NCG210417 DMR SW (2)

1
STORMWATER DISCHARGE OUTFALL(SDO)
MONITORING REPORT
GENERAL PERMIT NO.NCG210000 _ SAMPLES COLLECTED DURING CALENDAR YEAR: >/� •
CERTIFICATE OF COVERAGE NO.NCG21n—nn (This monitoring report is due at the Division no later than 30 days from
I the date the facility receives the sampling results from the laboratory.)
ILITY NAME CUS-I-Qi ') P 1) - r Cr6t l RECEIVED COUNTY (Y'ectde4 6 am'
PERSON COLLECTING SAMPLES, 7-Y26 J Miiiscb uJPHONE NO.( 76 912./ 0'00
CERTIFIED LABORATORY Kf W LfretS Lab# .551 MAY 2 5 2016
Lab# PLEASE SIGN ON THE REVERSE-*
Part A: Specific Monitoring Requirements'
CEN S L FILES
DWR SECTION
Outfall Date 00530 00400 00340
No. Sample Collected, Total Rainfall, Total Suspended Solids, pH, Chemical Oxygen Demand(COD),
mo/dd/yr inches mg/L Standard units mg/L
Benchmark* - - 100 Within 6.0-9.0 120
OF / "5-T- /6 -5 165 i6 3go
OP 2 3-'.�- /o -5 —
*Note.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.
'Monitoring 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.
A facility that does not retain exposed(either exposed to incident precipitation or exposed to stormwater run on)piles of sawdust,wood chips,bark,mulch,or other similar material on
site for more than seven(7)days before removing the material is not required to monitor for the parameters in Table 1 of the General Permit. If at any time the material is not removed
within this time frame,the facility must begin analytical monitoring immediately. (Reminder. This condition does not exempt any facility from qualitative monitoring of SDOs.)
If the facility removes such materials within seven days to meet the monitoring exemption,the Permittee shall record and maintain in the facility's SPPP a log which documents, at a
minimum, the dates when material is generated and removed, how removed, and by whom. The log must be sufficient to establish that no materials were exposed for longer than seven
days. For record-keeping purposes,the Permittee may also maintain in the SPPP this form with the signed certification below:
"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 or other similar materials were stored exposed(either to incident precipitation or to
stormwater run on)for longer than seven (7)days before removal since filing the last discharge monitoring report."
M(ke Szczepan. le (�
Name(Print name) °
'&etwitrq. { nna 11/1-'
Title( nt titl
/ ![— 5- /g-/6
(Si ature) U (Date)
SWU-245-110408
Page 1 of 2

DID THIS FACILITY PERFORM VEHICLE MAINTENANCE ACTIVIES USING MORE THAN 55 GALLONS OF NEW MOTOR OIL PER MONTH,ON
AVERAGE,IN THE CALENDAR YEAR?
❑ YesXNo(If yes,complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall Date 00400 _ 00556 _ 00530
No. Sample Collected, Total Rainfall, New Motor Oil Usage, pH, Oil and Grease, Total Suspended Solids,
mo/dd/yr inches Annual average gal/mo Standard units mg/L mg/L
Benchmark* - - - 6.0—9.0 30 100
*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
Mail original and one copy to:
Division of Water Quality
Attn. Central Files
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED IN PARTS A AND/OR B:
"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."ne
../V,
cirr '
(Signature of Permit(ee) (Date)
SWU-245-110408
Page 2 of 2