NCG140215 DMR SW

STORMWA=TER DISCHARGE,OUTFALLI(SDO) Sem'is,Annu"af--MON,ITORING�FORK_'-
GENERAL PERMIT NO..NCG140000.,
CERTIFICATE OF COVERAGE NO.
FACILITY NAME:
PERSON COLLECTING SAMPLES
CERTIFIED LABORATORY i�rlv�F�cH-� Lab# Z&
Lab #
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: (O
SAMPLING-PEjRIQD: y -December January -June
COUNTY C,h I oZ�C
PHONE NO. (,Z3co)
ADD TO LISTSERVE? ❑YES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQVJ ❑PNA ❑Trout ❑Other
.Date Samples
.. .-
Collected
Outfall No. — =
(mo/dd/yr OR
NO FLOW)
pH -- _ n ,, .
TSS
(Standard
(mg/L) .{
Units),.
-Event . .-
Duration- --- ------
(minutes)
.Total-_
4
Rainfall----
(in)
In Tier 2 ,
- -
Monthly - # of Months in Tier
Monitoring?- 2 Sani"pling2
y/n)-
(y/n)-
6=92 1002'3
&9 2
r
A
21 2016
4
SECTION
1 If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" or "NO DISCHARGE" for each outfall here. Please make.sure to mark the sample period above.
2 If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 orTier 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/I, except when discharging to ORW, HOW, Trout, and PNA waters where they are 50 mg/l.
_J
4 For each sampled measurable,storm event the total precipitation must be recorded using data from an on-site rain gauge.
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 1 of 2

Part B: Vehicle Maintenance Activity Monitoring -Requirements -for facilities using > 55 gal of new motor oil/month — averaged over a calendar year
_
- -
- -,111 �
_ y;'�; Iti�f'':{•.iYsa`ti ""i:'."y�' �i'el Fr�it>'+•,��
'Ir - if}x'�K; _ ,`�S,n 1-•-+ '1�''_l`� YS�+F`n{+
_ 7'es • "
- ] .L
- 's
- ' 'S li:
9`i�
TP.H,usi'ri` a .o#al5us^"ended.-,' ve`nt,��••'r:.. lotaf; ,� "w,�IVlotor.'Oil:i-�#`of}Nlon
., --
p. e;-_
nc! ,�, -•.r
- Sta aY 4A:GT�HE :R
=vr- d .1 S -
6E,
( z e
o lectetl`` -g
- , oni•`orn`
- t
i•L u e n 'n��h°�
-'• Y F
Lf, - - •=:i
al mat Sam` lin'
'l c
1
3, nv
- nyV, ,rl,Mi "
-3. A
-91 _•{.}
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
1'
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 orsupervision 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 awar that there are
sig�nifican ' alties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee) (Date) ;
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2