NCG060209 DMR SW (12)

CERTIFICATE OF
FACILITY NAME
COUNTY
PERSON COLLEC
LABORATORY
SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NCG06000
0
Date submitted S a— % 6 'Q'P�4%Q ��
;RAGE NO CG06� ri SAMPLE COLLECTION YEAR ��
QO
Or 0 FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats use animal fa s/byproducts Tit
SAMPLES - DISCHARGING TO SALTWATERS? AYES PNO
Lab Cert. #
Part Aa Stormwater Benchmarks and Mnnitnrino Qow„ltm
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
14—
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$ ' Jw� r '�y
a rvie..{I.R:�
yr iv o viscnarge rnrs period
'yi d� •
010
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oniyraplies to f illtl h
p ac es t at use/process meats. A ` n � + O F2 O
The total precipitation must be recorded using data from an on-site rain gauge. "` (� G,
a3For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? [] yes ❑ no (fes complete Part B)
Part B: Vehicle Maintenance Area Monitoring Ramilte! nnlu fnr fornitiee . ae --i —a ....... --a_.. _si i..__—.,
go : IN`
--•--. 400— lat-mues mai use process meats.
s
ZThe total precipitation must be recorded using data from an on-site rain gauge.
For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
4see General Permit text, Table 3, Identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
SWM -249
r--.. n_ -.t -_a. n .a..t- .- 10 nnl n
--•--. 400— lat-mues mai use process meats.
s
ZThe total precipitation must be recorded using data from an on-site rain gauge.
For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
4see General Permit text, Table 3, Identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
SWM -249
r--.. n_ -.t -_a. n .a..t- .- 10 nnl n

-FOR.PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART li S TION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDEN S FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES NO ❑
IF YES, HAVE YOU CONTACTED THEQ GI QFFICE7 XES O ❑
REGIONAL OFFICE CONTACT NAME.. ► 1 i't\1
Mail an orlainai and one copy of this DMR. inc/udlna all "No Discharge" reports, within 30 dans of receipt of the lob, results for at end of
monitorina period In the case. of "No Discharae" reports) to:
Division of Water Quality
Attn: DWQ Central Files
161XMail Service Center
Raleigh, NC 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. I am aware that there are significant penalties for submitting false
information, including the possibility of fines and imprisonment for knowing violations."
(Signature of
S1 -lc,
(Date)
Additional copies of this form may be downloaded at: http:/Iportal.ncdenr.org/­web/­w--ci/­ws/­su/`nodessw#tab-4
SWU-249
Last Revised: October 18, 2012
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