NCG080015 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
GENERAL PERMIT NO. NCGO80000
CERTIFICATE OF COVERAGE NO.,N—,CG0111
40
FACILITY NAME 1h, .--e, S
PERSON COLLECTING SAMPLES Wil.'Ay-5
CERTIFIED LABORATORY .CA,iz,-/,/-&,,,,.,..✓ 1 Lab# 3-7-21 ;4
Lab #
SAMPLES COLLECTED DURING CALENDAR YEAR: _Uj5
(This monitoring report is due at the Division no later than 30 days from
the date the facility receives the sampling s
re ts om the laboratory.)
'
COUNTY 4 2 ' �
PHONE NO. -1 ql—, 417(.3'
A
PLEASE SIGN ON THE REvERMECEIVED
Part A: Vehicle Maintenance Areas Monitoring Requirements
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor. oil per month? . yes
(if yes, report your analytical results in the table immediately below)
no
JUN 2 9 2015
CENTRAL FILES
Note: if you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier I or Tier 2 responses.
See General Permit text.
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminniq
ACI�
q 0�;
"a A in nti ve.
C.,
4
Note: if you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier I or Tier 2 responses.
See General Permit text.
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminniq
ACI�
boll
C.,
4
STORM EVENT CHARACTERISTICS:
Date 6 � 4 (first event sampled) 5
Total Event Precipitation (inches): I
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Mail Original and one copy to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SWU-250-102107
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0
STORM EVENT CHARACTERISTICS:
Date - (first event sampled) 5
Total e t Precipitation (inches): b
Date (list each additional event sampled this reporting period, and rainfall amount)
Total Event Precipitation (inches):
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
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 II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE AME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO
REGIONAL OFFICE CONTACT NAME.
Mail an oriainal and one cony of this DMR. includina all "No Discharae" reports, within 30 dovs of receipt of the lab results (or at end of monitorinq period in
the case of "No Discharae" reports) 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 I am aware that
there are significant penalties for s4mitting false information, including the possibility of fines and imprisonment for knowing violations "
(Signature/6f Permittee
(Date)
Additional copies of this form may be downloaded at..http://portal ncdenr.org/web/wq/ws/su/npdessw#tab-4
SWU-250
last revised April 11, 2013
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