NCG140138 DMR SW (3)

STORMWATER DISCHARGEOUTFALL (SDO) - Semi-Annual MONITORING FORM
GENERAL PERMIT NO. NCG140000
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, CERTIFICATE OF COVERAGE NO. N + ��� � ;.,�� ��;
SAMPLE COLLECTION YEAR:
FACILITY NAME: „,” / Proph COUNTY td0F,.,
SAMPLING PERIOD: ❑July-December anuary-June
; PERSON COLLECTING S MPLES' „ fi�A
CERTIFIED LABORATORY ab# PHONE NO. (' �j� ) f��,� Cf ,
( L/� 6 Lab# D�a`� ADD TO LISTSERVE? I YES NO EMAIL:
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OPTIONAL INFO: DISCHARGING TO CLASS: EISA ❑HQW ❑PNA ❑Trout ❑ �/OtherC S,
Part A:Stormwater Monitoring Requirements
,Date�Sample - __ _ - In Tier 2'' Event Total ,_';Collected, - 'TSS a Monthly #of Months=in Tier
-Outfall No. (Standard _- DurationRainfall
- - - (mo/dd/yrOR= (mg/L)-- -Monitoring? 2 Sampling - _
(minutes) - '(in)
_- NO FLOW) , _ - (Yin) _- - '
1002,3 _ -
- .. _
Oa/ 52 /G 7 3, o10, 0,75-/#1,
/)-i;)/ 17 /, F 11 CE1V D
Fa
.JUN 1 5 2016
CENT FAL FILER
DWR 5CC"�►�N
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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.
4For each sampled measurable storm event the total precipitation must be recorded using data from an on-site rain gauge.
Permit Da; -;1/2011-60/30/2015 Last Revis-",'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.
„ H ": ; • = In Tier 2 #of Months'y
_ -TPH,using,method .Total Suspended Event` Total 'New Motor Oil ',Monthl
Outfall, �Date'Sample 1664A SGT'HEM" Solids _ � � Duration Rainfall ` Usage - y' in Tier 2
No. ti - .Collected (Standard Monitoring? 2
)1 -Units) • (mg/L) (mg/I.) (minutes) ,• (in)' (gal/month) (y/n) Sampling
(mo/dd/yr) �,
II
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL(INCLUDING VEHICLE MAINTENANCE)? YES ❑ NO 44
HAVE YOU CONTACTED THE REGION? YES ❑ NO❑
fi 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 . -gathering th- ;nformaiion,the information submitted is,to the best of my knowledge and belief,true,accurate, and complete. I
am awarthat.t.he-r--rare signif 9 nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
�= 1 � ;/ ,// i _,_ to _
(Signa' ermittee)! ( )
Permit Date:7/1/2011-60/30/2015 Last Revised 7/13/11
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