NCG020766 DMR SW (2)

ANNUAL SUMMARY DMR - STORMWATER
SEND TO CENTRAL OFFICE *
STORMWATER DISCHARGE OUTFALLS (SDO)
GENERAL PERMIT NO. NCG020000
*Report ALL STORMWATER Monitoring Data on this form (including No Flow and No Discharge and Permit Limit Violations) by MARCH 1 of each year.
CERTIFICATE OF COVERAGE NO. N
FACILITY NAME: �f1�1dL,2 A -t -* 7 a b
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY Lab #
Lab #
Part A • Ctnrmwatar Mnnitnrina RvnnirPmenk
SAMPLE CLETION YEAR: d I S -
COUNTY
G/✓
PHONE NO. 1 C2 �1©
ADD TO LISTERVE? YES ❑ NO EMAIL:
TOTAL RAINFALL:
EVENT DURATION:
INCHES
MINUTES
Date Sample
Collected
Outfall No. (mo/dd/yr OR
NO FLOW)
In Tier 2
Monthly
Monitoring?
(y/n)
# of Months in
Tier 2
Sampling2
Total Flow
'(MG)
Total Suspended a
Turbidity
Solids (NTLI)
(mg/1)
Settleable Solids
(ml/1)
1003'4 See Footnote 3's
0.1
E
02 Z1116
QWR
fw r LES
J
'If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here and the Date Range.
2 Per NCG02: Tier 2 Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range
3 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.
4 TSS benchmark values are 100 mg/1 except in ORW, HWQ, trout, and PNA waters where they are 50 mg/1.
5 The discharge shall not cause an instantaneous measurement of the turbidity of the receiving water to exceed: 10 NTU for freshwater streams, lakes, and reservoirs designated
as trout waters; 25 NTU for all lakes and reservoirs, and all salt waters; 50 NTU for all other streams and surface waters. Turbidity may be monitored at the SDO.
Alternatively, the permittee may choose to monitor turbidity in the receiving water, directly upstream and downstream of the SDO.
Permit Date: 1/1/2010-12/31/2014 Last Revised 01-19-10
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Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 eal of new motor oil/month on average
Outfall
No.
Date Sample
Collected
(mo/dd/yr OR
NO FLOW)1
In Tier 2
Monthly
Monitoring?
(y/n)
# f
oMonths
m Tier 22
Sampling
New Motor Oil Total Flow
Usage (MG)
(gal/month)
TPH using Total Suspended pH,
method 1664A Solids, (Standard
SGT -HEM (mg/1) Units)
(mg/1)
- -
153 1003 6-93
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEENDENCES
AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES [:]NO ❑
HAVE YOU CONTACTED THE REGION? YES [:]NO ❑
WHO AT THE REGION HAVE YOU SPOKEN WITH?
MAIL ORIGINAL AND ONE COPY OF THIS ANNUAL SUMMARY (INCLUDING ALL "NO FLOW". "NO DISCHARGE" & LIMIT
VIOLATIONS) BY MARCH I OF EACH YEAR TO:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOUMUST SIGN THIS CER TIFICA TION FOR ANYINFORMA TION REPOR TED:
"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 lete. I am aware that there a significa penalties for submitting false information, including the possibility of fines and imprisonment for knowing
iolations "
_ /__�
(Si a re of Permittee) (Date)
Permit Date: 1/1/2010-12/31/2014 Last Revised 01-19-10
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