NC0087980_Renewal (Application)_20220315

yetw ZO
ROY COOPER yc l'
Governor . 'i
��J
ELIZABETH S.BISER . •n^
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
March 15, 2022
Stokes County Schools
Attn: Ricky Goins, Maintenance Dir.
PO Box 50
Danbury, NC 27016-0050
Subject: Permit Renewal
Application No. NC0087980
Pine Hall Elementary School WWTP
Stokes County
Dear Applicant:
The Water Quality Permitting Section acknowledges the March 15, 2022 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely, , 8..._
„%illin
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
wyDEQNorth Carolina Department of Environmental Quality Division of Water Resources
,}' Winston-Salem Regional Office 450 West Hanes Mill Road.Suite 300 Winston-Salem.North Carolina 27105
336 776 9800

North Carolina Modified Application Form 2A
Department of Environmental Quality Revised March 2021
Division of Water Resources
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
MAR 15 ,202
NCDEQ/DWR/NPDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
Form NC Department of Environmental Quality-Application for NPDES Permit to Discharge Wastewater
NPDES MINOR SEWAGE FACILITIES(Before completing this form,please read the instructions.Failure to follow
the instructions ma result in denial of the -yi iication.
SECTION 1.BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.21(j)(1)and(9))
1.1 Facility name
Pine Hall Elementary School WWTP
Mailing address(street or P.O.box)
P.O.Box 50
City or town State ZIP code
0 Danbury NC 27016
Contact name(first and last) Title Phone number Email address
RickyGoins Maintenance Director [phone] [e-mail]
Location address(street,route number,or other specific identifier) ❑ Same as mailing address
1400 Pine Hall Road
U-
City or town State ZIP code
Pine Hall NC 27042
1.2 Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑✓ No
requirements for new dischargers.
1.3 Is applicant different from entity listed under Item 1.1 above?
❑ Yes ❑✓ No 4 SKIP to Item 1.4.
Applicant name
Applicant address(street or P.O.box)
0
oCity or town State ZIP code
0
0
Contact name(first and last) Title Phone number Email address
n
a 1.4 Is the applicant the facility's owner,operator,or both?(Check only one response.)
❑✓ Owner ❑ Operator ❑ Both
1.5 To which entity should the NPDES permitting authority send correspondence?(Check only one response.)
❑✓ Facility El Applicant
❑ Facility and applicant
(they are one and the same)
1.6 Indicate below any existing environmental permits.(Check all that apply and print or type the corresponding permit
number for each.)
Existing Environmental Permits
a ✓❑ NPDES(discharges to surface ❑ RCRA(hazardous waste) ❑ UIC(underground injection
water) control)
E NC0087980
❑ PSD(air emissions) ❑ Nonattainment program(CAA) ❑ NESHAPs(CAA)
rn
❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section ❑ Other(specify)
404)
Page 1

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
1.7 Provide the collection system information requested below for the treatment works.
Municipality Population Collection System Type
i percentage) Ownership Status
Served Served (indicate pe ce tage)
Zoo %se arate sanitarysewer 0 Own ❑ Maintain
P
Z %combined storm and sanitary sewer 0 Own 0 Maintain
w ❑ Unknown 0 Own 0 Maintain
o %separate sanitary sewer 0 Own 0 Maintain
%combined storm and sanitary sewer 0 Own ❑ Maintain
co
_ 0 Unknown 0 Own ❑ Maintain
a %separate sanitary sewer 0 Own ❑ Maintain
c %combined storm and sanitary sewer 0 Own 0 Maintain
16 ❑ Unknown ❑ Own 0 Maintain
w %separate sanitary sewer 0 Own 0 Maintain
rn %combined storm and sanitary sewer 0 Own CI Maintain
c 0 Unknown 0 Own 0 Maintain
Total
w Population
c� Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of sewer line(in miles) no % 0/0
z' 1.8 Is the treatment works located in Indian Country?
0
o ❑ Yes 0 No
U
R 1.9 Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes ❑✓ No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
0.004 mgd
3 Annual Average Flow Rates(Actual)
.5 N
a R Two Years Ago Last Year This Year
c
Coco
_ 0.002 mgd 0.002 mgd 0.002 mgd
Maximum Daily Flow Rates(Actual)
ci Two Years Ago Last Year This Year
0.0033 mgd 0.0038 mgd 0.0032 mgd
w 1.11 Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
o Total Number of Effluent Discharge Points by Type
a. c. Constructed
P.'. 1- Treated Effluent Untreated Effluent Combined Sewer Bypasses Emergency
co. Overflows Overflows
V
N_
0 001
I
Page 2

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
Outfalls Other Than to Waters of the State of North Caroms
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 ❑✓ No 9 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume Continuous or Intermittent
Location Discharged to Surface
Impoundment (check one)
❑ Continuous
gpd 0 Intermittent
❑ Continuous
gpd ❑ Intermittent
0 Continuous
gpd ❑ Intermittent
s 1.14 Is wastewater applied to land?
❑ Yes ❑✓ No 4 SKIP to Item 1.16.
0 1.15 Provide the land application site and discharge data requested below.
0. Land Application Site and Discharge Data
N
o Continuous or
Location Size Average Daily Volume Intermittent
En Applied (check one)
N acresgpd 0 Continuous
0 Intermittent
El Continuous
s acres gpd 0 Intermittent
0
= acres d ❑ Continuous
gp ❑ Intermittent
- 1.16 Is effluent transported f i i f r
p ed to ac I ty o treatment prior to discharge?
o ❑ Yes m No 4 SKIP to Item 1.21.
1.17 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 El No 4 SKIP to Item 1.20.
1.19 Provide information on the transporter below.
Transporter Data
Entity name Mailing address(street or P.O.box)
City or town State ZIP code
Contact name(first and last) Title
Phone number Email address
Page 3

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
1.20 In the table below, indicate the name,address,contact information, NPDES number,and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name Mailing address(street or P.O.box)
Pine Hall Elementary School P.O.Box 50
City or town State ZIP code
O Danbury NC 27016
Contact name(first and last) Title
O Ricky Goins Maintenance
Phone number Email address
[phone] [e-mail]
O NPDES number of receiving facility(if any) 0 None Average dailyflow rate o.002 mgd
0_ 9 9
to
O 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
O not have outlets to waters of the State of North Carolina(e.g.,underground percolation,underground injection)?
rn
c ❑ Yes ❑✓ No 4 SKIP to Item 1.23.
O 1.22 Provide information in the table below on these other disposal methods.
d Information on Other Disposal Methods
o Disposal Location of Size of Annual Average Continuous or Intermittent
Method Daily Discharge
Description Disposal Site Disposal Site Volume (check one)
❑ Continuous
acres gpd 0 Intermittent
o 0 Continuous
acres gpd ❑ Intermittent
acres gpd ❑ Continuous
0 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.
d w 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
u Section 301(h)) 302(b)(2))
❑✓ 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 ❑✓ No+SKIP 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
0
Contractor name
(company name)
o Mailing address
(street or P.O.box)
City,state,and ZIP
code
Contact name(first and
ci last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
SECTION 2.ADDITIONAL INFORMATION(40 CFR 122.21(j)(1)and(2))
o Outfalls to Waters of the State of North Carolina
2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes ElNo 4 SKIP to Section 3.
= 2.2 Provide the treatment works'current average daily volume of inflow Average Daily Volume of Inflow and Infiltration
0
'73 and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
_
0
c
2.3 Have you attached a topographic map to this application that contains all the required information?(See instructions for
a specific requirements.)
2
❑ Yes ❑ No
2.4 Haveyou attached a process flow diagram or schematic to this application that contains all the required information?
E 9 PP q
3
See instructions fors ecific requirements.)
o to
P q )
as
o ❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
= Briefly list and describe the scheduled improvements.
0
is 1.
c
m
E
Q 2.
E
0
3.
n 4.
2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Affected Attainment of
Scheduled Begin End Begin
> Outfalls Operational
o Improvement Construction Construction Discharge
rz (list outfall Level
(from above) number) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY)
1.
v
2.
3.
•
4.
2.7 Have appropriate permits/clearances concerning other federal/state requirements been obtained?Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
SECTION 3.INFORMATION ON EFFLUENT DISCHARGES(40 CFR 122.21(j)(3)to(5))
3.1 Provide the following information for each outfall.(Attach additional sheets if you have more than three outfalls.)
Outfall Number Doi Outfall Number Outfall Number
State North Carolina
County Stokes
O City or town Pine Hall
0
s Distance from shore 16 ft. ft. ft.
.Q
Depth below surface 5 ft. ft. ft.
Average daily flow rate 0.0010 mgd mgd mgd
Latitude 36 19' 59 N
Longitude 80° 2' 55" W °
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o ❑ Yes ✓❑ No+ SKIP to Item 3.4.
3.3 If so,provide the following information for each applicable outfall.
Outfall Number Outfall Number Outfall Number
0
Number of times per year
O discharge occurs
a Average duration of each
discharge(specify units)
o Average flow of each mgd mgd mgd
u, discharge
Months in which discharge
occurs
3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑✓ No+SKIP to Item 3.6.
3.5 Briefly describe the diffuser type at each applicable outfall.
O.
Outfall Number Outfall Number Outfall Number
d
5
c vi 3.6 Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
w ❑ Yes ❑✓ No+SKIP to Section 6.
Page 6

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
3.7 Provide the receiving water and related information(if known)for each outfall.
Outfall Number Outfall Number Outfall Number
Receiving water name
Name of watershed,river,
0 or stream system
U.S.Soil Conservation
Service 14-digit watershed
rj code
15
Name of state
management/river basin
U.S.Geological Survey
8-digit hydrologic
cc cataloging unit code
Critical low flow(acute) cfs cfs cfs
Critical low flow(chronic) cfs cfs cfs
Total hardness at critical mg/L of mg/L of mg/L of
low flow CaCO3 CaCO3 CaCO3
3.8 Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number Outfall Number Outfall Number
Highest Level of ❑ Primary ❑ Primary 0 Primary
Treatment(check all that 0 Equivalent to ❑ Equivalent to ❑ Equivalent to
apply per outfall) secondary secondary secondary
❑ Secondary 0 Secondary 0 Secondary
• ❑ Advanced ❑ Advanced 0 Advanced
❑ Other(specify) El Other(specify) 0 Other(specify)
0
0
0. Design Removal Rates by
Outfall
y
d
BOD5 or CBOD5
E
TSS 0/0
❑Not applicable ❑Not applicable 0 Not applicable
Phosphorus
❑Not applicable 0 Not applicable 0 Not applicable
Nitrogen
Other(specify) El Not applicable ❑Not applicable 0 Not applicable
Page 7

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
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.
y
0
c
c
0
v
Outfall Number Outfall Number Outfall Number
0
.2- Disinfection type
N
Seasons used
Dechlorination used? ❑ Not applicable ❑ Not applicable ❑ Not applicable
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package?
❑ Yes ❑ No
3.11 Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑ Yes ❑ No 4 SKIP to 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
a) Number of tests of discharge
_ water
n.
Number of tests of receiving
• water
w
3.14 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?
❑ Yes 4 Complete Table B,including chlorine. ❑ No 4 Complete Table B,omitting chlorine.
3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
❑ Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18 attached the results to this application package?
❑ Yes ❑ No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
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?
El 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 ❑ 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 Summary of Results
(MM/DD/YYYY)
0)
d
C
c
0
co 3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
o toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23 Describe the cause(s)of the toxicity:
E'
3.24 Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25 Provide details of any toxicity reduction evaluations conducted.
3.26 Have you completed Table E for all applicable outfalls and attached the results to the application package?
El Yes ❑ Not applicable because previously submitted
information to the NPDES 'ermittin. authori .
Page 9

NPDES Permit Number Facility Name Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
SECTION 6.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
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 ❑ wl variance request(s) ❑ w/additional attachments
❑ Section 2:Additional 0 wl topographic map ❑ w/process flow diagram
Information ❑ wl additional attachments
❑ wl Table A ❑ wl Table D
❑ Section 3:Information on ❑ w/Table B ❑ wl additional attachments
Effluent Discharges
m
❑ w/Table C
is
Section 4:Not Applicable
0
Section 5:Not Applicable
-o Section 6:Checklist and
❑ Certification Statement ❑ wl attachments
N
Y 6.2 Certification Statement
1 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.lam 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) Official thief):r e.J) ,
LAH G C� 1 n S MA..4nTex+Ah ca d rac.. .4.as
Signature Date signed
Page 10

NPDES Permit Number Facility Name Duffel!Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School 001 Modified March 2021
TABLE A.EFFLUENT PARAMETERS FOR ALL POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Methods include units
Value Units Value Units Samples Methods (
)
Biochemical oxygen demand
0 BODs or o CBOD5 15.5 mg/L <2 mg/L 52 ❑ML
❑MDL
(report one)
Fecal coliform 2 MPN/100m1 1 MPN/100m1 52 ❑ML
❑MDL
Design flow rate 0.009 MGD 0.0019 MGD N/A
pH(minimum) 6 Std.Units
pH(maximum) 6.9 Std.Units
Temperature(winter) 18 °C 11.76 °C 65
Temperature(summer) 26 °C 20.46 °C 45 - - -
0 ML
Total suspended solids(TSS) 6.1 mg/L <5 mg/L 52 ❑MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
Page 11

EPA Idenfification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE B. EFFLUENT PARAMETERS FOR ALL POTWS WITH A FLOW EQUAL TO OR GREATER THAN 0.1 MGD
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Methods Include units
Value Units Value Units Samples ( )
❑ML
Ammonia(as N) ❑MDL
Chlorine ❑ML
(total residual.TRC)2 ❑MDL
ML
Dissolved oxygen ❑MDL
Nitrate/nitrite ❑ML
❑MDL
0 ML
Kjeldahl nitrogen ❑MDL
0 ML
Oil and grease ❑MDL
❑ML
Phosphorus ❑MDL
Total dissolved solids ❑ML
❑MDL
' Sampling shall be conducted according to sufficiently sensitive test procedures(i.e., methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I.subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection,do not use chlorine elsewhere in the treatment process,and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A(Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE C.EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method' (include units)
Value Units Value Units Samples
Metals,Cyanide,and Total Phenols
❑ML
Hardness(as CaCO3) ❑MDL
0 ML
Antimony,total recoverable ❑MDL
Arsenic,total recoverable ❑ML
❑MDL
ML
Beryllium,total recoverable ❑MDL
Cadmium,total recoverable ❑ML
❑MDL
Chromium.total recoverable ❑ML
❑MDL
0 ML
Copper,total recoverable ❑MDL
Lead,total recoverable ❑ML
❑MDL
ML
Mercury,total recoverable ❑MDL
Nickel,total recoverable ❑ML
❑MDL
Selenium,total recoverable ❑ML
❑MDL
Silver,total recoverable ❑ML
❑MDL
Thallium,total recoverable ❑ML
❑MDL
Zinc,total recoverable ❑ML
❑MDL
❑ML
Cyanide ❑MDL
0 ML
Total phenolic compounds ❑MDL
Volatile Organic Compounds
Acrolein ❑ML
❑MDL
❑ML
Acrylonitrile ❑MDL
Benzene ❑ML
❑MDL
Bromoform ❑ML
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method1 (include units)
Value Units Value Units Samples
❑ML
Carbon tetrachloride
❑MDL
Chlorobenzene ❑ML
❑MDL
Chlorodibromomethane ❑ML
❑MDL
Chloroethane 0 ML
❑MDL
0 ML
2-chloroethylvinyl ether ❑MDL
Chloroform ❑ML
❑MDL
❑ML
Dichlorobromomethane
❑MDL
❑ML
1,1-dichloroethane
❑MDL
1,2-dichloroethane ❑ML
❑MDL
171 ML
trans-1,2-dichloroethylene ❑MDL
CI ML
1,1-dichloroethylene ❑MDL
0 ML
1,2-dichloropropane ❑MDL
0 ML
1,3-dichloropropylene ❑MDL
O ML
Ethylbenzene ❑MDL
0 ML
Methyl bromide ❑MDL
0 ML
Methyl chloride ❑MDL
0 ML
Methylene chloride ❑MDL
1,1,2,2-tetrachloroethane ❑ML
❑MDL
0 ML
Tetrachloroethylene ❑MDL
Toluene ❑ML
❑MDL
1,1,1-trichloroethane ❑ML
❑MDL
1,1,2-trichloroethane ❑ML
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant
Value Units Value Units Number of Methods (include units)
Samples
Trichloroethylene ❑ML
❑MDL
❑ML
Vinyl chloride ❑MDL
Acid-Extractable Compounds
p-chloro-m-cresol ❑ML
❑MDL
❑ML
2-chlorophenol ❑MDL
2,4-dichlorophenol ❑ML
❑MDL
2,4-dimethylphenol ❑ML
❑MDL
4,6-dinitro-o-cresol ❑ML
❑MDL
2,4-dinitrophenol ❑ML
❑MDL
2-nitrophenol ❑ML
❑MDL
❑ML
4-nitrophenol ❑MDL
Pentachlorophenol ❑ML
❑MDL
Phenol ❑ML
❑MDL
2,4,6-trichlorophenol ❑ML
❑MDL
Base-Neutral Compounds
Acenaphthene o ML
❑MDL
Acenaphthylene ❑ML
❑MDL
Anthracene ❑ML
❑MDL
Benzidine ❑ML
❑MDL
Benzo(a)anthracene ❑ML
❑MDL
Benzo(a)pyrene ❑ML
❑MDL
3,4-benzofluoranthene ❑ML
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
Modified March 2021
NC0087980 Pine Hall Elementary School
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method' (include units)
Value Units Value Units Samples
o ML
Benzo(ghi)perylene ❑MDL
CI ML
Benzo(k)fluoranthene ❑MDL
CI ML
Bis(2-chloroethoxy)methane ❑MDL
CI ML
Bis(2-chloroethyl)ether ❑MDL
0 ML
Bis(2-chloroisopropyl)ether ❑MDL
CI ML
Bis(2-ethylhexyl)phthalate ❑MDL
0 ML
4-bromophenyl phenyl ether ❑MDL
CI ML
Butyl benzyl phthalate Cl MDL
0 ML
2-chloronaphthalene ❑MDL
LI ML
4-chlorophenyl phenyl ether ❑MDL
❑ML
Chrysene ❑MDL
0 ML
di-n-butyl phthalate 0 MDL
CI ML
di-n-octyl phthalate ❑MDL
Dibenzo(a,h)anthracene ❑MDL
1,2-dichlorobenzene CI ML
❑MDL
1,3-dichlorobenzene ❑ML
❑MDL
1,4-dichlorobenzene CI ML
❑MDL
3,3-dichlorobenzidine ❑ML
❑MDL
CI ML
Diethyl phthalate ❑MDL
0 ML
Dimethyl phthalate ❑MDL
2,4-dinitrotoluene ❑ML
❑MDL
2,6-dinitrotoluene ❑ML
❑MDL
EPA Form 3510-2A(Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant
Value Units Value Units Number of Method1 (include units)
Samples
1,2-diphenylhydrazine ❑ML
❑MDL
Fluoranthene CI ML
❑MDL
Fluorene ❑ML
❑MDL
Hexachlorobenzene CI ML
❑MDL
Hexachlorobutadiene CI ML
❑MDL
Hexachlorocyclo-pentadiene ❑ML
❑MDL
Hexachloroethane ❑ML
❑MDL _
Indeno(1,2,3-cd)pyrene ❑ML
❑MDL
Isophorone ❑ML
❑MDL
Naphthalene ❑ML
❑MDL
Nitrobenzene CI ML
❑MDL _
N-nitrosodi-n-propylamine CI ML
❑MDL
N-nitrosodimethylamine ❑ML
❑MDL
N-nitrosodiphenylamine CI ML
❑MDL
Phenanthrene CI ML
❑MDL
Pyrene CI ML
❑MDL
1,2,4-trichlorobenzene CI ML
❑MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A(Revised 3-19) Page 17

NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NC0087980 Pine Hall Elementary School Modified March 2021
TABLE D.ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING AUTHORITY
Pollutant Maximum Daily Discharge Average Daily Dischar e Analytical ML or MDL
gist) Value Units Value Units Number of Method', (include units)
Samples
❑ No additional sampling is required by NPDES permitting authority.
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
0 ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
0 MDL
0 ML
❑MDL
❑ML
❑MDL
❑ML
0 MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required
under 40 CFR chapter I,subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18

Sludge Management Plan
Pine Hall Elementary School
NPDES Permit No. NC 0087980
Sludge from the Pine Hall Elementary School wastewater treatment plant are disposed of in the
following manner:
Solids accumulate in the septic and recirculation tanks. The tanks are pumped annually by
Green Way Solutions Group, a licensed septic pumper from Concord, NC and solids are
disposed of at the City of Winston-Salem Wastewater Treatment Plant.

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