NC0007323_Renewal (Application)_20230622 (2)

DocuSign Envelope ID: 287BB1 8B-G485-4440-8C65-AFD2579DA1 EA
FriShaping Communities Together
meg 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 by:
E
� 3OI� t,S
F989937702B444D...
MATTHEW R JONES, P.E.
Project Manager
Enclosures
cc: Kamara Barnett, Town Manager
22.01103/J H. NPDES.20230621.doc
MCGILL ASSOCIATES 7- - _

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
mod% EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•
•D
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 0✓ No
If yes, STOP. Do NOT 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
z
and Form 213.
1 and Form 2C.
a
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 Complete Form 0✓ No
fp
and Form 2D.
1 and Form 2E.
A-1
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-
• •
2.1
Facility Name
Town of Yanceyville WTP
0
2.2
EPA Identification Number
R
0
J
110006710960
13
R
2.3
Facility Contact
N
Name (first and last)
Title
Phone number
v
Kamara Barnett
Town Manager
[phone]
CM Q
Email address
c
[e-mail]
2
a
2.4
Facility Mailing Address
z
Street or P.O. box
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
N
2.5
Facility Location
.Y
Street, route number, or other specific identifier
Q 0
1282 Main Street West
U
0)
0
County name
County code (if known)
CU
Caswell
0
E _j
City or town
State ZIP code
z
Yanceyville
NC 27379
SECTIONCODES
3.1
SIC Code(s)
Description (optional)
4941
a
0
U
U
U
z
3.2
NAICS Code(s)
Description (optional)
c
v
221310
SECTIONOPERATOR
INFORMATION
4.1
Name of Operator
Inframark
0
4.2
Is the name you listed in Item 4.1 also the owner?
w
E
`0
❑ Yes ❑✓ No
4.3
Operator Status
0
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
Street or P.O. Box
cc
E
220 Gibralter Rd, Ste 200
City or town
State
ZIP code
0
Horsham
PA
19044
c00i
R
Email address of operator
Q
0
[e-mail]
SECTION•
0
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. EXISTING ENVIRONMENTAL1
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
❑ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
oti
water)
fluids)
NC0007323
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
Zn
X
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
w
SECTIONI
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
8.1
Describe the nature of your business.
Municipal Water treatment and distribution
m
_
N
3
m
0
O
N
3
iC
Z
SECTION'
COOLING
WATER INTAKE STRUCTURES (40 '
9.1
Does your facility use cooling water?
d
❑ Yes ❑✓ No 4 SKIP to Item 10.1.
R Z
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
o Y
NPDES permitting authority to determine what specific information needs to be submitted and when.)
o
U �
SECTION
1
10.1
1 1
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
cn
when.)
❑ 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
❑ wl attachments
.-
❑✓ Section 6: Existing Environmental Permits
❑ w/ attachments
d
❑✓ Section 7: Map
w/ topographic
❑ma Elw/ additional attachments
Y
o
❑✓ Section 8: Nature of Business
Elw/ attachments
c
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
d
❑✓ Section 10: Variance Requests
❑ w/ attachments
,3
c
N_
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
d
11.2
Certification Statement
z
U
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. 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
by:
EDocuSigned
�a �_,_ -ll
6/21/2023
DsaaoesAo960420
EPA Form 3510-1 (revised 3-19) Page 4

PLAN
2000 0 1000 2000 4000
GRAPHIC SCALE DIVISION VALUE = 2000 FEET
© �.
1-MILE RADIUS FROM TOWN v Vanceyville
OF YANCEY\ALLE WTP t
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� 86.
t �o
15 po
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ST
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OUTFALL y :
—
001
TOWN OF -
YANCEYMLLE — -
WATER '
TREATMENT
PLANT `
2)
TOWN OF YA NCEYVILLE 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
I
June 2023
NPDES PERMIT RENEWAL
WATER TREATMENT
mcg
1240196, Street Lane NW
826.326.2024
Hickory, NC 28661
NC Firm License • C-0459
PROJECT #
22.0„03
TOWN
OF
YAN
EYV
LLE
PLANT TOPOGRAPHIC
MAP
�
mcgillassoaates.com
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 \".EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
Provide information on each of the facility's outfalls in the table below
ca Number Receiving Water Name Latitude Longitude
ca
0 001 Fullers Creek 36' 24' 56" N 79' 21' 3.3" W
J
C
7
0
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J �
o ❑✓ Yes ❑ No
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
"Outfall Number" 001
Operation Average Flow
Filter backwash 0.0284 mgd
mgd
mgd
CZ mgd
to
3
0 Treatment Units
U_
Description 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
Dual Settlement Lagoon I S-T
RECEIVED
JUN 2 2 2023
NCDEQ/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�
c
Y
0
U
c
a>
E
a) m
L
**Outfall Number**
R
(n
o
Operations Contributing
Operation
to Flow
Average Flow
a),
mgd
R
a'
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?
wK;
�
❑ Yes ❑✓ No 4 SKIP to Section 4.Cn
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 03/05/19
110006710960 NC0007323 Town of Yanceyville WTP OMB No. 2040-0004
SECTION• 41
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑ Yes ✓❑ No + SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if necessar .
Frec
uency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/Week
MonthsNear
Average
Dail
days/week
months/year
mgd
mgd
days
odays/week
months/year
mgd
mgd
days
LL
c
days/week
months/year
mgd
mgd
days
m
E
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
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION•••D
• I
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No 4 SKIP to Section 6.
U)
5.2
Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory
Regulatory Citation
w
m
R
Q
O.
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
Outfall
Number
Operation, Product, or Material
Quantity per Day
Unit of
Measure
d
f/!
R
m
C
O
w
U
3
O
L
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-•
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
o
Project
(list outfall
Discharge
Required
Projected
CL
number
E
CL
CL
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?
L
No; a waiver has been requested from my NPDES
❑✓ Yes ❑permitting
authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
W
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
w.
❑ Yes ✓❑ No 4 SKIP to Item 7.8.
CD
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
w
❑ 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
d
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
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?
U
❑✓ 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
3
❑✓ 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 -�- 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 TOXICS
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
8.1
an intermediate or final product or byproduct?
r
❑ Yes ❑✓ No 4 SKIP to Section 9.
u
3
8.2
List the pollutants below.
•-
1. 4. 7.
0
N
2. 5. 8.
F3. 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?
y ❑ Yes ❑✓ No 4 SKIP to Section 10.
9.2
Identify the tests and their
purposes below.
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
x
Permitting Authority?
O
U
ElYes ElNo
O
O
m
❑ Yes ❑ No
❑ Yes ❑ No
SECTIO�
10. CO�NTRACT
10.1
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑ Yes ❑✓ 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 laboratory/firm
d
�,
Laboratory address
ca
a
w
w
Phone number
Pollutant(s) analyzed
SECTIONDD
• •- • i
11.1
Has the NPDES permitting authority requested additional information?
o
❑ Yes ❑✓ No 4 SKIP to Section 12.
E
11.2
List the information requested and attach it to this application.
0
1. 4.
R
0
2. 5.
a
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•
1
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
12.1
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 fete 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
w/ list of each user of
❑ Section 3: Average Flows and
Elw/ 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
❑ ❑
d
request
N
❑ Section 7: Effluent and Intake
❑✓ w/ Table A ❑✓ w/ Table B
c
Characteristics
❑✓ w/ Table C ❑✓ w/ Table D
d
❑✓ w/ Table E El w/ analytical results as an
c�
attachment
c❑✓
Section 8: Used or Manufactured
❑ w/ attachments
Toxics
❑ 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
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:
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
Form Approved 03/05/19
110006710960 Town of Yanceyville WTP
OMB No. 2040-0004
TABLE
A. CONVENTIONAL AND NON•
• '• 1
Effluent
Intake
Waiver
o tional
Maximum
Maximum
Long -Term
Pollutant
Requested
Units
(if applicable)
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
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
❑
Concentration
Mass
(COD)
Concentration
3.
Total organic carbon (TOC)
❑
Mass
Concentration
mg/I
45.0
30
4.
Total suspended solids (TSS)
❑
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
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 9

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
Number Facility Name Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
(and CAS Number, if available)
Presence or Absence
check one
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
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
(7440-36-0)
❑
✓1
Concentration
Mass
1.2
Arsenic, total
(7440-38-2)
❑
❑✓
Concentration
Mass
1.3
Beryllium, total
(7440-41-7)
❑
El
✓
Concentration
Mass
1.4
Cadmium, total
(7440-43-9)
❑
❑
❑
Concentration
Mass
1.5
Chromium, total
(7440-47-3)
Concentration
Mass
1.6
Copper, total
(7440-50-8)
Concentration
Mass
1.7
Lead total
(7439-92-1)
✓
Concentration
Mass
1.8
Mercury, total
(7439-97-6)
❑
❑
✓❑
Concentration
Mass
1.9
Nickel, total
(7440-02-0)
❑
❑
Concentration
Mass
1.10
Selenium, total
(7782-49-2)
❑
Concentration
Mass
1.11
Silver, total
(7440-22-4)
Concentration
Mass
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 Outfall Number
110006710960 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
Long -Term
Long -
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)Maximum
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(if available)
Discharge
Analyses
Value
Analyses
if available
1.12
Thallium, total
❑
Concentration
Mass
(7440-28-0)
1.13
Zinc, total
Concentration
ug/I
0.06
0.048
3
Mass
(7440-66-6)
1.14
Cyanide, total
El
❑
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
El❑
Concentration
Mass
(107-02-8)
2.2
Acrylonitrile
❑
❑✓
Concentration
Mass
(107-13-1)
2.3
Benzene
❑
Concentration
Mass
(71-43-2)
2.4
Bromoform
Concentration
Mass
(75-25-2)
2.5
Carbon tetrachloride
El
❑
❑
Concentration
Mass
(56-23-5)
2.6
Chlorobenzene
El
El
Concentration
Mass
(108-90-7)
2.7
Chlorodibromomethane
❑
❑
❑✓
Concentration
Mass
(124-48-1)
L2.8
Chloroethane
❑
0Concentration
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
11000671, Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Poll utant/Parameter
Testing
'
Units
Maximum
Maximum
Long -Term
Long-
and CAS Number, if available
( )
Required
q
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
2.9
2-chloroethylvinyl ether
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66-3)
❑
❑
❑✓
Concentration
Mass
1
Dichlorobromomethane
❑
El
❑
Concentration
Mass
r12
(75-27-4)
11-dichloroethane
✓
Concentration
Mass
(75-34-3)
2.13
1,2-dichloroethane
❑
El
0Concentration
Mass
(107-06-2)
2.14
11-dichloroethylene
❑
El
0✓
Concentration
Mass
(75-35-4)
2.15
12-dichloropropane
❑
❑
❑
Concentration
Mass
(78-87-5)
2.16
13-dichloropropylene
❑
❑
❑
Concentration
Mass
642-75-6)
217
Ethylbenzene
✓
Concentration
Mass
(100-41-4)
2.18
Methyl bromide
❑
Concentration
Mass
(74-83-9)
219
Methyl chloride
❑
El
❑
Concentration
Mass
(74-87-3)
2.20
Methylene chloride
❑
❑
❑
Concentration
Mass
(75-09-2)
2.21
1,1,2 2- tetrachloroethane
Concentration
Mass
(79-34-5)
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 I Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
(and
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
°f
Analyses
Long -
Term
Average
Value
Number
of
Analyses
2.22
Tetrachloroethylene
(127-18-4)
El
El
IZI
Concentration
Mass
2.23
Toluene
(108-88-3)
Concentration
Mass
2.24
1 2-trans-dichloroethylene
(156-60-5)
❑
❑✓
Concentration
Mass
225
1,1,1-trichloroethane
(71-55-6)
❑
El
❑✓
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
❑
Concentration
Mass
2.27
Trichloroethylene
(79-01-6)
❑
❑
❑✓
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
❑
✓❑
Concentration
Mass
24-dichlorophenol
63.2 20-83-2)
Concentration
Mass
3.3
2 4-dimethylphenol
(105-67-9)
El
❑
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
❑
❑
❑
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
ElIZ
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

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
TOXICTABLE B.
•PHENOLS,ORGANIC
TOXICPOLLUTANTS
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
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
3.6
2-nitrophenol
❑
11
❑✓
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
EJ
El
✓
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
❑
❑
n7
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
❑
❑
✓❑
Concentration
Mass
(87-86-5)
3.10
Phenol
Concentration
Mass
(108-95-2)
3.11
2 4,6-trichlorophenol
❑
El
0✓
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
El
El
IZI
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
El
El
IZI
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 Facility Name Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Units
(specify)
Effluent
Pollutant/Parameter
(and CAS Number, if available )
Testing
Required
q
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
4.7
3 4-benzofluoranthene
(205-99-2)
❑
0
Concentration
Mass
4 8
Benzo (ghi) perylene
(191-24-2)
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
El
❑
❑
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
El
El
❑
Concentration
_
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
El
11
❑
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
11
❑
✓0
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
ElConcentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
El❑
Concentration
- -- - —
Mass
—
---
4.16
2-chloronaphthalene
(91-58-7)
❑
El
❑
Concentration
Mass
_
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
ElConcentration
Mass
4.18
Chrysene
(218-01-9)
El
❑
0
Concentration
Mass
[4Dibenzo
.19
(a,h) anthracene
(53-70-3)
El
El
❑
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
Intake
check one
Effluent
(optional)
Poll utant/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
a
(iifavailabe)
Daily
of
Average
of
re
( Q )
(
Discharge
Analyses
Analyses
if available
4.20
12-dichlorobenzene
❑
✓❑
Concentration
Mass
(95-50-1)
4.21
13-dichlorobenzene
❑
❑
❑✓
Concentration
Mass
(541-73-1)
4.22
1 4-dichlorobenzene
❑
❑
❑✓
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
El
1:1
✓
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
❑
❑
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
❑
❑
❑✓
Concentration
Mass
(131-11-3)
4.26
Di-n-butyl phthalate
❑
❑
©
Concentration
Mass
(84-74-2)
4.27
2,4-dinitrotoluene
❑
❑
✓❑
Concentration
Mass
(121-14-2)
4.28
2 6-dinitrotoluene
❑
❑
❑✓
Concentration
Mass
(606-20-2)
4.29
Di-n-octyl phthalate
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
El
❑
❑✓
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
Concentration
Mass
(206-44-0)
4.32
Fluorene
❑
❑
Q
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
NPDES Permit Number Facility Name I Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)Maximum
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Lon g-
Term
Average
Value
Number
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
❑
❑
✓❑
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
El
❑
✓❑
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
❑
❑
2✓
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
0
0Concentration
Mass
4.38
Isophorone
(78-59-1)
❑
✓❑
Concentration
Mass
4.39
Naphthalene
(91-20-3)
❑
El
✓❑
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
E✓
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
❑
❑
✓❑
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
El
El
0
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
Concentration
Mass
L4.45Pyrene
(129-00-0)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name I 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
4.46 1,2,4-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
El
El
El
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
❑
IZI
Concentration
Mass
(319-85-7)
5.4
y-BHC
❑
❑
❑✓
Concentration
Mass
(58-89-9)
5.5
b-BHC
❑
El
El
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
❑
Concentration
Mass
(57-74-9)
5.7
4 4'-DDT
❑
El
El
Concentration
Mass
(50-29-3)
5.8
4 4'-DDE
❑
El
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
❑
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
❑
Concentration
Mass
(60-57-1)
5.11
a-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 I Outfall Number
Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
• I
Pollutant/Parameter
(and CAS Number, if available )
•
Testing
Required
q
• I •'
Presence or Absence
check one
• , 191WO1111111111rXII1
Units
(p tv)
(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
5.12
R-endosulfan
(115-29-7)
El
❑
❑
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
❑
❑
Concentration
Mass
5.14
Endrin
(72-20-8)
❑
❑
✓❑
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
❑
❑
❑
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
El
❑
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)
El
ElIZI
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
❑❑
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑IZI
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
❑
❑
❑✓
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑
✓❑
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
❑
❑
IZI
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
NPDES Permit Number Facility Name I 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
Long
Maximum
Maximum
Long -Term
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term Number
Present
Absent
Discharge
ge
Discharge
Daily
of
of
Average
(if available)
Discharge
g
Analyses
Value Analyses
if available
Toxaphene
5.25
✓0
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-24464EDD-A541-6546722DFAB9
EPA Identification Number
110006710960
Facility Name
Town of Yanceyville WTP
Number
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
Monthly
Long -Term
Average Daily
Number of
Long -Term
Number of
Present
Absent
Discharge
Discharge
Discharge
Analyses
Average
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
El
❑✓
Concentration
Mass
mg/I
(24959-67-9)
2'
Chlorine, total
✓
El
Concentration
Concentration
17
17
24
residual
3.
Color
✓❑
❑
Concentration
NTu
50
Mass
4.
Fecal coliform
❑
ElConcentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
El
�
Concentration
Mass
7'
Nitrogen, total
❑
IZI
Concentration
Mass
organic (as N)
8.
Oil and grease
❑
✓❑
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 Identification Number NPDES Permit Number Facility Name Outfall Number
110006710960 Town of Yanceyville WTP
Form Approved 03/05/19
OMB No. 2040-0004
JMPollutant
•
• • •
Presence or Absence
check one
• ••
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
rage
Value
Number of
Analyses
12
Sulfite (as S03)
(1426545-3)
❑
❑
Concentration
Mass
13.
Surfactants
El
❑✓
Concentration
Mass
14.
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15.
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16.
Boron total
(7440-42-8)
El
Concentration
Mass
17.
Cobalt, total
(7440.484)
El
El
Concentration
Mass
18
Iron total
(7439-8M)
❑
❑
Concentration
Mass
19
Magnesium, total
(7439-954)
❑
❑
Concentration
Mass
20.
Molybdenum,
total
7439-98-7
❑
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22.
Tin total
(7440-31-5)
El
Concentration
Mass
L23.Titanium,
total
(7440-32-6)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

DocuSign Envelope ID: 350DCBFA-2446-4EDD-A541-65467220FAB9
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
•
• • •
• ••
1
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Monthly
Long -Term
Average Daily
Number of
Long -Term
Number of
Present
Absent
Discharge
Discharge
Discharge
Analyses
Average
Analyses
(required)
f available
if available
Value
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
C
Z
®
M
•�
L
N i
rV
W C
0
M
m
0
W
EPA Form 3510-2C (Revised 3-19) Page 25

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 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
1.
Asbestos
❑
❑✓
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
❑
❑✓
17.
Cresol
❑
❑✓
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.
Diquat
❑
❑✓
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
N • 1
Presence or Absence
Pollutant check one Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
39.
Guthion
❑
0
40.
Isoprene
❑
0
41.
Isopropanolamine
❑
42.
Kelthane
❑
43.
Kepone
❑
0
44.
Malathion
❑
0
45.
Mercaptodimethur
❑
0
46.
Methoxychlor
❑
IZI
47.
Methyl mercaptan
❑
0
48.
Methyl methacrylate
❑
49.
Methyl parathion
❑
0
50.
Mevinphos
❑
51.
Mexacarbate
❑
52.
Monoethyl amine
❑
0
53.
Monomethyl amine
❑
IZI
54.
Naled
❑
0
55.
Naphthenic acid
❑
IZI
56.
Nitrotoluene
❑
0
57.
Parathion
❑
0
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
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
El
❑✓
71.
Trichlorofon
❑
✓❑
72.
Triethanolamine
❑
✓❑
73.
Triethylamine
❑
❑✓
74.
Trimethylamine
❑
0
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
Presence or Absence
177Vinyll
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed Believed
(specify units)
Present Absent
acetate
❑
❑✓
78.
Xylene
❑
❑✓
79.
Xylenol
❑
❑✓
80.
Zirconium
❑
❑✓
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 31

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
TCDD Presence or
Congeners Absence
Pollutant Used or check one Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD 0
EPA Form 3510-2C (Revised 3-19) Page 33

DATE PROJECT#
JUNE 2023 22,01104 WATER TREATMENT PLANT
1240 18, Street Lane NW OFFICE MANAGER DESIGNER
rncg�ll Hickory 2NC 024 1
828.32D. CHAPMAN M JONES
TOWN OF YAN C EYV I L L E.2024
NC Finn License #C-o45s PROJECT MANAGER REVIEWER
mcyillassociates.com M. JONES CASWELL COUNTY, NORTH CAROLINA
-
SHEET
PROCESS FLOW SCHEMATIC FIG. 2
-
SHEET
PROCESS FLOW SCHEMATIC FIG. 2