NC0067016_renewal application_20210415 (2)

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North Carolina
Department of Environmental Quality
Division of Water Resources
Prink Form 7
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
Facility Name
Fomi
NPDES
PAR J.J A,r 6Le rri • 5cAcb c.
Modified Application Form 2A
Modified March 2021
NC Department of Envh entityt Quay- Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILRIES (Before completing this form, please read the itstm lions. Failure to follow
the instructions result in denial ofthe 111
SECTION 1. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1 Facility name
Pik Kw P Er? E (1 •12 V 50400 /.
Mailing address (street or P.O. box)
!is- 2 O C6R
1.2
City or town
bookke
State
NIQP C.Pr9-cl-xr4
Contact name (first and last) Title ORe - Acss�svAnr Phone number
Flu BOr�(.1c NAxrtTe4i34e6" aue. (%2%)JI,4. c.3ct3 1.bo1;
ZIP code
A$Ce0-1,
Email address
Scld
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
I Co a *,1 5 ��ac c _ ?-.o .
City or town State ZIP code
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission 9— No
requirements for new dischargers.
Applicant Information
1.3
1.4
Existing Environmental Permits
1.5
1.6
Is applicant different from entity listed under Item 1.1 above?
El' Yes
❑ No 4 SKIP to Item 14.
Applicant name
(O ((Port 80rWeo
Applicant address (street or P.O. box)
City or town
no tv c-
Contact name (first and last)
State
AleiZr, (4121.)4-XPf1
ZIP code
`tCQo-1
Title pRC. - AssxstANr Phone number Email address
RTC jc C-- ►!��+x tar.tA cc 9si2.- 028)2CoL%{e3SS boi;ckeIWaiw► ,Schc
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑ Owner 0r Operator 9 Both
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility
Er- Applicant
"IFacility and applicant
(they are one and the same)
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.
Existing Environmental Permits
ErNPDES (discharges to surface
water)
❑ RCRA (hazardous waste)
❑ UIC (underground injection
control)
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
Ocean dumping (MPRSA)
❑ NESHAPs (CAA)
❑ Dredge or fill (CWA Section ❑ Other (specify)
404)
s .
Page 1

NPDES Permit Number
i NEOoC4,7016,
Facility Name
PPiVkw' y 1. S
Modified Application Form 2A
Modfied March 2021
Collection System and Population Served
1.7
Provide the collection system information requested below for the treatment works.
Municipality
Served
Population
Served
Collection System Type
(indicate percentage)
OiAmership Status
t 00 %separate sanitary sewer
Er Own Er Maintain
53Q 0
%combined storm and sanitary sewer
❑ Own 0 Maintain
❑ Unknown
■ Own 0 Maintain
%separate sanitary sewer ❑ Own 0 Maintain
%combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
• Own 0 Maintain
%separate sanitary sewer
0 Own 0 Maintain
%combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own • Maintain
%separate sanitary sewer
0 Own 0 Maintain
%combined storm and sanitary sewer
0 Own 0 Maintain
Total
Population
Served
" F 6
5
❑ Unknown
0 Own 0 Maintain
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles) !�
C 60 %
%
Indian Country
1.8
Is the treatment works located in Indian
❑ Yes
Country?
Er No
1.9
Does the facility discharge to a receiving
❑ Yes
water that flows through Indian Country?
111 No
Design and Actual
Flow Rates
1.10
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
mgd
mgd
mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
mgd
mgd
mgd
Discharge Points
by Type
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Discharge Points by Type
Treated Effluent
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
0
O
0
p
Page 2

Outfalls and Other Discharge or Disposal Methods
NPDES Permit Number Facility Name Modified Application Form 2A
t Cr.- QOt- 1 O 1 Co •Pp, �(}i GGL�f1, . SL R MocSfiedMarch2021
Outfalls Other Than to Waters of the State of North Carolina
1.12 Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes Et-- No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
1.14
Surface Impoundment Location and Discharge Data
Average Daily Volume
Location Discharged to Surface
Impoundment
gPd
gpd
gpd
Continuous or Intermittent
(check one)
❑ Continuous
❑ Intermittent
❑ Continuous
❑ Intermittent
❑ Continuous
❑ Intermittent
Is wastewater applied to land?
❑ Yes 9 No4SKIPtoItem1.16.
1.15
Provide the land application site and discharge data requested below.
Location
Land Application Site and Discharge Data
Average Daily Volume
Size
Applied
acres
gpd
Continuous or
Intermittent
icheck one;:
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
1.16
Is effluent transported to another facility for treatment prior to discharge?
❑ Yes 13-- No 4 SKIP to Item 1.21.
1.17
gpd
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19
Provide information on the transporter below.
❑ Continuous
❑ Intermittent
Transporter Data
Entity name Mailing address (street or P.O. box)
City or town
State
Contact name (first and last)
Title
Phone number
ZIP code
Email address
Page 3

NPDES Permit Number
Facility Name
Outfalls and Other Discharge or Disposal Methods Continued
Contractor Information
C..-1
+4v Em . sc
Modified Application Form 2A
Modified March 2021
1.20
In the table below, indicate the name, address, contact infnrma
receiving facility.
+'on, NPDES number, and average daily flow rate of the
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
NPDES number of receiving facility (if any) 0 None
Average daily flow rate mgd
1.21
Is the wastewater disposed of in a manner other than those a
not have outlets to waters of the State of North Carolina (e.g.,
❑ Yes Er- No
ready mentioned in Items 1.14 through 1.21 that do
underground percolation, underground injection)?
-, SKIP to Item 1.23.
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
DescMethod riptionDisposal
Location of
Site
Size of
Disposal Site
Annual Average
Ili Vly ol ie �e
Continuous or Intermittent
(check one)
acres
gp
❑ Continuous
❑ Intermittent
acres
gPd
❑ Continuous
• Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
❑ Discharges into marine waters (CWA ❑ Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
[r Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes D No 4SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Mailing address
(street or P.O. box!
City, state, and ZIP
code
Contact name (first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number
CC)Ou70IC�
SECTION 2. ADDITIONAL INFORMATION (40 CFR 122.21(j)(1) and (2))
OutfalIs to Waters of the State of North Cara
Facility Name
6-2041
Modified Application Form 2A
Modified March 2021
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes Eir No 4 SKIP to Section 3.
2.2
Inflow and Infil
Provide the treatment works' current average daily volume of inflow ` Average Daily Volume of Inflow and Infiltration
and infiltration.
.e003
1_
Indicate the steps the facility is taking to minimize inflow and infiltration.
WATGR 50014 , Atla A'wae. ESs .rM rY0" G1.4 12cu S
000�
2.3
gpd
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
111 Yes ❑ No
0 co
m
'c
Scheduled Improvements and Schedules of Implementation
2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for specific requirements.)
❑ Yes [r No
2.5 Are improvements to the facility scheduled?
❑ Yes
Er No4SKIPtoSection3.
Briefly list and describe the scheduled improvements.
1.
2.
4.
2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled
Improvement
(from above)
1.
2.
Scheduled or Actual Dates of Completion for Improvements
Affected
Outfalls
(list outlet'
number)
Begin
Construction
(MMIDDIYYYY)
3.
End
Construction
(MM/DDlYYYY)
Begin
Discharge
(MM/DD!`fYYY)
Attainment of
Operational
Level
(NMWDD/YYYY))
4.
2.7
Have appropriate permits/clearances concerning other federallstate requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 6

NPDES Permit Number
(\1 G p • CcrtdCo 1�•,�
Facility Name
AJ'
SECTION 3. INFORMATION ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
3.1
0
715
0
Description o
Modfied Application Form 2A
Modfied March 2021
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number
Outfalt Number
Outfall Number
State
County
City or town
\t'{P T ;1/41\
be O0a6
Distance from shore
5
ft.
Depth below surface
Average daily flow rate
0
ft.
ft
ft.
b 065
Latitude
mgd
mgd
31 13 , 53 "
mgd
Longitude 6 (0 3 3 ' Ll 1„
Seasonal or Periodic Discharge Data
3.2
Do any of the outfalls described under Item 3.1 have seasona or periodic discharges?
❑ Yes [r No 4 SKIP to Item 3.4.
3.3
If so, provide the following information for each applicable outfall.
Outfall Number
Outfall Number
Outfalt Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
Months in which discharge
occurs
mgd
mgd
mgd
a)
Q
r
ta
3
i5
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes 9 No SKIP to Item 3.6.
3.5
3.6
Briefly describe the diffuser
pe at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
Er Yes ❑ No +SKIP to Section 6.
Page 6

Receiving Water Description
Facility Name
t',/.4gVP) Pry may. �G
3.7 Provide the receiving water and related information (if known) for each outfall.
NI otS ip 10 t
Outfall Number I
Outfall Number
Mocified Application Form 2A
Mocified March 2021
Outfall Number
Receiving water name
I—AcroN C12.G04-
Name of watershed, river,
or stream system
U.S. Soil Conservation
Service 14-digit watershed
code
Nest 1.v62 Sr
Name of state
management/river basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
New ktv6lz 8x*
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
Treatment Description
mg/L of
CaCO3
mg/L of
CaCO3
mg/L of
CaCO3
3.8 Provide the following information describing the treatment provided for discharges from each outfall.
Highest Level of
Treatment (check all that
apply per outfall)
Outfall Number I
Outfall Number Outfall Number
IEr Primary
❑ Equivalent to
secondary
❑ Secondary
❑ Advanced
❑ Other (specify)
❑ Primary
❑ Equivalent to
secondary
❑ Secondary
❑ Advanced
❑ Other (specify)
Design Removal Rates by
Outfall
oA
o%
0 Not applicable
Phosphorus
0 Not applicable
Nitrogen
0
Primary
Equivalent to
secondary
Secondary
Advanced
Other (specify)
0 Not applicable
0 Not applicable
❑ Not applicable
❑ Not applicable
Other (specify)
0 Not applicable
0 Not applicable
❑ Not applicable
NPDES Permit Number
Page 7

NPDES
j\. C 066,101(o
Permit Number
PFW
Facility Name
P11 6-2.611. Sc 14
Mocified Application Form 2A
Modified March 2021
1
tc
O
c
a
.-
0f,
`
g
es
0
it
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
C\Al_0V.I.1`kC 1i,CL�LCr$
Outfall Number
t
Outfatl Number
Outfall Number
Disinfection type
G l-allata6 'j'At TS
Seasons used
at.L y GAR_ c-otic•
Dechlorination used?
•
Not applicable
❑ Not applicable
❑ Yes
❑ No
❑ Not applicable
❑ Yes
❑ No
Er
' ❑
for
tests
water
Yes
No
2
A
c
c
d
E
w
W
3.10
3.11
Have you completed monitoring
❑ Yes
all Table A parameters and attached the results to the
9 No
during the 4.5 years prior to the date of the application
near the discharge points?
Er No 4 SKIP to
app ication package?
Have you conducted any WET
discharges or on any receiving
❑ Yes
on any of the facility's
Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests
water
Number of tests
water
of discharge
of receiving
3.14
3
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
[r Yes 4 Complete Table B, including chlorine. ❑ No -4 Complete Table B, omitting chlorine.
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
❑ Yes D No
3.18
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
attached the results to this application package?
❑ Yes No additional sarrpling required by NPDES
permitting authority.
Page 8

NPDES Permit Number
N1C066,10ICo
Facility Name
�
it iZkLkIN`1 Eccm. ScA
Modfied Application Form 2A
Modified March 2021
c.
Effluent Testing Data Continued
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes Er No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
[MMrDOPNYYI
Summary of Results
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No4SKIPtoItem3.26.
3.23
Describe the cause(s)
of the toxicity:
works conducted a toxicity reduction
3.24
Has the treatment
❑ Yes
evaluation?
❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed
❑ Yes
Table E for all applicable outfalls and attached the results to the application package?
Not applicable because previously submitted
©�
information to the NPDES permittin• authorih
Page 9

NPDES Permit Number
Facility Name
AICooc07c CP
P zkw Pei Go
SECTION 6. CHECKLIST AND CERTIFICATION STATEMENT s40 CFR 122.22(a) and (d))
Checklist and Certification Statement
Modified Application Form 2A
Modified March 2021
6.1 In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
❑
Section 1: Basic Application
Information for All Applicants
❑
Section 2: Additional
Information
❑ w/ variance request(s)
❑ w/ additional attachments
❑ w/ topographic map ❑ w/ process flow diagram
❑ w/ additional attachments
❑ Section 3: Information on
Effluent Discharges
Section 4: Not Applicable
❑ w/ Table A
❑ w/ Table B
❑ w/ Table C
❑ w/ Table D
❑ w/ additional attachments
Section 5: Not Applicable
❑/ Section 6: Checklist and
Certification Statement
❑ w/ attachments
6.2
Certification Statement
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 fine
and imprisonment for knowinr; violations.
Name (print or type first and last name)
Signature
Official title 0RC..
T ; ■. c.x TC' ].a Chia
Date signed
15 ao,v-1
Page 10