NCG140135 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. IVT •._ (d
FACILITY NAME.
PERSON COLLECTING SAMPLES�4�/PT
CERTIFIED LABORATORY Lab # /097
Lab #
OPTIONAL INFO:
SAMPLE COLLECTION YEAV. o2Ci I -
SAMPLING PERIOD: July -December ❑ January -June
COUNTY �1 i'1 5 Cllr
PHONE NO. ( ZO) 3 1.57
ADD TO LISTSERVE? ❑YES [:]NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout ❑Other
Part A: Stormwater Monlioringrcequ�remencb
Date Sample
Collected pH TSS
Outfall No. (Standard
(mo/dd/yr OR Units) (mg/L)
NO FLOW)
Event Total a
Duration Rainfall
(minutes] (in)
In Tier 2
Monthly
Monitoring?
(Y/n)
# of Mont hs in Tier
2 SamplingZ
Ifte, i)
za
6-9Z 100,
_
_
-
RECEIVI
CENTRALF11
E)VVR SECT!,
.ter -n i__ Wl n -L- -irn +r, marl, tho camnle nerind above.
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW 7 or NO DISCHARGE Tor each uuudu lac -a. ---11M, mow,- L- --• •- I- -- - - -
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/1, except when discharging to ORW, HQW, Trout, and PNA waters where they are SO mg/I.
° For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
a
15
ES
)N
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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Part B: Vehicle Maintenance Activitv 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)I
pH
(Standard
Units)
6-9
TPH using method
1664A SGT -HEM
(mg/L)
15
Total Suspended Event
Solids Duration
m L minutes
( gJ) (minutes)
100 ' -
Total New Motor OilIn Tier 2 # of Months
a Monthly
Rainfall Usage in Tier 2
) (gal/month Monitoring? Sam lin 2
('�n } (y/n) p g
- - - -
I
'
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑
—HAVE -YOU -CONTACTED THE REGION? YES ❑ NO ❑
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 persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am awaMtoat thergjare significa?it peryalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of
Permit Date: 7/1/2011-60/30/2015
(Date)
Last Revised 7/13/11
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