SW Discharge Monitoring Report

Quarterly Stormwater Discharge Monitoring Report
for North Carolina Division of Water Quality General Permit No. NCG240000
Date submitted SLS► ��/Sl
CERTIFICATE OF COVERAGE NO. NCG24,0 Q Q
FACILITY NAME ► c wq!q li�H
COUNTY Sq s r
PERSON COLLEC ING SAMPLES
LABORATORY
Lab Cert. #
Comments on sample collection or analysis:
1
ivionimy sampling linsteaa of quarterly) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
3The total precipitation must be recorded using data from an on-site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
3 For sampling periods with no discharge, you must still submit this discharge monitoring report with a checkmark here.
4The TSS benchmark value is 100 mg/L; except when discharging to ORW, HQW, Trout, and PNA waters in which case the benchmark is 50 mg/L.
SAMPLE COLLECTION YEAR d O/tf
SAMPLE QUARTER [A Jan -March ❑ April -June ❑ July -Sept
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
[]Zero -flow []Water Supply OSA
NOther G , 5 wa app
❑ Oct -Dec
Permit Date: 10/1/2011-9/30/2016 Last Revised 12/02/11
Page 1 of 2

Footnotes from Part A also apply to this Part B
for oil/month.
FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES INA ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR including all "No Discharge" reports within 30 days of receipt of the lab results (or at end of monitorina period
in the case of "No Discharge" reports) 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 aware thp�here are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Sigr(afure of Perm
Permit Date: 10/1/2011-9/30/2016
5
(Date)
Last Revised 12/02/11
Page 2 of 2