NC0007323_Renewal (Application)_20230622 (3)

DocuSign Envelope ID: 287131318B-C485-4440-8C65-AFD2579DA1 EA
I,, Shaoin Communities Together
meJ ill
June 21, 2023
John Hennessy
NC DEQ — DWR — NPDES Unit
Archdale Building, 9th Floor
512 North Salisbury Street
Raleigh, NC 27604
RE: NPDES Permit Renewal Application, NCO07323
Town of Yanceyville
Caswell County, North Carolina
Dear Mr. Hennessy:
RECEIVED
JUN 2 2 2023
NCDEQ/DWR/NPDES
Please find enclosed for your review Application Form 1 and Form 2C for the NPDES Permit
Renewal for the Town of Yanceyville Water Treatment Plant, NPDES Permit Number NC007323.
If you have any questions during your review or require further information regarding this project,
please do not hesitate to give me a call at 910-295-3159.
Sincerely,
McGILL ASSOCIATES, P.A.
DocuSigned Eby:
,�e�.c.s
F9899377028444D_.
MATTHEW R JONES, P.E.
Project Manager
Enclosures
cc: Kamara Barnett, Town Manager
22.01103/JH.NPDES.20230621.doc
MCGILL ASSOCIATES �_ _ ��� ��_ . '?,_�I_F �'�`� _ - �- �,3�1 / �� 1�� ?��� ?'� / ^;1C- -ASS �',

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110006710960
NC0007323
Town of Yanceyville WTP
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
SOEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete No
If yes, STOP. Do NOT ✓0 No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
oYes
4 Complete Form 1 No
Yes 4 Complete Form No
a
and Form 26.
1 and Form 2C.
z
@
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
Yes 4 Complete Form 1 ❑✓ No
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 ❑✓ No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15 .
SECTIONDD-
• • r
21
Facilit Name
Town of Yanceyville WTP
0
2.2
EPA Identification Number
U
O
J
110006710960
Ca
2.3
Facility Contact
Name (first and last)
Title
Phone number
v
Kamara Barnett
Town Manager
[phone]
Q
Email address
c
[e-mail]
6
2.4
Facility Mailing Address
CU
E
Street or P.O. box
z
1282 Main Street West
City or town
State
ZIP code
Yanceyville
NC
27379
EPA Form 3510-1 (revised 3-19) Page 1

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110006710960
NC0007323
Town of Yanceyville WTP
OMB No. 2040-0004
'60
2.5
Facility Location
a .
Street, route number, or other specific identifier
Q 0
1282 Main Street West
cm0
0
County name
County code (if known)
Caswell
0
E
City or town
State ZIP code
z 0
Yanceyville
NC 27379
SECTION•D
1
3.1
SIC Code(s)
Description (optional)
4941
N
d
O
U
N
U
z
3.2
NAICS Code(s)
Description (optional)
a
c
U
221310
co
4.1
Name of Operator
Inframark
0
4.2
Is the name you listed in Item 4.1 also the owner?
0
❑ Yes ❑✓ No
7Z
4.3
Operator Status
O
❑ Public —federal ❑ Public —state ❑ Other public (specify)
p
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
R
E
220 Gibralter Rd, Ste 200
= r
City or town
State
ZIP code
o v
cc
Horsham
PA
19044
Q
Email address of operator
O
[e-mail]
SECTION1
c
5.1
Is the facility located on Indian Land?
J
❑ Yes ❑✓ No
EPA Form 3510-1 (revised 3-19) Page 2

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
SECTION'•
6.1 Existing Environmental Permits (check
1
all that apply and print or type the corresponding permit number for each)
R
❑ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
a
water)
fluids)
w
NC0007323
w a
rn
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
x
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
SECTION1
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
C
specific requirements.)
❑✓ Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
1
Describe the nature of your business.
8.1
Municipal Water treatment and distribution
w
w
m
c
.N
m
0
d
a
z
SECTION••
1
9.1 Does your facility use cooling water?
d
❑ Yes ❑✓ No 4 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
a, w�
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.)
6 4'
O Y
�
U c
ECTION
10. VARIANCE
REQUESTS1 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
10.1
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
N
when.)
d
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
110006710960
NC0007323
Town of Yanceyville WTP OMB No. 2040-0004
SECTION•
1
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
❑✓ Section 1: Activities Requiring an NPDES Permit
❑ w/ attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑✓ Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
❑✓ Section 6: Existing Environmental Permits
❑ w/ attachments
E
w;
❑✓ Section 7: Map
w/ topographic
❑✓ Elw/ additional attachments
map
w.
Cn
o
❑✓ Section 8: Nature of Business
Elw/ attachments
Y
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
�'
❑✓ Section 10: Variance Requests
❑ w/ attachments
c
N
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
a
11.2
Certification Statement
U
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 knowing violations.
Name (print or type first and last name)
Official title
Kamara Barnett
Town Manager/Clerk
Signature
Date signed
DocuSigned by:
Ara b_,_ ll
t
6/21/2023
D6480B9A0960420...
EPA Form 3510-1 (revised 3-19) Page 4

1-MILE RADIUS FROM TOWN
OF YANCEYVILLE WTP
n
PLAN
2000 0 1000 2000 4000
GRAPHIC SCALE DIVISION VALUE = 2000 FEET
of
T
J
t
— y
1
vy Yanceyville
N.
4\
l'
OUTFALL
001
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TOWN OF Y
YANCEYVILLE — -
WATER _
TREATMENT
.,PLANT
z,
TOWN OF YANCEYVILLE
WTP
Receiving Stream:
Fullers Creek
Drainage Basin:
Roanoke River
Stream Class:
C
Latitude:
36' 23' 29" N
Longitude:
79' 20' 57" W
Sub —Basin:
03-02-04
DATE
WATER TREATMENT PLANT
FIGURE
June 2023
NPDES PERMIT RENEWAL
WATER TREATMENT
mcgill
1240 19th street Lane Nw
Hickory NC28601
se
NC Firm Licen• C-0459
PROJECT #328.328.2024 22.0,103
TOWN
F YANCEYVILLE
PLANT TOPOGRAPHIC
MAP
mcgi0assocla1es.tmrn
PROJECT MANAGER
J. WHITFORD
CASWELL COUNTY, NORTH CAROLINA

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C \Aw EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATION1
1.1 Provide information on each of the facility's outfalls in the table below.
o Outfall
Number Receiving Water Name Latitude Longitude
U
0 001 Fullers Creek 36' 24' 56" N 79' 21' 3.3" W
J
ca
3
0
SECTIONDRAWING
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
3 balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J �
o ❑✓ Yes ❑ No
SECTION•
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number** 001
Operations
Operation Average Flow
Filter backwash 0.0284 mgd
c
E mgd
co
mgd
co mgd
0 Treatment Units
w
m Description Code from Final Disposal of Solid or
(include size, flow rate through each treatment unit, Table 2C 1 Liquid Wastes Other Than
a retention time, etc.) by Discharge
Dual Settlement Lagoon 5-T
10MIX91=40]
JUN `G 2 2023
NC®EQ/DWR/NPDES
EPA Form 3510-2C (Revised 3-19) Page 1

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110006710960
NC0007323
Town of Yanceyville WTP
OMB No. 2040-0004
3.1
**Outfall Number**
Cont.
Operations,
Operation
Average Flow
mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Discharge
a�
Y
/0
V
Wi
_
Cd
C
W
L
**Outfall Number**
cc
o
Operations Contributing to Flow
Operation Average Flow
U-
mgd
d
Q
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Discharge
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d
❑ Yes ❑✓ No -+ SKIP to Section 4.
co �
3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑✓ No
EPA Form 3510-2C (Revised 3-19) Page 2

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
SECTION• 1
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑ Yes ❑✓ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outtall.
Attach additional pages, if necessar .
Freq
uency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
Months/Year
Average
Dail
dayslweek
months/year
mgd
mgd
days
fn
o
dayslweek
months/year
mgd
mgd
days
LL
days/week
months/year
mgd
mgd
days
w
E
days/week
months/year
mgd
mgd
days
a�
days/week
months/year
mgd
mgd
days
c
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
dayslweek monthslyear mgd mgd days
SECTION"•I
• 1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
5.1
❑ Yes ❑✓ No 4 SKIP to Section 6.
5.2
Provide the following information on applicable ELGs.
ELG Category
Ell Subcate o
Regulatory Citation
w
m
R
U
a
n
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
❑ Yes ❑✓ No 4 SKIP to Section 6.
0
w
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
'0
Outfall
Number
Operation, Product, or Material
Quantity per Day
Unit of
Measure
d
N
m
C
O
w
U
7
O
a
EPA Form 3510-2C (Revised 3-19) Page 3

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
SECTION. IMPROVEMENTS (40
6.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑✓ No 4 SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
Required
Projected
o
Project
(list outfall
Discharge
a.
number
E
N
d
R
CL
n.
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑✓ No ❑ Not applicable
SECTION
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑ Yes ❑✓ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
y
requested and attached the results to this application package?
❑✓ Yes ❑ No; a waiver has been requested from my NPDES
R
permitting authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
c
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
Y
❑ Yes ✓❑ No 4 SKIP to Item 7.8.
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
LU
w
El Yes ❑ No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Primary Industry Category
Required GC/MS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110006710960
NC0007323
Town of Yanceyville WTP
OMB No. 2040-0004
7.7
Have you checked `Testing Required" for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑ No
7.8
Have you checked "Believed Present" or "Believed Absent' for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑✓ Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are "Believed Present' in your discharge?
✓❑ Yes ❑ No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
then SKIP to Item 7.12.
=
7.11
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
o
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
N
pollutants you have indicated are "Believed Present' in your discharge?
✓❑ Yes ❑ No
w
Table C. Certain Conventional and Non -Conventional Pollutants
7.12
Have you indicated whether pollutants are "Believed Present' or 'Believed Absent' for all pollutants listed on Table C
for all outfalls?
❑✓ Yes ❑ No
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
'Believed Present'?
d
❑✓ Yes ❑ No
W
Table D. Certain Hazardous Substances and Asbestos
7.14
Have you indicated whether pollutants are "Believed Present' or "Believed Absent' for all pollutants listed in Table D for
all outfalls?
❑✓ Yes ❑ No
7.15
Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
❑✓ Yes ❑ No
Table E. 2,3,7,8-Tetrachlorodibenzo• -Dioxin 2,3,7,8•TCDD
7.16
Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑ No
SECTIONOR
MANUFACTURED TOXICSi
8.1
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
w
U
❑ Yes ❑✓ No 4 SKIP to Section 9.
3
8.2
List the pollutants below.
0
1. 4. 7.
0
fq
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
SECTION' BIOLOGICAL TOXICITY1
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
( ❑ Yes ❑✓ No 4 SKIP to Section 10.
9.2
Identify the tests and their
Durposes below.
w
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
X
Permitting Authority?
O
75-
❑ Yes ❑ No
U
O
O
co
❑ Yes ❑ No
❑ Yes ❑ No
SECTION•
10.1
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑ Yes 0 No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratoryffirm
0
cn d
Laboratory address
C
a
U
R
w
_
0
Phone number
Pollutant(s) analyzed
SECTIONADDITIONAL
INFORMATION
11.1
Has the NPDES permitting authority requested additional information?
_
❑ Yes ❑✓ No 4 SKIP to Section 12.
0
11.2
List the information requested and attach it to this application.
0
1. 4.
_
O
a
2. 5.
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
110006710960
Town of Yanceyville WTP OMB No. 2040-0004
SECTION•
CERTIFICATION STATEMENT (40
12.1
In Column 1 below, mark the sections of Form 2C 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 com lete all sections or provide attachments.
Column 1
Column 2
✓❑ Section 1: Outfall Location
❑ w/ attachments
❑✓ Section 2: Line Drawing
✓❑ w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
❑✓
w/ list of each user of
❑ w/ attachments ❑ privately owned treatment
Treatment
works
❑✓ Section 4: Intermittent Flows
❑ w/ attachments
❑✓ Section 5: Production
❑ w/ attachments
w/ optional additional
❑✓ Section 6: Improvements
❑ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ w/ request for a waiver and ❑ w/ explanation for identical
supporting information outfalls
w/ small business exemption w/ other attachments
El ❑
d
request
N
❑ Section 7: Effluent and Intake
❑✓ w/ Table A ❑✓ w/ Table B
r-
Characteristics
❑✓ w/ Table C ❑✓ w/ Table D
:c
d
❑✓ w/ Table E ❑ w/ analytical results as an
c�
attachment
❑ Section 8: Used or Manufactured
❑ wl attachments
N
Toxics
.79
❑ Section 9: Biological Toxicity
❑ w/ attachments
Tests
U
❑✓ Section 10: Contract Analyses
❑ w/ attachments
❑✓ Section 11: Additional Information
❑ w/ attachments
✓❑ Section 12: Checklist and
❑ w/ attachments
Certification Statement
12.2
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. 1 am aware that there are significant penalties for submitting false information, including the
possibility of tine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Kamara Barnett
Town Manager/Clerk
Signature
Date signed
DocuSigned by:
I A,a banuff
6/21/2023
EPA Form 3510-2C (Revised 3-19) Page 7

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110006710960 Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
TABLE A. CONVENTIONAL AND NON•
• •• I
Effluent
Intake
Waiver
Units
o tional
Maximum
Maximum
Long -Term
Pollutant
Requested
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1
Biochemical oxygen demand
❑
Concentration
Mass
(BOD5)
2.
Chemical oxygen demand
El
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑
Mass
Concentration
mg/I
45.0
30
4.
Total suspended solids (TSS)
El
Mass
Concentration
5.
Ammonia (as N)
❑
Mass
6.
Flow
❑
Rate
Temperature (winter)
❑
°C
°C
7.
Temperature (summer)
❑
°C
°C
pH (minimum)
❑
Standard units
s.u.
6
8.
pH (maximum)
❑
Standard units
s.u.
9
I 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 3510-2C (Revised 3-19) Page 9

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110006710960 Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
• I
•
• 1 •'
• •• 1
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
f available
Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
❑
❑
✓❑
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
El
El
IZI
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
El
El
IZI
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
Concentration
Mass
(7440-47-3)
1.6
Copper, total
Concentration
Mass
(7440-50-8)
1.7
Lead total
El
El
IZI
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
Concentration
Mass
(7439-97-6)
1'9
Nickel, total
El
11
El
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
El
Concentration
Mass
(7782-49-2)
1.11
Silver, total
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name
Outtall Number Form Approved 03/05/19
110006710960 Town of Yanceyville WTP
OMB No. 2040-0004
TABLE•XIC METALS, CYANIDE, TOTAL PHENOLS,ORGANIC TOXIC'• 1
Presence or Absence
Intake
check one
Effluent (optional)
Pollutant/Parameter Testing Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available) Required Believed Believed (specify)
Daily
Monthly
Average
Number
Term
Number
Present Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
f available
1.12
Thallium, total
El
El
0
Concentration
Mass
(7440-28-0)
1.13
Zinc total
El
El
El
Concentration
ug/I
0.06
0.048
3
Mass
(7440-66-6)
1.14
Cyanide, total
❑
Concentration
ug/I
0.013
0.013
1
Mass
(57-12-5)
1.15
Phenols, total
❑
❑
❑✓
Concentration
Mass
Section 2.Organic Toxic Pollutants (GCIMS Fraction
—Volatile Compounds)
2.1
Acrolein
✓
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
❑
❑
✓❑
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
❑
0
Concentration
Mass
(71-43-2)
2.4
Bromoform
❑
❑
❑✓
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
❑
❑
❑
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
❑
❑
❑✓
Concentration
_
Mass
(124-48-1)
2.8
Chloroethane
❑
❑
0
Concentration
Mass
(75-00-3)
EPA Form 3510-2C (Revised 3-19) Page 12

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name I Outfall Number
110006710960 Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
cifavailabe)
Daily
of
Average
of
( q )
(
Discharge
Analyses
Analyses
if available
2.9
2-chloroethylvinyl ether
1:1
El
0
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
0
Concentration
Mass
2.11
Dichlorobromomethane
El
El
F21
Concentration
Mass
(75-27-4)
212
1, 1 -dichloroethane
✓
Concentration
Mass
(75-34-3)
2.13
12-dichloroethane
✓
Concentration
Mass
(107-06-2)
2.14
11-dichloroethylene
1:1
El
Q
Concentration
Mass
(75-35-4)
2.15
12-dichloropropane
El
El
✓
Concentration
Mass
(78-87-5)
2.16
1 3-dichloropropylene
El
IZI
Concentration
Mass
(542-75-6)
2.17
Ethylbenzene
1:1
El
✓
Concentration
Mass
(100-41-4)
218
Methyl bromide
0
Concentration
Mass
(74-83-9)
2.19
Methyl chloride
El
El
✓
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
El
0
Concentration
Mass
(75-09-2)
2.21
1 1,2 2- tetrachloroethane
El
Concentration
(79 34 5)
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
• •
Pollutant/Parameter
and CAS Number, if available
( )
•
Testing
Required
q
• • •-
Presence or Absence
check one
• •• 1 101
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
❑
Concentration
Mass
224
1,2-trans-dichloroethylene
(156-60-5)
El
El
a
Concentration
Mass
2.25
1 1,1-trichloroethane
(71-55-6)
Concentration
Mass
2.26
1,1,2-trichloroethane
(79-00-5)
El
❑
❑
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
El
❑
❑
Concentration
Mass
Section 3.Organic Toxic Pollutants (GCIMS Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
❑
El
❑✓
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
❑
❑
✓❑
Concentration
Mass
3.3
2,4-dimethylphenol
(105-67-9)
1:1❑
❑
Concentration
Mass
3.4
4 6-dinitro-o-cresol
(534-52-1)
El
El
IZI
Concentration
Mass
512
-dinitrophenol
-28-5)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
3.6
2-nitrophenol
❑
o
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
❑
El
❑
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
El
❑
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
Concentration
Mass
(87-86-5)
3.10
Phenol
11
❑
ID
Concentration
Mass
(108-95-2)
3.11
2 4,6-trichlorophenol
❑
El
❑
Concentration
Mass
(88-05-2)
Section 4.Organic Toxic Pollutants (GCIMS Fraction
—Base /Neutral
Compounds)
4.1
Acenaphthene
❑
❑✓
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
❑
✓❑
Concentration
Mass
(208-96-8)
4.3
Anthracene
❑
❑
✓❑
Concentration
Mass
(120-12-7)
4.4
Benzidine
❑
✓0
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
0
❑
IZI
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number I Facility Name
Town of Yanceyville WTP
Number
Form Approved 03/05/19
OMB No. 2040-M
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
g
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4 7
3 4-benzofluoranthene
(205-99-2)
El
R1
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
❑
❑
❑✓
Concentration
Mass
4'9
Benzo (k) fluoranthene
(207-08-9)
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
Ej
El
O
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
El
IZI
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
El
11
0
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
El
a
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
El
El
0
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
1:1
El
0
Concentration
Mass
4.18
_
Chrysene
(218-01-9)
Concentration
Mass
4.19
Dibenzo (a,h) anthracene
(53-70-3)
a
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available
(and
Required
q
Believed
Believed
(p y)
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
f available
4.20
1,2-dichlorobenzene
❑
❑
✓❑
Concentration
Mass
(95-50-1)
4.21
1,3-dichlorobenzene
El
El✓❑
Concentration
Mass
(541-73-1)
4.22
1 4-dichlorobenzene
❑
❑
✓❑
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
❑
✓❑
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
✓❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
11
✓❑
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
©
Concentration
Mass
(84-74-2)
4.27
2 4-dinitrotoluene
❑
11
✓❑
Concentration
Mass
(121-14-2)
4.28
2 6-dinitrotoluene
❑
11
❑✓
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
❑
❑✓
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
❑
❑✓
Concentration
Mass
(206-44-0) ,
4.32
Fluorene
❑
❑
✓❑
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
Facility Name I Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
g
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
El
❑
❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
El
❑
✓I
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
El
11
❑✓
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
Concentration
Mass
4.39
Naphthalene
(91-20-3)
El
❑
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
❑
❑
✓I
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
❑
❑
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
❑
11
❑�
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
❑
❑
Concentration
Mass
45
L 45Pyrene
(129-00-0)
El
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110006710960 Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
12
012
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
14.46
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Analyses
if available)Value
1,24-trichlorobenzene
Concentration
Mass
(120-82-1)
Section 5.Organic Toxic Pollutants (GC/MS Fraction
—Pesticides)
5.1
Aldrin
❑
❑
❑✓
Concentration
Mass
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
R-BHC
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
IZI
Concentration
Mass
(58-89-9)
5.5
b-BHC
Concentration
Mass
(319-86-8)
5.6
Chlordane
Concentration
Mass
(57-74-9)
5.7
4 4'-DDT
El
El
0
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
Concentration
Mass
(72-55-9)
5 9
4,4'-DDD
El
IZI
Concentration
Mass
(72-54-8)
5.10
Dieldrin
Concentration
Mass
(60-57-1)
5.11
o-endosulfan
El
El
IZI
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name
Town of Yanceyville WTP
Number
Form Approved 03/05/19
OMB No. 2040-0004
•
Pollutant/Parameter
(and CAS Number, if available)
•
Testing
Required
• 1 • '
Presence or Absence
check one
• ' •111IF1101111141111 I
Units
(spec) )
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
m
LDisch:arge
Number
°f
Analyses
Long-
Term
Average
Value
Number
°
Analyses
5.12
(i-endosulfan
(115-29-7)
ID
El
0
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
Q
Concentration
Mass
5.14
Endrin
(72-20-8)
El
121
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
✓❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
✓❑
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
✓0
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
✓❑
Concentration
Mass
Concentration
5.23
PCB-1260
(11096-82-5)
Mass
5.24
PCB-1016
(12674-11-2)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name I Outfall Number
11000671/ Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
�: • •111011ul
No 1:1
" I$]•m acul
g 1110421
• •• 1
Intake
Presence or Absence
check one
Effluent
(optional)
PollutantlParameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
Toxaphene
5.25
Concentration
Mass
(g001-35-2)
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 3510-2C (Revised 3-19) Page 21

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110006710960 Town of Yanceyville WTP OMB No. 2040-0004
• • • • • '• 1
Presence or Absence Intake
check one Effluent
(Optional)
Pollutant Units Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required)
if available if available)Value
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑
❑
Concentration
mg/I
17
17
24
Mass
residual
3.
Color
❑✓
❑
Concentration
NTU
50
Mass
4.
Fecal coliform
❑
ElConcentrationMass
5
Fluoride
❑
❑✓
Concentration
Mass
(16984-48-8)
6
Nitrate -nitrite
❑
❑✓
Concentration
Mass
7.
Nitrogen, total
❑
❑
Concentration
Mass
organic (as N)
8.
Oil and grease
El✓❑
Concentration
Mass
9.
Phosphorus (as
❑
✓
Concentration
Mass
P), total (7723-14-0)
10.
Sulfate (as SO4)
❑
❑✓
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
❑✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identitication Number
110006710960
NPDES Permit Number Facility Name WWI Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
•
Pollutant
• • •
Presence or Absence
check one
• '•
1
Effluent
Intake
(Optional)
Units
(specify)
Believed
Present
Believed
Absent
Maximum Daily
Discharge
(required)
Maximum
Monthly
Discharge
f available
Long -Term
Average Daily
Discharge
if available
Number of
Analyses
Long -Term
Average
Value
Number of
Analyses
12
Sulfite (as S03)
(1426545-3)
❑
❑✓
Concentration
Mass
13.
Surfactants
❑
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑✓
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
—i
16.
Boron total
(7440A2-8)
El
❑
Concentration
Mass
o
17.
Cobalt, total
(7440A8A)
❑
✓❑
Concentration
Mass
18
Iron total
(7439-89-0)
❑
✓❑
Concentration
Mass
19
Magnesium, total
(7439-95-4)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
❑✓
Concentration
Mass
21.
Manganese, total
(7439-96-5)
El
❑
Concentration
Mass
22
Tin, total
(7440-31-5)
❑
a
Concentration
Mass
23
Titanium, total
(7440-32-6)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
11000671/ Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Long -Term
Long -Term
Present
Absent
Discharge
Monthly
Average Daily
Number of
Average
Number of
(required)
Discharge
Discharge
Analyses
Value
Analyses
if available
if available
24. Radioactivity
Alpha, total
❑
❑
Concentration
Mass
Beta, total
❑
❑✓
Concentration
Mass
Radium, total
❑
✓❑
Concentration
Mass
Radium 226, total
❑
❑✓
Concentration
Mass
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).
z
0
M
(m
`
` rn
C
2 rn
z
N i
N
CA.) C
rn
m
0
W
EPA Form 3510-2C (Revised 3-19) Page 25

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03I05119
110006710960 Town of Yanceyville WTP OMB No.2040-0004
'Be • 1
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
7 Present Absent
FlAsIbestos
❑
❑✓
2.
Acetaldehyde
❑
❑✓
3.
Allyl alcohol
❑
✓❑
4.
Allyl chloride
❑
❑✓
5.
Amyl acetate
❑
❑✓
6.
Aniline
❑
❑✓
7.
Benzonitrile
❑
❑✓
8.
Benzyl chloride
❑
✓❑
9.
Butyl acetate
❑
10.
Butylamine
❑
❑✓
11.
Captan
❑
✓❑
12.
Carbaryl
❑
❑✓
13.
Carbofuran
❑
❑✓
14.
Carbon disulfide
❑
✓❑
15.
Chlorpyrifos
❑
❑✓
16.
Coumaphos
❑
❑✓
Cresol
El✓❑
r17.
18.
Crotonaldehyde
❑
❑✓
19.
Cyclohexane
❑
❑✓
EPA Form 3510-2C (Revised 3-19) Page 27

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110006710960 Town of Yanceyville WTP OMB No. 2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
20. 2,4-D (2,4-dichlorophenoxyacetic acid) ❑ ✓❑
21.
Diazinon
❑
✓❑
22.
Dicamba
❑
❑✓
23.
Dichlobenil
❑
❑✓
24.
Dichlone
❑
❑✓
25.
2,2-dichloropropionic acid
❑
❑✓
26.
Dichlorvos
❑
✓❑
27.
Diethyl amine
❑
✓❑
28.
Dimethyl amine
❑
❑✓
29.
Dintrobenzene
❑
❑✓
30.
Dicluat
❑
❑✓
31.
Disulfoton
❑
❑✓
32.
Diuron
❑
❑✓
33.
Epichlorohydrin
❑
❑✓
34.
Ethion
❑
❑✓
35.
Ethylene diamine
❑
❑✓
36.
Ethylene dibromide
❑
❑✓
37.
Formaldehyde
❑
❑✓
38.
Furfural
❑
❑✓
EPA Form 3510-2C (Revised 3-19) Page 28

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110006710960 Town of Yanceyville WTP OMB No. 2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
7 Present Absent
99.
Guthion
❑
❑✓
40.
Isoprene
❑
❑✓
41.
Isopropanolamine
❑
❑✓
42.
Kelthane
❑
❑✓
43.
Kepone
❑
❑✓
44.
Malathion
❑
❑✓
45.
Mercaptodimethur
❑
❑✓
46.
Methoxychlor
❑
❑✓
47.
Methyl mercaptan
❑
✓❑
48.
Methyl methacrylate
❑
❑✓
49.
Methyl parathion
❑
❑✓
50.
Mevinphos
❑
❑✓
51.
Mexacarbate
❑
❑✓
52.
Monoethyl amine
❑
❑✓
53.
Monomethyl amine
❑
❑✓
54.
Naled
❑
❑✓
55.
Naphthenic acid
❑
❑✓
56.
Nitrotoluene
❑
❑✓
57.
Parathion
❑
❑✓
EPA Form 3510-2C (Revised 3-19) Page 29

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110006710960 Town of Yanceyville WTP OMB No. 2040-0004
me
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58.
Phenolsulfonate
❑
❑✓
59.
Phosgene
❑
❑✓
60.
Propargite
❑
✓❑
61.
Propylene oxide
❑
✓❑
62.
Pyrethrins
❑
✓❑
63.
Quinoline
❑
✓❑
64.
Resorcinol
❑
❑✓
65.
Strontium
❑
✓❑
66.
Strychnine
❑
✓❑
67.
Styrene
❑
❑✓
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
❑✓
70
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
71.
Trichlorofon
❑
❑✓
72.
Triethanolamine
❑
❑✓
73.
Triethylamine
❑
❑✓
74.
Trimethylamine
❑
❑✓
75.
Uranium
❑
❑✓
76.
Vanadium
❑
❑✓
EPA Form 3510-2C (Revised 3-19) Page 30

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Form Approved 03/05/19
110006710960
Town of Yanceyville WTP
OMB No. 2040-0004
A:
'�•
• 1
Presence or Absence
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
77.
Vinyl acetate
❑ ❑✓
78.
Xylene
❑
✓❑
79.
Xylenol
❑
❑✓
80.
Zirconium
❑
❑✓
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 3510-2C (Revised 3-19) Page 31

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
This page intentionally left blank.

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110006710960 Town of Yanceyvill�VWVTP OMB No. 2040-0004
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑ ❑ ✓,
EPA Form 3510-2C (Revised 3-19) Page 33

t
DATE PROJECT#
JUNE 2023 2201104 WATER TREATMENT PLANT
12401WIStreet Lane NW OFFICEMANAGER DESIGNER
mcgill828.328.2024 Hickory, 1 D.CHAPMAN M.JONES TOWN OF YANCEYVILLE
2024
NC Firm License IF C-0459 PROJECT MANAGER REVIEWER
mcyillassociales.co" M. JONES CASWELL COUNTY, NORTH CAROLINA
I
I
I
I
I
I
J
SHEET
PROCESS FLOW SCHEMATIC FIG.
. 2
I
I
I
I
I
I
J
SHEET
PROCESS FLOW SCHEMATIC FIG.
. 2