NCG140423 - DMR SW

STrRMWATER J ISCHARGE •UTFALL (S llO) - S m -Annual M oNIITORING FORM
GENERAL PERMIT NO. lkCG140000
CERTIFICATE OF COVERAGE NO. G1.1.04A-Li SAMPLE COLLECTION YEA . Zo
FACILITY NAME: —0 r,51 1-V-1 QM l l SAMPLING PERIOD: uly-December ❑January-June
PERSON COLLECTING SAMPLESYlv, px�. COUNTY c�-tit\-A'N
CERTIFIED LABORATORY 17 (ILYLhA-- kvt.ktIUtab# 3(� PHONE NO. (35(4) C(1..,26i-OW(u
Yy f lav th . Lab# ADD TO LISTSERVE?OYES CWO EMAIL:
OPTIONAL INFO: DISCHARGING TO CLASS: OSA ❑HQW ❑PNA ❑Trout f lOther
Part A:Stormwater Monitoring Requirements
Date Sample In Tier 2
Collected pH Event Total TSS a Monthly #of Months in Tier
Outfall No. (Standard Duration Rainfall4 OR Units) (mg/L) (minutes) (in) Monitoring? 2 Sampling2
NO FLOW)1 (y/n)
- - 6-92 1002'3 - - - -
I 10\Ce-01 I LP —1,C1 `-I 2-5-7 t LC) 0
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.
Permit Date:7/1/2011-60/30/2015 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 a New Motor Oil Monthl #of Months
(Standard 1664A SGT-HEM Solids Duration Rainfall Usage y in Tier 2
No. Collected Monitoring? z
(mo/dd/yr)1 Units) (mg/L) (mg/L) (minutes) (in) (gal/month) Sampling
(Yin)
6-92 152 1002'2 - - - - -
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDNJES AT ANY ONE OUTFALL(INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO 0(
HAVE YOU CONTACTED THE REGION? SES El NO
.
REGIONAL OFFICE CONTACT NAME: �LU.:1-or `��)J2A.."--
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 per:. . 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 tha there a - .:nificant penalties for submitting false information,including the possibility f fines and imprisonment for knowing violations."
i / II G � )Le
(Signature of Permittee) 1 (Dat )
Permit Date:7/1/2011-60/30/2015 Last Revised 7/13/11
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