEAR: �L
(This monitoring report is due at the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY 5 0"J _
PHONE NO. ( D &a4q —
PLEASE SIGN ON THE REVERSE 4
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*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 -yo
nses of°t feral Permit.
'Momtoring is required only if the facility stores exposed piles of sawdust, wood chips. bark, mulch, or other similar material fli%site for on eYntkn 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 cliips,.b�xk, mulch, or other similar material on
site for more than seven (7) days before removing the material is not required to morutor for the parameters in Table I 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 eAempt 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 beforeremovalsince filing the last discharge monitoring report."
4 �
Name (Print name)
Title (P t title)
(Signature) (Date)
SR7U-245-110408
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IF
DID THIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH, ON
AVERAGE, IN THE CALENDAR YEAR?
❑ Yes 1* No (If yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
*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 impriso ent for owing violations."
(Signature of 'ttee) (Date)
SWU-245-110408
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