NCG140215 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
i
CERTIFICATE OF COVER4GE NO.CCMA y'
FACILITY NAME: ���� M:� of�ci2eyc C'a.
PERSON COLLECTING SAMPLES ���.vw�/ 12a-IL,banc
CERTIFIED LABORATORY?rSeAZe�I�+cJ�wn-fs/fi'c�/ Lab !# ?,cJ
Lab d
OPTIONAL INFO:
Part A: Stormwater Monitoring Reauirements
SAMPLE COLLECTION YEAR: o201s
SAMPLING PERIOD: July -December QJanuary-June
COUNTY Gam; (�o�
PHONE NO. (�)
ADD TO LISTSERVE? RYES ❑NO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA []Trout []Other
Date Sample
Collected
Outfall No.
(mo/dd/yr OR
NO FLOW)'
pH
{Standard
Units)
TSS
(mg/L)
Event
Duration
(minutes)
Total
� a
Rainfall
(in)
Wrier 2
Monthly
Monitoring?
(y/n)
!# of Months in Tier
2 Samplingz
- -
6-92
1002,3
-
-
-
•
71 .1?1
1414
3
�
D r
D , ,
11 //�� //!Rpp
M1
I
IED
T15
!LES
ION
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 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be ¢one until 3 consecutive samples are below the benchmark or within the benchmark range.
a TSS benchmark values are 100 mg/1, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/I. "
`Far each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge. -
Permit Date: 7/1/2011-60/0/2015 1 Last Revised 7/13/11
1 Page 1 of 2

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 cop of this DMR(including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sam le 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 athering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that thereare significa t nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
1 - I g -boy
(Signature of Permittee) ! (Da3 te)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
Page 2 of 2
Part e: Vehicle Maintenance Activity Monitoring Requirements for facilities using > 55 gal of new motor oil/month
—averaged over a calendar year.
OutfallFDaaeSample
No.
pH
TPH using method
1664A SGT
Total Suspended Event Total
New Motor Oil In Tier 2(Standard
of Months
Units)
-HEM
(mg/L)
Solids Duration Rainfall°
(mg/L) (minutes) (in}
Usage Monthly#
Monitoring?
inTier 2
(gal/month)
(Y/n)
Sampling 2
6-9
15
100 ' _
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 cop of this DMR(including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sam le 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 athering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that thereare significa t nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
1 - I g -boy
(Signature of Permittee) ! (Da3 te)
Permit Date: 7/1/2011-60/30/2015
Last Revised 7/13/11
Page 2 of 2