NCG140423 DMR SW (6)

1 \
STORM_ WATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. N
FACILITY NAME: i5
PERSON COLLECTING SAM LES An nte,Y
CERTIFIED LABORATORY Lab #
Lab #
OPTIONAL INFO:
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD:July-December 0 January -June
COUNTY
PHONE N -d
ADD TO LISTSERVE? OYES ONO EMAIL:
DISCHARGING TO CLASS: OSA OHQW OPNA [Trout Other
Part A: Stormwater Monitoring Requirements In Tier 2
Date Sample pH Event Total
TSS a Monthly # of Months in Tier
Collected (Standard Duration Rainfall Monitoring? 2 Sampling2
Outfall No.
(mo/dd/yr OR Units) (mg/L) (minutes) (in) (y/n)
NO FLOW)l _
_ 6-92 1002'3
A_J
E
APR
DIA/ t_ FILES
..r / hin Dirr'HARGE" for each outfall here. Please make sure to mark the sample period above.
If "NO FLOW" or " r-
v4u Ln—n—,
2 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 Tier responses in
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, HQW, Trout, and PNA waters where they are 50 mg/I.
"For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
Last Revised 7/13/11
Page 1 of 2
Permit Date: 7/l/2011-60/30/2015

in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
# of Months
in Tier 2
Sampling2
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 theinfor1mation submitted ison submitted. Baet o the best on my inquiry
my knowledge and belief, true, a curatehe system, or
and complete.
those persons directly responsible for gathering the information, the
;ama�w"at ther significant penalties for submitting false information, including the possibilit of fines and imprisonment for knowing violations."
(Date)
ature of P ittee)
Last Revised 7/13/11
Permit Date: 7/1/2011-60/30/2015 Page 2 of 2
Activity Monitoring Requirements f or
facilities using > 55 gal of new motor oil/month —
averaged over a calendar year.
,
Part B: Vehicle Maintenance
In Tier 2
pH TPH using method
Total Suspended Event Total
New Motor Oil Monthly
Outfall Date Sample
(Standard 1664A SGT -HEM
Solids Duration Rainfall°
(in)
Usage Monitoring?
(gal/month)
No. Collected Units) (mg/L)
(mg/L) (minutes)
(y/n)
(mo/dd/yr)1
6-92 15
100, 3 - -
- -
FACILITY HAD 4 OR MORE BENCHMARK EXCEEDE ES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NC,
HAS YOUR
HAVE YOU CONTACTED THE REGION? YES ❑ N
REGIONAL OFFICE CONTACT NAME:
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
# of Months
in Tier 2
Sampling2
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 theinfor1mation submitted ison submitted. Baet o the best on my inquiry
my knowledge and belief, true, a curatehe system, or
and complete.
those persons directly responsible for gathering the information, the
;ama�w"at ther significant penalties for submitting false information, including the possibilit of fines and imprisonment for knowing violations."
(Date)
ature of P ittee)
Last Revised 7/13/11
Permit Date: 7/1/2011-60/30/2015 Page 2 of 2

TOTAL PRECIPITATION
DAILY LOGYEAR: 1
Directions: Enter on-sit- daily rainfall amounts in inches.
a
,
MUS
MMMMMMMMM;
Form #5