Spreadsheet: 0d0f66dd-dd49-439d-93ee-c9d7d3824f9e
Sheet: Common

Industrial Stormwater Discharge Monitoring Report - 1200-Z Permit
Permittee Legal Name: |  |  |  |  | ODEQ File No./Facility ID:
Facility Common Name: |  |  |  |  | Reporting Period: |  | July 1, |  | to | June 30,
Facility Location: |  |  |  |  | Laboratory Name:
County: |  |  |  |  | ORELAP# |  |  |  | SIC Code(s):
Monitor for the following pollutants at sampling point(s) specified in your SWPCP and use the sampling point name or number from your SWPCP.  Add more sheets if necessary (e.g., if more than 4 samples are collected per pollutant or facility has more than 4 sampling points).  You MUST also attach a copy of laboratory results sheet(s).
[NAME]: 4 times per year, every year
Name or Number of Sampling Point(s) (group data per sampling point) | Sample Date | pH | Total Suspended Solids | Oil and Grease, Total | Copper, Total | Lead, Total | Zinc, Total | E. coli * | * E. coli only required for landfills accepting septage/biosolids and sewage treatment plants.
 |  | s.u. | mg/L | mg/L | mg/L | mg/L | mg/L | [NAME] | Fill out only those rows and columns that apply to your specific site.
Geometric Mean (Note 3)
Geometric Mean (Note 3)
Geometric Mean (Note 3)
Geometric Mean (Note 3)
Permit Benchmark |  | 5.5 - 9.0 | 100 | 10 | 0.02 | 0.04 | 0.12 | 406
Name/Title Principal Executive Officer or Authorized Delegate
(Please Print)  First Name: |  |  |  | Last Name: |  |  |  |  | Title:
Telephone: |  |  | [NAME]:
40 CFR 122.22 I certify, under penalty of law, that this document and all attachments were prepared under my direct 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.
Sign Here: |  |  |  |  |  |  |  | Date:
Page 1 |  |  |  |  |  |  |  |  |  |  | Last updated 6/17/2013 | 08-WQ-033
Additional Sampling
 |  | 8 samples during first 3 years |  |  |  | 4 samples during first 3 years
 |  | All Permittees |  |  |  | Auto Salvage & Scrap Recycling Facilities |  | Scrap Recycling Facilities |  | *  PCBs should be reported as the sum of the following aroclors 1016, 1221, 1232, 1242, 1248, 1254, 1260.  Do not use any value for any aloclor that is non-detect,  Should all Aloclors be non-detect report the ND value for the highest non-detect value from the lab report; typically, this will be ND (0.002).
Name or Number of Sampling Point(s) (group data per sampling point) | Sample Date | Cadmium, Total | Nickel, Total | Chromium, Total |  | Mercury, Total |  | Total PCBs *
 |  | mg/L | mg/L | mg/L |  | mg/L |  | mg/L
 |  | Use method 3113B, 200.8, or other method specified in 40CFR136 for NPDES reporting |  |  | MQL | 0.0024 |  | 0.002
For facilities located within the following local jurisdictions, please submit one (1) copy of this report, the laboratory results sheet(s), QA/QC documentation and Chain of Custody (COC) forms to the local jurisdiction annually by July 31st: |  |  |  | For all other locations, please submit one (1) copy of this report and laboratory results sheet(s) to the appropriate DEQ regional office annually by July 31st:
Page 2