NCG140184 DMR SW

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STORMWATER DISCHARGE OUTFALL (SDO) - Semi-Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
CERTIFICATE OF COVERAGE NO.aN $"j_.-r4_ SAMPLE COLLECTION YEAR:
FACILITY NAME: 4Q_iot ilk P(4h-1- SAMPLING PERIOD: 2July-December t]January-June
PERSON COLLECTING SAMPLES /71;ke .5.e+2.Pr' COUNTY � 'to.Nrj lni\(.1\C
CERTIFIED LABORATORY A4V/ractt P Lab# ,eq c( PHONE NO.( ( 1O ) 3 71 - le-57o7 6
Lab# ADD TO LISTSERVE?IZJCYES ❑NO EMAIL: fluke _5Q4-zei® (454s- 1".""‘"1/4
OPTIONAL INFO: DISCHARGING TO CLASS: OSA EHQW PNA ❑Trout ['Other
Part A:Stormwater Monitoring Requirements
Date Sample In Tier 2
pH Event Total
Collected TSS , Monthly #of Months in Tier
Outfall No. (Standard Duration Rainfall 2
(mo/dd/yr OR (mg/L) (minutes) (in) Monitoring? 2 Sampling
NO FLOW)1 Units) (y/n)
.2 9 psi yea 7.s3 4/-3 i
3 qhs-l/4 C>j <o'r se G,-,74.,,,g.
�,,,.......S.... REQ
ri. uml\f I�L�
- NOV 07 ?616
- CENTRAL ILES
DWR SECTIONt
I
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/l.
For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
_ Permit Date:7/1/2011-60/30/2015 I Last Revised 7/13/11
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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
Outfall Date Sample pH TPH using method Total Suspended Event Total o New Motor Oil Monthl R of Months
No. (Standard 1664A SGT-HEM Solids Duration Rainfall Usage y in Tier 2
Collected Monitoring?
(mo/dd/yr)' Units) (mg/L) (mg/L) (minutes) (in) (gal/month) (y/n) SamplingZ
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 all"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 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 aw. e +t t re are sig.*ant pi nalties for submitting false information,including the possibility Ines a�d imprisonment for knowing violations."
( ignature of Permittee)
(Date)
Permit Date:7/1/2011-60/30/2015 Last Revised 7/13/11
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