NCG020007 DMR SW (4)

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) STQRMWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year
*Report ALL STORMWATER monitoring data on this form(include"No Flow"PNo Discharge"and Benchmark
Exceedances)from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NIOD,OZIENDIEN
Facility NameK ek_rQ
County: c -�-
Phone Number: (Q(( Total no. of SDOs monitored
Certified Laboratory Lab#
Lab#
Stormwater Discharge Outfall (SDO) No. VMA-Outfall? Yes❑ Nog
Is this outfall currently in Tier 2 for any parameter? Yes❑ No 0
Was this outfall ever in Tier 2 during the past year? Yes 0 No 0
if this outfall was in Tier 2 last year,was monthly monitoring discontinued?
Yes,enough consecutive samples below benchmarks to decrease frequency 0 L''
Yes,received approval from DEMLR to reduce monitoring frequency 0 JAN 1 8 201/
No,turbidity benchmark exceedances did not require monthly monitoring 0 CENTRAL FILES
Other ❑ DWR SFCrt0N
Upstream Downstream New
Total TSS, SS, Turbidity, (U)Turbidity, (D)Turbidity, Non-polar Motor Oil
Outfall No. Rainfall, mgll mill NTU NTU NTU O&G, mgli Usage
inches (VMA) (gallmo.)
t ue
Circle NIA N/A a55galimo.
Stormwater rndicatoNO Benchmark Benchmark platerQuatfly 1Yaterquahly 15 TSSr averages
Benchmarks oppl0ieable 100/50 0.1 50/25/10 Standard applies Standard applies OSG monitoring
Date Sampler - s w�
Cotiected, • -3"
mo/ddl r• .= ,, - = ` `' f -,`<'., 't
j d a e e_i2.r1.17,2u
�f Q 2 a I
Permit Date 101112016®9130/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCGO2 Eaag
Additional Outfall Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall (SDO) No. VIVIA Outfall? Yes❑ No'
Is this outfall currently in Tier 2 for any parameter? Yes❑ No 0
Was this outfall ever in Tier 2 during the past year? Yes 0 No 0
If this outfall was in Tier 2 last year,was monthly monitoring discontinued?
Yes,enough consecutive samples below benchmarks to decrease frequency 0
Yes,received approval from DEMLR to reduce monitoring frequency ❑
No,turbidity benchmark exceedances did not require monthly monitoring 0
Other ❑
Total TSS, ss, Turbidity, Upstream . Downstream New
Outfall No. (U)Turbidity, (0)Turbidity, Non-polar Motor Oil
Rainfall, mgtl mi/l NTU NTU NTU O , mg/I, Usage
inches (VMA) (gal/mo.)
Ctrcle Circle
Stormwater Indicate 110 Benchmark Benchmark N/A N/A erage requires
FL04YJr natcrQuali! Water QualitaveandNon-poly
Benchmarks appIicah/c IUB/5U �•� 50/2$/10 Standard applies Standard applies 'I5 TSS and Non-polar
rri pie i , -_ - - c`, _ - _ _ ., 055 monitoring
Date Sa
Collected, ;i __ • 'a= _ _ ,� !i -
mo/dd/yr
Permit Date 10/1/2015—9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCGO2 ®[ 1®
Additional Outfall Attachment (make copies as needed for additional outfalls)
Stormwater Discharge Outfall(SDO) No. VMA Outfall? Yes ❑ No
Is this outfall currently in Tier 2 for any parameter? Yes❑ No❑
Was this outfall ever in Tier 2 during the past year? Yes ❑ No 0
If this outfall was in Tier 2 last year,was monthly monitoring discontinued?
Yes,enough consecutive samples below benchmarks to decrease frequency 0
Yes,received approval from DEMLR to reduce monitoring frequency
No,turbidity benchmark exceedances did not require monthly monitoring ❑
Other 0
Upstream Downstream New
Total TSS, ss, Turbidity, (U)Turbidity, (D)Turbidity, Non-polar Motor Oil
Outfall No. Rainfall, mg/I mill NTU NTU NTU O&O, mg/I Usage
inches (VMA) (gal/mo.)
Circle Circle a55 gatimo.
Stormwater linrca(e110 Benchmark Benchmark NIA N/A averago requires
Benchmarks app0r ati; 100/50 0.1 50/25/10 Standard1ppi esStaaterd apps ualitas 15 TSS and
monilodngr
DS
Date Sample =�_ • _ )! ' =_ ; - -- i
Collected, I • -i
mo/dd/yr - : - _ _ _ .t i:
•
Permit Date 10/1/2015—9/30/2020
Last Revised 10-2-2015

Certificate of Coverage No. NCGO2 noon
CERTIFICATION
"1 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 anelief, true, accurate and complete. I am aware that there are significant penalties for
submitting fall informa den, in ludinti the possibility of fines and imprisonment for knowing violations."
i:!
(Required by 4f C R§122. '1
Signature ..��diL lat
,.e
Date I 0 .2112- ' 't r�
Mail Annual Summary Stormwater DMR to the NCDEQ Central Office:
Note the address is correct—Central Files is housed in DWR(not DEMLR)
N.C. Department of Environmental Quality(DEQ) ,
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 10/112015—9/30/2020
Last Revised 10-2-2015
1