NCG020895 Template SW Annual DMR to CO

ANNUAL SUMMARY DISCHARGE MONITORING
REPORT (DMR) — STORMWATER
SUBMIT TO CENTRAL OFFICE*
General Permit No. NCG020000
Calendar Year
*Report ALL STORMWATER monitoring data on this form (include "No Flow"/"No Discharge" and Benchmark
Exceedances) from the previous calendar year to the DEQ by MARCH 1 of each year.
Certificate of Coverage No. NCG020895
Facility Name:
County:
Phone Number: () Total no. of SDOs monitored
Certified Laboratory Lab #
Lab #
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 ❑
If this outfall was in Tier 2 last year, was monthly monitoring discontinued?
Yes, enough consecutive samples below benchmarks to decrease frequency ❑
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No, turbidity benchmark exceedances did not require monthly monitoring ❑
Other ❑
Outfall No.
Total
Rainfall,
inches
TSS,
mg/I
SS,
ml/I
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mg/I
(VMA)
New
Motor Oil
Usage
(gal/mo.)
Storm water
Benchmarks
Indicate NO
FLOW if
a licable
circle
Benchmark
100/50
0.1
Circle
Benchmark
50/25/10
N/A
Water Quality
Standard applies
N/A
Water Quality
Standard applies
1 5
>55 gal/mo.
average requires
TSS and Non -polar
O&G monitoring
Date Sample
Collected,
mo/dd/yr
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Outfall No.
Iron,
mg/I
continued
Total
Stormwater
Benchmarks
N/A
Date Sample
Total Hg,
Collected,
Ilixi,
mo/dd/vr
Certificate of Coverage No. NCG020895
Supplemental parameters:
Total Ni, Total Zn, Total Sb, Total As, Total Be, Total Cd, Total Cu,
mg/I mg/I mg/I mg/I mg/I mg/I mg/I
0.335 1 0.126 1 0.09 1 0.34 1 0.065 1 0.003 1 0.010
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC
Total
Ouffall No.
Total Pb,
Total Hg,
Total Se,
Total Ag,
Hardness,
continued
Stormwater
Benchmarks
0.075
0.000012
0.056
0.0003
N/A
Date Sample
Collected ,
molddlvr
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Certificate of Coverage No. NCG020895
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 ❑
If this outfall was in Tier 2 last year, was monthly monitoring discontinued?
Yes, enough consecutive samples below benchmarks to decrease frequency ❑
Yes, received approval from DEMLR to reduce monitoring frequency ❑
No, turbidity benchmark exceedances did not require monthly monitoring ❑
Other ❑
Outfall No.
Total
Rainfall,
inches
TSS,
mg/I
SS,
ml/I
Turbidity,
NTU
Upstream
(U) Turbidity,
NTU
Downstream
(D) Turbidity,
NTU
Non -polar
O&G, mg/I
(VMA)
New
Motor Oil
Usage
(gal/mo.)
Storm water
Benchmarks
Date Sample
Collected,
mo/dd/yr
Indicate NO
FLOW if
a licable
circle
Benchmark
100/50
0.1
Circle
Benchmark
50/25/10
N/A N/A
Water Quality Water Quality 15
Standard applies Standard applies
>55 gal/mo.
average requires
TSS and Non -polar
O&G monitoring
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Outfall No.
continued
Stormwater
Benchmarks
Date Sample
Collected,
mo/dd/vr
Certificate of Coverage No. NCG020895
-3,uppiementai parameters:
Iron, Total Ni, Total Zn, Total Sb, Total As, Total Be, Total Cd, Total Cu,
mg/I mg/I mg/I mg/I mg/I mg/I mg/I mg/I
N/A 1 0.335 1 0.126 1 0.09 1 0.34 1 0.065 1 0.003 1 0.010
Ouffall No.
continued )
Total Pb,
Total Hg,
Total Se,
Total Ag,
MOEN
Stormwater
Benchmarks
Date Sample
Permit Date 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC

Certificate of Coverage No. NCG020895
CERTIFICATION
"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."
[Required by 40 CFR §122.22]
Signature
Date
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)
DWR Central Files
512 N. Salisbury St.
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 5/31/17 — 9/30/2020
Revised 5/31/17 for Additional Monitoring Specific to this COC