NCG140107 DMR SW (3)

STORMWATER DISCHARGE OUTFALL (SDO) - Semi-Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COV r7/56C
NO. N - .kV_ SAMPLE- - 6
SAMPLE COLLECTION YEAR: dC3/6 !
FACILITY NAME: /J X'A) / ' ` �e SAMPLING P IQD 11 fJuully-December g January-June
PERSON COLLECTING SAMPLES / �i/xe �vge.) PHONE NO.COUNTY C/�.SJ T '��� AUVO
CERTIFIED LABORATORY Lab# { )
Lab# ADD TO LISTSERVE?DYES LINO EMAIL:
OPTIONAL INFO: DISCHARGING TO CLASS: LISA ❑HQW ❑PNA ❑Trout ❑Other
Part A:Stormwater Monitoring Requirements
Date SampleIn Tier 2
Collected (Standard pH TSS Event Tatal 4 Monthly Months in Tier
Outfall No. (mo/dd/yr OR (mg/L) Duration Rainfall2
Monitorin 2 Sampling
1 Units) (minutes) (in)
NO FLOW)1
23 -
6-9 100 ' - �VE�� -
JUN 016
_ )..: \ �� S 7-,
ii\)(!) ,
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 done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/I,except when discharging to ORW,HQW,Trout,and PNA waters where they are 50 mg/I.
°For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
LastrRevi ed 7/13/11
Permit Date:7/1/2011-60/30/2015 Page 1 of 2

Part B: Vehicle Maintenance Activity Monitoring Requirements for facilities using>55 gal of new motor oil/month—averaged over a calendar year.
In Tier 2
pH TPH using method Total Suspended Event Total New Motor Oil onths
Outfall Date Samplea Month!
(Standard 1664A SGT-HEM Solids Duration Rainfall Usagein Tier 2
No. Collected s Units) (mg/L) (mg/L) (minutes) (in) (gal/month) M ring? Sampling2
(mo/dd/yr) (Yin)
6-92 '151 1002'3 - - ,
1 eLi
N. 6 cf-‘ \
,..,---------"---------'\ _ . _
l7.
z,...„.....„------" ,
• _
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 copy of this DMR (including^alI "No Flow" &"No Discharge"reports)within 30 days of receipt of sample 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 perso d' ctly `:,,i nsi.le f'r gather'ng the information,the information submitted is,to the best of my knowledge and belief,true,accurate,and complete.
am aw h ter• a 1! : l if a t u II ' for submitting false information,including the possibili of fines ndm risonment for knowing violations."
(Signature of Permittee) ' (Date)
Permit Date:7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2 of 2