NCG140135 DMR SW (4)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO. RNA td lid
FACILITY NAME: yrn
PERSON COLLECTING SAMPLES -1.`i
CERTIFIED LABORATORYFJ�i!/�,y,,,wto7 � Lab # is
Lab #
OPTIONAL INFO:
-�o1G
SAMPLE COLLECTION YEAR:
SAMPLING PERIOD: ❑ July -December 4 January -June
COUNTY QAJ,5104-_�
PHONE NO. (fZL)—)
ADD TO LISTSERVE? []YES ®NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout []Other,
Part A: �-iOrmwaier rvronuunng nc.{uuc.ncu..
Date Sample
Collected
Outfall No.
(mo/dd/yr OR
NO FLOW)1
the
PH
(Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total
a
Rainfall
{in)
In Tier 2
Monthly
Y
Monitoring?
(y/n)
# of Months in Tier
2 Sampling?
_ -
6-9z
100"3
_
_
-
I2.
� e
I
vii I.
_ __ _ _.
_._ ____
J -Lam....
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outtall here. Please maKe sure to marK the barr,Nic NCS lou auoVe-
2 If a value is In excess of the benchmark, or outside the benchmark range (for pH), you must Implementthe 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 50 mg/I.
° For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
RAL FILES
SECTION
Permit Date: 7/1/2011-60/30/2015 ; Last Revised 7/13/11
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Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year.
Outfall
No.
PH TPH using method Total Suspended Event Total New Motor oil
Date Sample a
(Standard 1664A SGT -HEM Solids Duration Rainfall Usage
Collected
(mo/dd/yr)1 Units) (mg/L) (mg/L) (minutes) (in) (gal/month)
In Tier 2 # of Months
Monthly
in Tier 2
Monitoring? Z
Sampling
Win)
6-9 15 100
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANYONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO ❑
HAVE YOU CONTACTED THE REGION? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail Original and one copv of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample for 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 awar hat ther e ignificant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signa ure of P mittee) ! (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
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