NCG190050 DMR SW

RECEIV D
STORMWATER DISCHARGE OUTFALL(SDO) AUG 12 2 U l b
GENERAL PERMIT NO.NCG190000
DISCHARGE MONITORING REPORT(DMR) CENTRAL ALES
DWR SECTION
CERTIFICATE OF COVERAGE(COC)NO.:llyEzn C EU4 SAMPLE COLLECTION CALENDAR YEAR: v70/6
(This monitoring report is due at the Division no later than 30 days from
FACILITY NAME: OS'eS" SE�<: /4-4-40 D1--X7'42C ,c2•1 /Y/WD41 the date the facility receives the sampling results from the laboratory.)
SAMPLE COLLECTION NAME: .. 5.Pvc,"/9 -E-'t 6/99.
'9(23/A303-70o FACILITY COUNTY: G ,'/' 4 E /
CERTIFIED LABORATORY:��Z'e', t4 y7 z. Lab# /
Lab# PHONE NO.:(23 ;,-W 7- 5/53
Part A: Specific Monitoring Requirements
Outfall=. ; Sample ,00530 TPH by method 01119 == 01104= ==, 01094__ 01114
1664(SGT-REIVIl
Collection Date, Total Rainfall,' Total-Stispended Non-Polar Oil& Copper2'3,mg/L Aluininum2,mg/L Zinc2'3,mg/L Lead2'3,mg/L
mo/dd/yr inches Solids,m /L ;Grease,mg/); . ,
Freshwater - 100 15 0.010_ :0.75. 0:126 0.075
(Saltwater) _ (0.005) . (0.095)_ (0.220)
Benchmarks _
DC/y//6 , l�3 a 4r' ) c 07/ 33 N�
If a value is in excess of the benchmark,you must implement the Tier 1 or Tier 2 responses in the General Permit.
2 Total recoverable metal. //ri!'dt-4lf, 7N6 77E' / 4 '0'.'-'E
3 These benchmarks are water hardness dependant. Values shown based on a hardness of 50 mg/L. -
Solvent Management Plan Certification:
Mail original and one copy to: "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit requirement for
Division of Water Resources managing solvents,I certify that to the best of my knowledge and belief,no leak,spill,or dumping of concentrated solvents
Attn: Central Files into the stormwater or onto areas which are exposed to rainfall or stormwater runoff has occurred since filing the last discharge
1617 Mail Service Center monitoring report. I further certify that this facility is implementing all the provisions of the Solvent Management Plan
Raleigh,North Carolina 27699-1617 - included in the Stormwater Pollution Prevention Plan."
7G- P/LC/023/(
(Sign ture Of Permittee)
(Date)
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: l J
"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."
G 1 754-'/60
(Sign ture of Permittee) (Date)
P rm. ate:6/02/2015-5/31/2020 SWU-253-060515
Page 1 of 1

United States Coast Guard
. a
. Dep Stars HmneI Second,
EXPOSED SIGNIFICANT MATERIALS ASSESSMENT
FORM 4
EXPOSED SIGNIFICANT MATERIALS ASSESSMENT Facility: SFO Fort Macon
Inspector: EPS-Todd Ogle, ",---.2-----.-- , Date: tri .lulu 701A
Instructions: Describe the significant materials that were exposed to storm water during the past year and/or are currently exposed. Significant materials
include, but are not limited to raw materials, fuels, solvents, detergents, metals, hazardous substances, fertilizers, pesticides and waste products that
have a reasonable potential to release pollutants into storm water discharges.
Description of Period of Quantity Location(as Method of Storage Description of Proper Material Management Practices
Exposed Exposure Exposed indicated or (e.g., pile covered, drum sealed)
Significant Material (units) on the site map) Disposal(e.g.,pile,
drum,tank)
Diesel ASTs > 1 year 2 @ 1000 gallon Multi Purpose Bldg AST Double-walled tanks ,
Gasoline and Diesel > 1 year 1 @ 500 gallon Station Fuel on Pier AST Double-walled tanks
AST 1 @ 1000 gallon
Used Oil AST > 1 year 1 @ 500 gallon Station Pier AST Double-walled tank
Used oil and oily > 1 year 1 @ 500 gallon Hazwaste Shed Area Mobile Double-walled tanks
water trailer 2 @ 1000 gallon Containers
Recycle Metals > 1 year Misc metal Between Engineering Pile None,working to relocate inside pebble shed or out of
and IPD stormwater path to SDO pipe.
Private Boats > 1 year Approx 20 Near shoreline Boats None
revetment on NW
side
Buoy and. Chain > 1 year Varies Near NE corner and Piles of chain None
Storage -at ATON area Buoys
Surveyed 55 ANB < 1 year Exposed antifoul,Near SDO location, On jack stands, None, 55 ANB sold and removed Apr 2016.
hull, shaft zincs adjacent to 110 pier. awaiting disposal

tgi United States CosGuard
FORM 5
FACILITY PREVENTATIVE MAINTENANCE INSPECTION REPORT
Building/Area: / 5-4e, &,-/NQc,�.nzg1 /2 Date: /S j iLy ,,Vele-
Inspector:X4,1 661 /()t✓p ,57-[7zErc Time: / i'
Perform facility inspection and inspect all applicable storm water management devices. Check yes or no,
and provide details under comments List suggested corrective actions at bottom of form.
Are the following storm water management and/or pollution control measures in place, maintained,
and functioning properly? Look for evidence of leaks or potential storm water contamination
problems.
MEASURE/ITEM YES NO COMMENTS
Facility storm water drainage system (i.e., catch vr-
basins, inlets, culverts, headwalls, ditches)
Existing sediment and erosion control devices tic-1"'c- / (T, ,,.,49/,�,q,7f„z,
Retention ponds/detention basins — — _N/4
Temporary storm water diversion dikes/devices - ,,1/.
Subsurface storm drains - N 14
Graded pavement -- _ hi Ai
Oil/water separators/grit chambers - - IV l/1
Fuel/oil sumps - - 1'J 21-
Fuel/oil/other pumps and hose connections .,_ - NI/,,9
Secondary containment structures v/ T413 M67413 XPGS51J1
Pipes, valves, and valve fittings - - IVA
Mobile equipment / ./C �,� -41,, /'�rfezv /vs,Di-
Dumpsters/bins(garbage, grease, crap met 1.// ge--Le j,,,e /,,r. a'..=s//2 ss"l,'Q
Other equipment
40777; P41,Zv2/i✓f /2i-i9vr,'/IWl$ • c2 ,', 7 - , 2I 7J-r--s iv //r :9LG— 111141&s."1-
_972,f.,-7
s.",.
_972 -,i °t- 7 - b' Z:29��G'obii, arm,e e -e%

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted AIMIMMIL
CERTIFICATE OF COVERAGE NOshI;CGa210_
SAMPLE COLLECTION YEAR 2016
FACILITY NAME BCI Materials, Inc. SAMPLE PERIOD X Jan-June July-Dec
COUNTY Mecklenburg or ❑ Monthly' (month)
PERSON COLLECTING SAMPLES N/A Es, eSCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY N/A Lab Cert.#N/A Gc ❑Zero-flow ['Water Supply OSA
Comments on sample collection or analysis: N/A AUG 15 ®Other C
Lino
DTRAL 1 ' PLEASE REMEMBER TO SIGN ON THE REVERSE-)
Part A: Stormwater Benchmarks and Monitoring Results R SEC7'to,
❑ No discharge this period?2
Date Sample 24-hour rainfall
Outfall No. 1
Collected amount,
(mo/dd/yr) Inches3 Total Suspended Solids
Benchmarks===> - - 100 mg/L or 50 mg/L4
001 N/A N/A No Plant Personal at Plant During
Discharge
002 N/A N/A No Plant Personal at Plant During
Discharge
003 N/A N/A No Plant Personal at Plant During
Discharge
1 Monthly sampling(instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall,you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text,Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example,do not report Below Detection Limit, BDL,<PQL, Non-detect, ND, or other similar non-
numerical format. When results are below the applicable limits,they must be reported in the format, "<XX me/L",where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
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.
' Permit Date:10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging> 55 gal of new oil per month.
❑ No discharge this period?2
Date Sample 24-hour rainfall
Outfall No. 1
Collected amount, Non-polar O&G by EPA
(mo/dd/yr) Inches3 1664(SGT-HEM) Total Suspended Solids
Benchmarks===> - - 15 mg/L 100 mg/Lor 50 mg/L4
Footnotes from Part A also apply to this Part B
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 SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO
IF YES,HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? 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 Resources
Attn:DWR 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."
'V/6
(Signature of Permitt (Date)
Permit Date:10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 -Asphalt
Date submitted
CERTIFICATE OF COVERAGE NO. * "p + T SAMPLE COLLECTION YEAR 2016
FACILITY NAME Blythe Construction Inc-Concord SAMPLE PERIOD ®Jan-June ❑July-Dec
COUNTY Cabarrus or ['Monthly' (month)
PERSON COLLECTING SAMPLES N/A DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY N/A Lab Cert.#N/A ❑Zero-flow ❑Water Supply ESA
Comments on sample collection or analysis:Sample collected on ®Other C
11/02/2015 was invalid for being received out of hold time for TSS test"
ED
parameter and therefore,could not be analyzed for TSS.The sample �' � � PLEASE REMEMBER TO SIGN ON THE REVERSE 4
was obtained as soon as feasible upon discovery. AUG 1 2016
Part A: Stormwater Benchmarks and Monitoring Results CENTRAL FILES
DWR SECTION
® No discharge this period.
Date Sample 24-hour rainfall
Outfall No. 1
Collected amount,
(mo/dd/yr) Inches3 Total Suspended Solids
Benchmarks===> - - 100 mg/L or 50 mg/L4
001 N/A N/A No Discharge
1 Monthly sampling(instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall,you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text,Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example,do not report Below Detection Limit, BDL,<PQL, Non-detect, ND,or other similar non-
numerical format. When results are below the applicable limits,they must be reported in the format, "<XX mg/L",where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
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.
Permit Date:10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging> 55 gal of new oil per month.
❑ No discharge this period?2
Date Sample 24-hour rainfall
Outfall No. 1
Collected amount, Non-polar O&G by EPA
(mo/dd/yr) ° Inches3 1664(SGT-HEM) Total Suspended Solids
Benchmarks===> - - 15 mg/L 100 mg/L or 50 mg/L4
N/A
Footnotes from Part A also apply to this Part B
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 SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO
IF YES,HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? 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 Resources
Attn: DWR 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."
Yc7//6.
(Signature of Permit ee) (Date)
Permit Date:10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000 - Asphalt
Date submitted
,
CERTIFICATE OF COVERAGE NO. I G;11' D7 SAMPLE COLLECTION YEAR 2016
FACILITY NAME Blythe Construction Inc.- Pit#1 SAMPLE PERIOD ®Jan-June ❑July-Dec
COUNTY Guilford a f x w or ❑ Monthly1 (month)
PERSON COLLECTING SAMPLES Russ Taggart Ln DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY ALS Group USA, Corp Lab Cert.#624-2015 Po1 5 2016 ❑Zero-flow ®Water Supply ESA
Comments on sample collection or analysis: NA ®Other NSW
CENTRAL IES
DWR SECTION ION PLEASE REMEMBER TO SIGN ON THE REVERSE—)
Part A: Stormwater Benchmarks and Monitoring Results
n No discharge this period?2
Date Sample 24-hour rainfall
Outfall No. 1
Collected amount,
(mo/dd/yr) Inches3 Total Suspended Solids
Benchmarks===> - - 100 mg/Lor 50 mg/L4
002 N/A N/A Was Not Present At Time of
Discharge
003 N/A N/A Was Not Present At Time of
Discharge
1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall,you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text,Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example,do not report Below Detection Limit, BDL, <PQL, Non-detect, ND, or other similar non-
numerical format. When results are below the applicable limits,they must be reported in the format, "<XX mg/L",where XX is the numerical value of the
detection limit, reporting limit, quantitation limit, etc. in mg/L.
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.
Permit Date: 10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging> 55 gal of new oil per month.
n No discharge this period?2
Date Sample 24-hour rainfall
Outfall No. Collected) amount, Non-polar O&G by EPA
(mo/dd/yr) Inches3 1664(SGT-HEM) Total Suspended Solids
Benchmarks===> - - 15 mg/L 100 mg/Lor 50 mg/L°
Footnotes from Part A also apply to this Part B
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 SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO El
IF YES,HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? 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 Resources
Attn: DWR 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."
111101. 79/46
(Signature of Per ittee) (Date)
Permit Date:10/1/2014-9/31/2019 SWU-252, last revised 9/17/2014
Page 2 of 2

Semi-annual Stormwater Discharge Monitoring Report (DMR)
for North Carolina DEMLR General Permit No. NCG160000-Asphalt
Date submitted 07/16/2016
CERTIFICATE OF COVERAGE Nta?�N Q SAMPLE COLLECTION YEAR 2016
FACILITY NAME: APAC Atlantic,Inc. Plant#40 SAMPLE PERIOD ®Jan-June ❑July-Dec
COUNTY:Forsyth or ❑Monthly1 (month)
PERSON COLLECTING SAMPLES: Robert Settle ---DISCHArRGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
LABORATORY: Prism Lab Cert.#402 AUG 12 alb ❑Zero-flow ❑Water Supply OSA
Comments on sample collection or analysis: ®Other: Leak Fork
CENTRAL FILES
DWR SECTION PLEASE REMEMBER TO SIGN ON THE REVERSE -*
Part A:Stormwater Benchmarks and Monitoring Results
❑ No discharge this period?2
Outfall No`. Date Sample 24-hour rainfall.
Collected' - amount,
(mo/dd/yr) Inches
Total Suspended Solids
-
Benchmarks===> - - - • 100 mg/Lor 50 mg/L4
001 07/06/2016 0.2 88
1 Monthly sampling(instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall,you must still submit this discharge monitoring report with a checkmark here.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
4 See General Permit text,Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Note: Results must be reported in numerical format. For example,do not report Below Detection Limit, BDL,<PQL, Non-detect, ND,or other similar non-
numerical format. When results are below the applicable limits,they must be reported in the format,"<XX mg/L",where XX is the numerical value of the
detection limit, reporting limit,quantitation limit,etc. in mg/L.
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.
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging>55 gal of new oil per month.
Permit Date:10/1/2014-9/31/2019 SWU-252,last revised 9/17/2014
Page 1of2

n No discharge this period?2
Date Sample. 24-hour rainfall
Outfall No. Collected' amount, Non-polar O&G by EPA
(mo/dd/yr) Inches3 ,1664(SGT-HEM) Total Suspended Solids '-
Benchmarks===> _ - - 15-mg/L - -100 mg/Lor 50 mg/L4
Footnotes from Part A also apply to this Part B
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 SINGLE BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDANCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑NO❑
IF YES,HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE AS REQUIRED BY THE PERMIT? 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 Resources
Attn: DWR 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."
dQ '
(0t
(Signature of Permittee (Date)
Permit Date:10/1/2014-9/31/2019 SWU-252,last revised 9/17/2014
Page 2 of 2