NC0040975_application (renewal)_20211013

EPA Identification Number
NPDES Permit Number
1•4' e 04(24. r?{
Facility Name
cola ri ci q2 arme trRF
Form Approved 03/05/19
OMB No. 2040-0004
Form
1
NPDES
:qv" EPA
U.S. Environmental Protection Agency y
Application for NPDES Permit to Discharge Wastewater
GENERAL INFORMATION
SECTION
1. ACTIVITIES REQUIRING
AN NPDES PERMIT (40 CFR 122.21(f) and (f)(1))
Activities Requiring an NPDES Permit
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
treatment works?
If yes, STOP. Do NOT complete No
Form 1. Complete Form 2A.
1 1 2
Is the facility a new or existing treatment works
treating domestic sewage?
If yes, STOP. Do NOT No
complete Form 1, Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1,2,1
Is the facility a concentrated animal feeding
operation or a concentrated aquatic animal
production facility?
Yes 4 Complete Form 1 [g. No
and Form 28.
1.2.2
Is the facility an existing manufacturing,
commercial, mining, or silvicultural facility that is
currently discharging process wastewater?
Yes 4 Complete Form Egj No
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
mining, or silvicultural facility that has not yet
commenced to discharge?
Yes 4 Complete Form 1 No
and Form 2D.
1.2.4
Is the facility a new or existing manufacturing,
commercial, mining, or silvicultural facility that
discharges only nonprocess wastewater?
Yes 4 Complete Form Ki No
1 and Form 2E.
1.2.5
Is the facility a new or existing facility
discharge is composed entirely of stormwater
associated with industrial activity or
discharge is composed of both stormwater
non-stormwater?
Yes 4 Complete Form 1
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15 .
whose
whose
0
and
No
2..NAME,
MAILING ADDRESS,AND LOCATION (40 CFR 122.21(f)(2))
.
I
Name, Mailing Address, and Location
2.1
.
Facility Name
CO LZ v-, 4 e c z EAi/T4Py L
2.2
EPA Identification Number
2.3
Facility Contact
Name (first and last)
FRi) TI-InWN
Title
0/2L
Phone number
336-27-/8i0/
Email address
-?+hh7me
he r ndvl p c_2_,h c. u s
2.4
Facility Mailing Address
Street or P.O. box
27-3 4_5 A.171-E pv.isE sr
City or town
State
ZIP code
EPA Form 3510-1 (revised 3-19)
Page 1

EPA Identification Number
NPDES Permit Number
N6.0040975
Facility Name
col erici9.R EL.Emig/41T
Form Approved 03/05/19
OMB No. 2040-0004
' .Sc
m Name, Mailing Address,
Operator Information SIC and NAILS Codes and Location Continued
2,5
N 3. SIC
3.1
Facility Location
Street, route number, or other specific identifier
«ZS N- H/q/h4)4V 72s.
County name
_RP+N DO) P/f
County c de (if known)
City or town
cderrai-...P
AND NAICS CODES (40 CFR 122.21(f)(3))
SIC Code(s)
State
NC
Description (optional)
ZIP code
273 6
3.2
NAICS Code(s)
Description (optional)
4.:OPERATOR
INFORMATION (40 CFR
122.21(f)(4))
4.1
Name of Operator
FRET) T1ON? E")
4.2
Is the name you listed in Item 4.1 also the owner?
❑ Yes L1 No
4.3
Operator Status
❑ Public —federal E. Public —state ❑ Other public (specify)
❑ Private ❑ Other (specify)
Phone Number of Operator
4.4
336.-2t /B11,
Indian m Operator Information
Land Continued
o •
4.5
Operator Address
Street or P.O. Box
P, i, Box 967
City or town
RIVASS k ft—
State
ZIP code
7-73/ 4
— _C
Email address of operator
5. INDIAN
LAND (40'CFR 122:21(0(5))
5.1
Is the facility located on Indian Land?
❑ Yes (KNo
EPA Form 3510-1 (revised 3.19)
Page 2

EPA Identification Number
N
NPDES Permit Number Facility Name
•I'•'
co)r,d'e &it,noe-
Form Approved 03/05/19
OMB No. 2040-0004
SECTION 6. EXISTING ENVIRONMENTAL PERMITS (40 CFR 122.21(f)(6))
6.1
c
E
c E
W
w
Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
• NPDES (discharges to surface
water)
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
fluids)
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
0 NESHAPs (CAA)
O Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
0 Other (specify)
SECTION 7. MAP (40 CFR 122.21(f)(7))
7,1
C.
cis
Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
�i` Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTION 8. NATURE OF BUSINESS (40 CFR 122.21(f)(8))
8.1
Nature of Business
Describe the nature of your business.
E LF MFN-71-4ra/ SGL vo L
SECTION 9: COOLING WATER INTAKE STRUCTURES (40 CFR 122.21(f)(9))
9.1
Does your facility use cooling water?
❑ Yes g No SKIP to Item 10.1,
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
SECTION 10. VARIANCE REQUESTS (40 CFR 122.21(f)(10))
10.1
Variance Requests
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
0 Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA
Section 301(c) and (g))
® Not applicable
❑ Thermal discharges (CWA Section 316(a))
EPA Form 3510-1 (revised 3-19)
Page 3

EPA Identification Number
NPDES Permit Number
-0` .
Facility Name
- d-.Q .•-,L
Form Approved 03/05119
OMB No. 2040-0004
SECTION
11. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
Checklist and Certification Statement
11.1
In Column 1 below, mark the sections of Form 1 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
a Section 1: Activities Requiring an NPDES Permit
❑ wl attachments
gi Section 2: Name, Mailing Address, and Location
❑ wl attachments
❑ Section 3: SIC Codes
❑ wf attachments
El Section 4: Operator Information
■
wf attachments
❑ Section 5: Indian Land
❑ wf attachments
❑ Section 6: Existing Environmental Permits
❑ wl attachments
Section 7: Map
❑ map pographic ❑ wl additional attachments
Section 8: Nature of Business
❑ wf attachments
❑ Section 9: Cooling Water Intake Structures
❑ wi attachments
❑ Section 10: Variance Requests
❑ wi attachments
❑ Section 11: Checklist and Certification Statement
❑ wl attachments
11.2
Certification Statement
l 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. 1 am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
F .D p Th is TFiwtEN
Official title
aQr,
Signature
Date signed
/ D-
EPA Form 3510-1 (revised 3-19)
Page 4

NC0040975 - Coleridge Elementary School
1,autucle: :35'38'45" Sub -Basin: 03-06-09
Longitude: 79°37'O1" River Basin: Cape Fear
USGS Quad: Coleridge, N.C. Hydrologic Unit: 0:30:30003
Stream ('lass: C
Receiving Stream: Deep River
Randolph County
Map not to scale