NCG080161 DMR SW (3)

Semi-annual Stormwater Discharge Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG080000
Date submitted
CERTIFICATE OF COVERAGE NOM U p � \
FACILITY NAME
COUNTY %% e) �
PERSON COLLE ,TING SAMPLES
LABORATORY VWX— Rm Lab Cert. # 534 Z -
Comments on sample collection or analysis:
SAMPLE COLLECTION YEAR Zd\
SAMPLE PERIOD ❑ [
Jan -June July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply [_]SA
®Other ��2�01`�e_
d �,► n�rr'4 �M!!2= RCU cs 4�, 1s tI cs. Ln
E REMEMBER TO SIGN ON THE REVERSE 4
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new M L6 oil p.,e�rrLt ? _yes o
(if yes, report your analytical results in the table immediately below) \ btu
GAN i R��G-�00�
Part A: Vehicle Maintenance Areas Monitoring Requirements (If applicable) DN1? S ❑ No discharge this period'
Outfall _ " Date -
= ' No. Sample Collected,
mo/dd/yr •
.00530--'
00400
'00556
°� 00400"°
' Total_Suspended -
° ,Solids; mg/L','
pH,
Standard units
Non -Polar Oil arid Grease/TPH EPA
Method 1664 (SGT -HEM), mg/L
New Motor Oil Usage,
Annual average-gal/mo-,
Benchmark a -
50 or 100 -see -permit ,
„Within 6.0 = 9.0
-15
•- =
tL ori 'Zy�S
/15.0
Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals (If applicable)
�Outfall
No. :°, '
Date
Sample Collected,
mo/dd/yr :
- 00556
00530
°� 00400"°
; ;IVon-Polar Oil and Grease/TPH'EPA Method
1664 (SGT -HEM), mg/L
Total Suspended Solids,
mg/L
'pH, . =
Standard units
Permit:Limit
15
50 or 100 see permit
_ 6.0-79.0 -
tL ori 'Zy�S
/15.0
I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
SWU-250 last revised April 11, 2013
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Datet7-111 (first event sampled)
Total Event Precipitation (inches):
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 RESUITS:
• 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 OUTFALLTRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• " TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES []NO[]
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR including all "No Discharge" reports within 30 days of receipt of the lab results (or at end of monitoring period in
the case of "No Discharge" 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 submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of 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
Page 2 of 2