NCG210219 DMR SW (2)

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STORMWATER D!SCIHAlt )UTFALL(51)0)
MONITORING hii,PORT
GENERAL PERMIT NO. NCG210000SAMPLES COLLECTED DURING CALENDAR YEAR:
CERTIFICATE OF COVERAGE NO. 'WI' tr,°'M (This monitoiiug report is due at the Division no later than 30 nays from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME °>-- _____ COUNTY 7,-1kk11—)
PHONE NO
. (9rL �i', .9e...43
PERSON COLLECTIN SAM'LES � —____— ) qV
CERTIFIED LABORATORY Lab# _F,REVERSE-� E E 8
Lab# PLEASE SIGN ON IED
II AUG 2 6 2016
Part A: Specific Monitoring Requirements' CENTRAL FILES
Outfall Date 00530 00400 00340 DWR SECTION
No. Sample Collected, total Rainfall, Total Suspended Solids, _ pH, Chemical Oxygen Demand(COD),
mo/dd/yr inches nig/L Standard units mg/L
Benchmark* - - 100 Within 6.0-9.0 120
-101 6-/6-goiC, .g " moa_ c°cl_
'Monitoung is required only if the facility stores exposed piles of sawdust,wood chips,bark,mulch,or other similar material on site for longer than seven (7)days
If the facility elects not to monitor because accumulated material is removed within seven(7) days or less,the certification below must be signed The facility shall
also record and maintain a log in its SPPP(Stounwater Pollution Prevention Plan)of dates when matetial is generated and removed, how,and by whom.
*Note:If you report a value in excess of the benchmark value,or outside the benchmark range(for pH),you must implement Tier 1 or Tier 2 responses in the General Permit.
Facilities that do not stole exposed (either exposed to incident precipitation or exposed to stormwater run on) piles of sawdust,wood chips,balk,mulch,or other similar material for
longer than seven(7)days on site may so certify,and the tequifement for analytical monitoring may be waived. For those facilities that quality for the analytical monitoring waiver, the
discharger shall sign the following certification statement:
"Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement for
analytical monitoring,I certify that to the best of my knowledge and belief,no piles of sawdust,wood chips,bark, mulch of
othet similar materials were stored exposed(either to incident precipitation or to stofmwatei run on)for longer than seven (7)
days befote removal since filing the las discharge monitoring report."
Name(Print me)
Title(Print title)
(Signature) (Date)
S W U-245-072808
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S'1'O(Mt 1 'A'l'Ml(1)1 IAR(;l' C)11'('l'`/4,I,I,(SDO)
MON1'('UK1N(; REPORT
"I certify,under penalty of law, that this document and ail 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 puss' ility of fines and imprisonment for knowing violations."
Q. ,....A.,.........., e: ®- r _
(Signature o 'ermittee) (Date)
Porus SWU-2.S4-O'l1400
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