NC0088331_Renewal (Application)_20230831

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Jeff Sanders, Field Manager Operations
Pamlico County
Subject: Permit Renewal
Application No. NCO088331
Kershaw WTP
Pamlico County
Dear Permiee:
NORTH CAROLINA
Environmental Quality
August 31, 2023
The Water Quality Permitting Section acknowledges the August 31, 2023 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https:lldgg. nc.govlpermits-regulationslpgrmit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
D_E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
Washington Regional Office 1 943 Washington Square Mall I Washington. North Carolina 27889
..+iwr/"� 252.946.6481

BOARD OF COMMISSIONERS
CHAIRMAN
EDWARD RIGGS JR. - TOWNSHIP #3
VICE-CHAIRMAN
CANDY BOHMERT - TOWNSHIP #2
DOUG BRINSON -AT LARGE
KARIFORREST-AT LARGE
PAT PRESCOTT - TOWNSHIP # I
CARL OLLISON - TOWNSHIP #4
MISSY BASKERVILL - TOWNSHIP #5
August 18, 2023
COUNTY OF PAMLICO
COUNTY MANAGER
TIMOTHY A. BUCK
CLERK TO THE BOARD
CHANTELLE M. ALLISON
COUNTY ATTORNEY
DAVID B. BAXTER, JR.
POST OFFICE BOX 776 RECEIVED
BAYBORO, NORTH CAROLINA 28515
[phone] / 745-5195
FAX [phone] QU i 1 2023
Division of Water Resources
Water Quality Permitting Section - NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Permitting Unit:
NCDEQ/DW/ PDES
Subject: NPDES Permit Renewal
Kershaw WTP
NPDES Permit #NC0088331
Pamlico County
Pamlico County Water Department is submitting the renewal application for NPDES permit
NCO088331 which is scheduled to expire on October 31, 2023. The permit application package
consists of:
- Cover letter
- EPA Form 1
- EPA Form 2E
- Table "A" from EPA Form 2C
- Table "B" from EPA Form 2C
- Table "C" from EPA Form 2C
- Topographic Map
If you have any additional questions or comments, please contact Mr. Jeff Sanders, Operator in
Responsible Charge (ORC), at 252-745-5453
Sincerely,
County

United States Office of Water EPA Form 3510-2C
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
��E�► Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Si Ivicu Itu ral Operations
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to collect information and
complete Form 2C to be 32.5 hours. This estimate includes time for reviewing instructions, searching
existing data sources, gathering and maintaining the needed data, and completing and reviewing the
collection of information. Send comments about the burden estimate or any other aspect of this
collection of information to the Chief, Information Policy Branch (PM-223), U.S. Environmental
Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, 725 17t' Street, NW,
Washington, DC 20503, marked "Attention: Desk Officer for EPA."

FORM 2C—INSTRUCTIONS
General Instructions
Who Must Complete Form 2C?
You must complete Form 2C if you answered "Yes" to Item 1.2.2 on
Form 1—that is, if you are an existing manufacturing, commercial,
mining, or silvicultural facility that currently discharges process
wastewater.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2C) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1-1 of Form 1's "General
Instructions" to identify your NPDES permitting authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2C (or related attachments) as
confidential.
You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2C. Note that NPDES authorities will deny claims for treating any
effluent data as confidential. If you do not assert a claim of
confidentiality at the time you submit your information to the
NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will handle
claims of confidentiality in accordance with the Agency's business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).
Completion of Forms
Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.
Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 2C and any attachments. If you do not know
your EPA Identification Number, contact your NPDES permitting
authority. See Exhibit 1-1 of Form 1's "General Instructions" for
contact information. Additionally, for Tables A through E, provide
the applicable outfall number at the top of each page.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter "NA" for "not applicable" to
show that you considered the item and determined a response was
not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority's satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
Definitions
The legal definitions of all key terms used in these instructions and
Form 2C are in the "Glossary" at the end of the "General
Instructions" in Form 1.
Line -by -Line Instructions
Section 1.Outfall Location
Item 1.1. Identify each of the facility's outfall structures by number.
For each outfall, specify the latitude and longitude to the nearest
15 seconds and name of the receiving water. The application form
provides reporting space for three outfalls. If your facility has more
than this number, attach additional sheets as necessary. The
location of each outfall (i.e., where the coordinates are collected)
shall be the point where the discharge is released into a water of
the United States. Latitude and longitude coordinates may be
obtained in a variety of ways, including use of hand held devices
(e.g., a GPS enabled smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finders,
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS).For
further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.
Section 2. Line Drawing
Item 2.1. Attach a line drawing showing water flow through your
facility, from intake to discharge. Indicate the sources of intake
water (e.g., city, well, stream, other); operations contributing
wastewater to the effluent including process and production areas,
sanitary flows, cooling water, and stormwater runoff; and treatment
units labeled to correspond to the more detailed descriptions under
Section 3. You may group similar operations into a single unit.
Construct a water balance on the line drawing by showing average
flows (specify units) between intakes, operations, treatment units,
and outfalls. Show all significant losses of water to products, the
atmosphere, and discharge. You should use actual measurements
wherever available; otherwise use your best estimate. If you cannot
determine a water balance for your activities (such as mining
activities), provide a pictorial description of the nature and amount
of any sources of water and any collection and treatment measures.
An example of an acceptable line drawing is provided in Exhibit
2C-1 at the end of these instructions.
Section 3. Average Flows and Treatment
Item 3.1. For each outfall identified under Item 1.1, provide the
following information: (1) all processes, operations, or production
areas that contribute wastewater to the effluent for the outfall,
including process wastewater, sanitary wastewater, cooling water,
and stormwater runoff; (2) average flow of wastewater contributed
by each operation in million gallons per day (mgd); (3) a description
of the treatment unit (including size of each treatment unit, flow rate
through each treatment unit, retention time, etc.); (4) the applicable
treatment code(s) from Exhibit 2C-2 (see end of instructions); and
(5) the ultimate disposal of any solid or fluid wastes that are not
discharged to the receiving water. You may describe processes,
operations, or production areas in general terms (e.g., "dye -making
reactor" or "distillation tower'). You may estimate the average flow
of point sources composed of stormwater; however, you must
2C-1

FORM 2C—INSTRUCTIONS CONTINUED
indicate the basis of the rainfall event and the method of estimation.
Add additional sheets as necessary.
Item 3.2. Answer whether you are applying for an NPDES permit to
operate a privately owned treatment works. If yes, continue to Item
3.3. If no, skip to Section 4.
Item 3.3. Attach a list to your application that includes the identity of
each user of the treatment works, then answer "Yes" to Item 3.3.
Section 4. Intermittent Flows
Item 4.1. Answer "Yes" or "No" to indicate whether any of the
discharges you described in Sections 1 and 3 of Form 2C are
intermittent or seasonal, except for stormwater runoff, spillage, or
leaks. An intermittent discharge is one that is not continuous. A
continuous discharge is one that occurs without interruption during
the operating hours of the facility, except for infrequent shutdowns
for maintenance, process changes, or other similar activities. A
discharge is seasonal if it occurs only during certain parts of the
year. If yes, continue to Item 4.2. If no, skip to Section 5.
Item 4.2. By relevant outfall number, identify each operation that
has intermittent or seasonal discharges. Indicate the average
frequency (days per week and months per year), the long-term
average and maximum daily flow rates in mgd, and the duration of
the intermittent or seasonal discharges. Base your answers on
actual data if available. Otherwise, provide your best estimate.
Report the average of all daily values measured during days when
the discharge occurred for "Long -Term Average," and report the
highest daily value for "Maximum Daily."
Section 5. Production
Item 5.1. Indicate whether any effluent limitation guidelines (ELGs)
promulgated under Section 304 of the Clean Water Act (CWA)
apply to your facility. If yes, continue to Item 5.2. If no, skip to
Section 6. All ELGs promulgated by EPA appear in the Federal
Register and are published annually in 40 CFR Subchapter N. An
ELG applies if you have any operations contributing process
wastewater in any subcategory covered by a Best Practicable
Control Technology Currently Available (BPT), Best Conventional
Pollutant Control Technology (BCT), or Best Available Technology
Economically Achievable (BAT) guideline. If you are unsure
whether you are covered by a promulgated ELG, consult your
NPDES permitting authority (see Exhibit 1-1 of the "General
Instructions" of Form 1). You must check "Yes" if an applicable ELG
has been promulgated, even if the ELG is being contested in court.
If you believe that a promulgated ELG has been remanded for
reconsideration by a court and does not apply to your operations,
you may answer "No" to Item 5.1 and skip to Section 6.
Item 5.2. Complete Item 5.2 by indicating the applicable ELG
category, ELG subcategory, and corresponding regulatory citation.
See the example below.
fn
w
43
5.2
ELG Category
ELG
Subcategory
Regulatory
Citation
Pulp, Paper,
Secondary Fiber
40 CFR 430,
and
Non-Deink
Subpart J
Paperboard
Subcategory
CL a
Point Source
Category
Item 5.3. Indicate if the limitations in the applicable ELGs are
expressed in terms of production or other measure of operation. For
operational parameter, it is expressed in terms of production (e.g.,
"pounds of biological oxygen demand per cubic foot of logs from
which bark is removed," or "pounds of total suspended solids per
megawatt hour of electrical energy consumed by smelting
furnace"). An example of an ELG not expressed in terms of a
measure of operation is one that limits the concentration of
pollutants. If yes, continue to Item 5.4. If no, skip to Section 6.
Item 5.4. Indicate the operations, products, or materials produced
at the facility for each outfall. For each operation, product, or
material produced, denote the quantity produced per day using the
measurement units specified in the applicable ELG. The NPDES
permitting authority will use the production information to apply
ELGs to your facility. You may not claim that the production
information you submit is confidential. You do not need to indicate
how you calculated the reported information. The production figures
provided must be based on a reasonable measure of actual daily
production, not on design capacity or on predictions of future
operations. To obtain alternate limits under 40 CFR 122.45(b)(2)(ii),
you must define your maximum production capability and
demonstrate to the NPDES permitting authority that your actual
production is substantially below maximum production capability
and that there is a reasonable potential for an increase above
actual production during the duration of the permit.
Section 6. Improvements
Item 6.1. Indicate if you are 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 your application. The requirements include,
but are not limited to, permit conditions, administrative enforcement
orders, enforcement compliance schedule letters, stipulations, court
orders, and grant or loan conditions. If yes, continue to Item 6.2. If
no, skip to Item 6.3.
Item 6.2. Briefly identify and describe each applicable project (e.g.,
consent decree, enforcement order, or permit condition). For each
condition, specify the affected outfall number(s), the source(s) of
the discharge, the projected final compliance date, and the
required final compliance date.
Item 6.3.OPTIONAL ITEM. If desired, attach descriptions of any
additional water pollution control programs (or other environmental
projects that could affect your discharges) that are now underway
or planned. Indicate in your attachments whether each program is
actually underway or is planned, and indicate your actual or
planned schedule for construction.
Section 7. Effluent and Intake Characteristics
Items 7.1 to 7.17. These items require you to collect and report
data for the parameters and pollutants listed in Tables A through E,
located at the end of Form 2C. The instructions for completing the
tables are table -specific in addition to the criteria for determining
who should complete them. In general, the following conditions
apply:
2C-2

FORM 2C—INSTRUCTIONS CONTINUED
Table
Pollutants/Parameters
Who Completes?
A
Conventional and non-
All applicants from all outfalls unless a
conventional pollutants
waiver is obtained from the NPDES
permitting authority.
B
Toxic metals, cyanide, total
Applicants in the primary industry
phenols, and organic toxic
categories listed in Exhibit 2C-3 at the
pollutants
end of these instructions.
C
Certain conventional and
Applicants subject to ELGs that limit
non -conventional pollutants
pollutants directly or indirectly and
applicants who believe pollutants may
be present in their facility's dischar e.
D
Certain hazardous
Applicants who believe pollutants may
substances and asbestos
be present in their facility's discharge.
E
2,3,7,8-tetrachlorodibenzo-
Applicants that use or manufacture the
p-dioxin (2,3,7,8-TCDD)
pollutant or believe the pollutant may
be present in the facility's discharge.
Important note: Read the "General Instructions for Reporting,
Sampling, and Analysis" on pages 2C-5 and 2C-6 before
completing Section 7 and Tables A through E.
Item 7.1 and Table A. All applicants must report at least one
analysis for each conventional and non -conventional pollutant listed
in Table A for each outfall (one table per outfall). This includes
outfalls discharging only noncontact cooling water or stormwater
runoff. However, at your request, the NPDES permitting authority
may waive the requirement to test for one or more of the listed
pollutants for specific outfalls, upon a determination that available
information is adequate to support issuance of your NPDES permit
with less stringent reporting requirements. You may also request a
waiver from your NPDES permitting authority for one or more of the
Table A pollutants for your industry category or subcategory.
Indicate whether you are requesting a waiver in response to Item
7.1. If yes, continue to Item 7.2. If no, skip to Item 7.3.
Item 7.2. Specify the outfalls for which you are requesting a waiver.
Next, indicate on Table A for the applicable outfalls the pollutants
for which the waiver is being requested. Attach your waiver request
and supporting information to your completed Form 2C.
Item 7.3. Test your effluent from each outfall for each pollutant
listed in Table A for which you have not requested a waiver. You
may also conduct optional tests of your intake water for the Table A
pollutants. See the "General Instructions for Reporting, Sampling,
and Analysis" on pages 2C-5 and 2C-6 for further information.
Item 7.4 and Table B. This item asks whether any of the facility's
processes that contribute wastewater fall into one or more of the
primary industry categories listed in Exhibit 2C-3. If you are
applying for a permit for a privately owned treatment works,
determine your testing requirements based on the industrial
categories of your contributors. This exercise is simply to determine
your testing requirements only. You are not giving up your right to
challenge your inclusion in the category determined for testing (e.g.,
for deciding whether an ELG is applicable) before your permit is
issued. If yes, continue to Item 7.5. If no, skip to Item 7.8.
Complete a separate Table B for each outfall. Section 1 of Table B
lists toxic metals, cyanide, and total phenols. Sections 2 through 5
of Table B list the pollutants in each of the gas
chromatography/mass spectrometry (GC/MS) fractions. Note that
inclusion of total phenols in Section 1 of Table B does not mean
that EPA is classifying the group as toxic pollutants.
Item 7.5. Because you indicated in Item 7.4 that the facility's
processes contribute wastewater that falls into one or more of the
primary industry categories, check "Testing Required" for all toxic
metals, cyanide, and total phenols in Section 1 of Table B. Answer
"Yes" to Item 7.5 once you have completed this task.
Item 7.6. Because you indicated in Item 7.4 that the facility's
processes contribute wastewater that falls into one or more of the
primary industry categories, list the primary industry categories
applicable to your facility. Next, review Exhibit 2C-3 to determine
whether testing is required and for which GC/MS fraction(s): volatile
compounds, acid compounds, base/neutral compounds, and
pesticides. Check the applicable boxes for each GC/MS fraction
requiring testing.
Item 7.7. For each of the required GC/MS fractions, check "Testing
Required" for each of the pollutants in the required fraction in
Sections 2 through 5 of Table B. Answer "Yes" to Item 7.7 once you
have completed this task.
Item 7.8 and Sections 1 through 5 of Table B. For all other cases
(secondary industries, nonprocess wastewater outfalls, and
nonrequired GC/MS fractions) and remaining pollutants, check
"Believed Present" or "Believed Absent" in Sections 1 through 5 of
Table B to indicate whether you have reason to believe that any of
the pollutants listed are discharged from your outfalls. Answer "Yes"
to Item 7.8 after you have completed this step.
Item 7.9 and Section 1 of Table B. For each pollutant you know or
have reason to believe is present in your discharge from each
applicable outfall in concentrations of 10 parts per billion (ppb) or
greater, you must report quantitative data. For every pollutant
expected to be discharged in concentrations less than 10 ppb, you
must submit quantitative data or briefly describe the reasons the
pollutant is expected to be discharged. For pollutants in intake
water, see the discussion under "General Instructions for Reporting,
Sampling, and Analysis" below. Answer "Yes" to Item 7.9 once you
have completed Section 1 of Table B.
Item 7.10. This item asks if you qualify as a "small business." If so,
you are exempt from submitting quantitative data for the organic
toxic pollutants on Table B (Sections 2 through 5). You still must
indicate, though, whether you believe any of the pollutants listed in
Sections 1 through 5 are present in your discharge per the
Instructions at Item 7.8 above.
You can qualify as a small business in two ways: (1) If your facility
is a coal mine and if your probable total annual production is less
than 100,000 tons per year, you may submit past production data
or estimated future production (such as a schedule of estimated
total production under 30 CFR 795.14(c)) instead of conducting
analyses for the organic toxic pollutants. (2) If your facility is not a
coal mine and if your gross total annual sales for the most recent
three years average less than $100,000 per year (in second
quarter 1980 dollars), you may submit sales data for those years
instead of conducting analyses for the organic toxic pollutants.
The production or sales data must be for the facility that is the
source of the discharge. The data should not be limited to
production or sales for the process or processes that contribute to
the discharge, unless those are the only processes at your facility.
2C-3

FORM 2C—INSTRUCTIONS CONTINUED
For sales data, in situations involving intra-corporate transfer of
goods and services, the transfer price per unit should approximate
market prices for those goods and services as closely as possible.
Sales figures for years after 1980 should be indexed to the second
quarter of 1980 by using the gross national product price deflator
(second quarter of 1980 = 100). This index is available online from
the U.S. Department of Commerce, Bureau of Economic Analysis
at http://bea.gov/national/pdf/SNTables.pdf.
If you qualify as a small business according to the criteria above,
answer "Yes" to Item 7.10. Check the box at the top of Table B to
show that you are not required to submit quantitative data for the
organic toxic pollutants (Sections 2 through 5 of Table B), then
skip to Item 7.12. Otherwise, answer "No" and continue to Item
7.11,
Item 7.11 and Sections 2 through 5 of Table B. Unless you
qualify as a small business (see Item 7.10), you must provide
quantitative data for all pollutants for which you marked "Testing
Required" in Sections 2 through 5 of Table B. You must also
provide quantitative data for all pollutants you marked as "Believed
Present" in Sections 2 through 5 of Table B if you discharge those
pollutants in concentrations of 10 ppb or greater, except for
acrolein, acrylonitrile, 2,4-dinitrophenol, and 2-methyl-4,6-
dinitrophenol. If you discharge any of the four latter pollutants in
concentrations of 100 ppb or greater, you must report quantitative
data. If you discharge the pollutants in Sections 2 through 5 of
Table B less than these thresholds (i.e., <100 ppb for acrolein,
acrylonitrile, 2,4-dinitrophenol, and 2-methyl-4,6-dinitrophenol and
<10 ppb for all others), you must submit quantitative data or briefly
describe the reasons the pollutant is in your discharge.
For pollutants in intake water, see the discussion under "General
Instructions for Reporting, Sampling, and Analysis" on pages
2C-5 and 2C-6 for further information.
Once you have completed these tasks, answer "Yes" to Item 7.11.
Item 7.12 and Table C. For each outfall (including outfalls
containing only noncontact cooling water or stormwater runoff),
indicate whether you know or have reason to believe that any of
the pollutants listed on Table C are present in your discharge. If
so, mark the box in the "Believed Present" column for each
applicable pollutant. If not, mark the box in the "Believed Absent"
column for each applicable pollutant. Answer "Yes" to Item 7.12
once you have completed the required task for each outfall.
Item 7.13 and Table C. You are required to report quantitative
data for any Table C pollutants that are directly limited in an
applicable ELG or are indirectly limited in an applicable ELG
through an expressed limitation on an indicator (e.g., use of total
suspended solids (TSS) as an indicator to control the discharge
of iron and aluminum). For all other pollutants that you marked as
"Believed Present," you must either report quantitative data or
briefly describe the reasons the pollutant is expected to be
discharged.
For pollutants in intake water, see the discussion under "General
Instructions for Reporting, Sampling, and Analysis" on pages
2C-5 and 2C-6 for further information.
Answer "Yes" to Item 7.13 when you have fully completed the
tasks associated with Table C and Items 7.12 and 7.13 above.
Item 7.14 and Table D. For each outfall, indicate if you believe that
any pollutant listed in Table D is "Believed Present" or "Believed
Absent" in your facility's effluent. Check the boxes in the applicable
columns on Table D next to each pollutant. For every pollutant
believed present, you must briefly describe the reasons the
pollutant is expected to be discharged and report any quantitative
data you have for that pollutant. Note that you are not required to
perform analytical tests for any of the Table D pollutants at this time.
However, if you have prior test results, you must report them.
Item 7.15. Answer "Yes" to this Item when you have completed
Table D.
Under 40 CFR 117.12(a)(2), certain discharges of hazardous substances
(listed in Exhibit 2C-4 at the end of these instructions) may be exempted from
the requirements of Section 311 of the CWA, which establishes reporting
requirements, civil penalties, and liability for cleanup costs for spills of oil and
hazardous substances. A discharge of a particular substance can be exempted
if the origin, source, and amount of the discharged substances are identified in
the NPDES permit application or in the permit, if the permit contains a
requirement for treatment of the discharge, and if the treatment is in place.
Exemptions are allowed from the requirements of CWA Section 311.
Applications for exemptions must set forth the following information:
1. The substance and the amount of each substance that may be discharged.
2. The origin and source of the discharge of the substance.
3. The treatment to be provided for the discharge by:
a. An onsite treatment system separate from any treatment system
treating your normal discharge;
b. A treatment system designed to treat your normal discharge and that is
additionally capable of treating the amount of the substance identified
under paragraph 1 above; or
c. Any combination of the above.
See 40 CFR 117.12(a)(2) and (c) or contact your NPDES permitting authority
for further information on exclusions from CWA Section 311.
Item 7.16. Indicate whether:
• Your facility uses or manufactures 2,4,5-trichlorophenoxy
acetic acid (2,4,5-T); 2-(2,4,5-trichlorophenoxy) propanoic acid
(Silvex, 2,4,5-TP); 2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloro-
propionate (Erbon); 0,0-dimethyl 0-(2,4,5-trichlorophenyl)
phosphorothioate (Ronnel); 2,4,5,-trichlorophenol (TCP); or
hexachlorophene (HCP).
• You know or have reason to believe that 2.3.7,8-
tetrachlorodibenzo-p-dioxin (TCDD) is or may be present in an
effluent.
If yes, continue to Item 7.17. If no, skip to Section 8.
Item 7.17 and Table E. If you answered "Yes" to Item 7.16, you
must report qualitative data, generated using a screening procedure
not calibrated with analytical standards, for TCDD. Your screening
analyses must be performed using gas chromatography with an
electron capture detector. A TCDD standard for quantitation is not
required. Describe the results of your screening analysis (e.g., "no
measurable baseline deflection at the retention time of TCDD" or "a
measurable peak within the tolerances of the retention time of
TCDD.") on Table E. The NPDES permitting authority may require
you to perform a quantitative analysis if you report a positive result.
Answer "Yes" to Item 7.17 when you have completed Table E
2C-4

General Instructions for Reporting, Sampling, and Analysis
Important note: Read these instructions before completing Tables
A through E and Section 7 of Form 2C.
General Items
Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit number,
facility name, and applicable outfall number at the top of each page
of the tables and any associated attachments.
You may report some or all of the required data by attaching
separate sheets of paper instead of completing Tables A through E
for each of your outfalls so long as the sheets contain all of the
required information and are similar in format to Tables A through
E. For example, you may be able to print a report in a compatible
format from the data system used in your GC/MS analysis
completed under Table B.
Table A requires you to report at least one analysis for each
pollutant listed. Tables B through D require you to report analytical
data in two ways. For some pollutants, you may be required to
check the box in the "Testing Required" column and test and report
the levels of the pollutants in your discharge whether or not you
expect them to be present in your discharge. For all other
pollutants, you must check the box in either the `Believed Present'
or "Believed Absent' columns based on your best estimate and test
for those you believe to be present (with some exceptions). Base
your determination that a pollutant is present in or absent from your
discharge on your knowledge of your raw materials, maintenance
chemicals, intermediate and final products and byproducts, and any
previous analyses known to you of your effluent or similar effluent.
For example, if you manufacture pesticides, you should expect
those pesticides to be present in contaminated stormwater runoff.
If you would expect a pollutant to be present solely because of its
presence in your intake water, you must mark "Believed Present'
but you are not required to analyze for that pollutant. Instead, mark
an "X" in the long-term average value of the 'Intake" column;
optionally, you may instead provide intake data.
Reporting of Effluent Data
Report sampling results for all pollutants in Tables A through C as
concentration and total mass, except for flow, temperature, pH,
color, and fecal coliform organisms. If you are reporting
quantitative data under Table D, report concentration only.
Flow, temperature, pH, color, and fecal coliform organisms must be
reported as mgd, degrees Celsius (°C), standard units, color units,
and most probable number per 100 milliliters (MPN/100 mL),
respectively. Use the following abbreviations in the columns
requiring "units" in Tables A through D.
Concentration
Mass
ppm = parts per million
Ibs = pounds
mg/L = milligrams per liter
ton = tons (English tons)
ppb = parts per billion
mg = milligrams
pg/L = micrograms per liter
g = grams
MPN = most probable number per
kg = kilograms
100 milliliters
T = tonnes (metric tons)
All reporting of values for metals must be in terms of "total
recoverable metal," unless:
• An applicable, promulgated ELG specifies the limitation for
the metal in dissolved, valent, or total form;
• All approved analytical methods for the metal inherently
measure only its dissolved form (e.g., hexavalent chromium);
or
• The permitting authority has determined that in establishing
case -by -case limitations it is necessary to express the
limitations of the metal in dissolved, valent, or total form to
carry out the provisions of the CWA.
Note that you are not required to complete the "Maximum Monthly
Discharge" and the "Long -Term Average Daily Discharge" columns
of Tables A through C; however, these fields should be completed
if data are available.
If you measure only one daily value, complete the "Maximum Daily
Discharge" columns of the tables and enter " 1" in the "Number of
Analyses" columns. The NPDES permitting authority may require
additional analyses to further characterize your discharges.
For composite samples, the daily value is the total mass or
average concentration found in a composite sample taken over the
operating hours of the facility during a 24-hour period. For grab
samples, the daily value is the arithmetic or flow -weighted total
mass or average concentration found in a series of at least four
grab samples taken over the operating hours of the facility during a
24-hour period.
If you measure more than one daily value for a pollutant and those
values are representative of your wastestream, you must report
them. You must describe your method of testing and data analysis.
When an applicant has two or more outfalls with substantially
identical effluents, the NPDES permitting authority may allow the
applicant to test only one outfall and report those quantitative data
as applying to the substantially identical outfall. If the permitting
authority grants your request, attach a separate sheet to the
application form identifying the outfall tested and describing why the
other ouffall(s) are substantially identical.
Reporting of Intake Data
You are not required to report data under the 'Intake" columns of
Tables A through C unless you wish to demonstrate your eligibility
for a "net' effluent limitation for one or more pollutants in Tables A
through C (i.e., an effluent limitation adjusted by subtracting the
average level of the pollutant(s) present in your intake water).
NPDES regulations allow net limitations only in certain
circumstances. To demonstrate your eligibility, under the "Intake"
columns report the average of the results of analyses of your intake
water and discuss the requirements for a net limitation with your
NPDES permitting authority. If your water is treated before use, test
the water after it has been treated.
2C-5

General Instructions for Reporting, Sampling, and Analysis Continued
Sampling
The collection of samples for the reported analyses should be
supervised by a person experienced in performing sampling of
industrial wastewater. You may contact your NPDES permitting
authority for detailed guidance on sampling techniques and for
answers to specific questions. See Exhibit 1-1 of Form 1 for
contact information. Any specific requirements in the applicable
analytical methods —for example, sample containers, sample
preservation, holding times, and the collection of duplicate
samples —must be followed.
The time when you sample should be representative of your normal
operation, to the extent feasible, with all processes that contribute
wastewater in normal operation, and with your treatment system
operating properly with no system upsets. Collect samples from the
center of the flow channel, where turbulence is at a maximum, at a
site specified in your present NPDES permit, or at any site
adequate for the collection of a representative sample.
Grab samples must be used for pH, temperature, cyanide, total
phenols, residual chlorine, oil and grease, fecal coliform (including
E. coh), and enterococci (previously known as fecal streptococcus
at 40 CFR 122.26(d)(2)(iii)(A)(3)), and volatile organic compounds.
For all other pollutants, a 24-hour composite sample, using a
minimum of four grab samples, must be used unless specified
otherwise at 40 CFR 136. However, a minimum of one grab
sample may be taken for effluents from holding ponds or other
impoundments with a retention period greater than 24 hours.
For stormwater discharges, a minimum of one to four grab
samples must be taken, depending on the duration of the
discharge. One grab sample must be taken in the first hour (or
less) of discharge, with one more grab sample (up to a minimum of
four) taken in each succeeding hour of discharge for discharges
lasting four hours or more.
Except for stormwater discharges, the NPDES permitting authority
may waive composite sampling requirements for any outfall for
which you demonstrate that use of an automatic sampler is
infeasible and that the minimum of four grab samples will be
representative of your discharge. Results of analyses of individual
grab samples for any parameter may be averaged to obtain the
daily average. Grab samples that are not required to be analyzed
immediately may be composited in the laboratory, if the container,
preservation, and holding time requirements are met and if sample
integrity is not compromised during compositing. See Table II at 40
CFR 136.3 for further information.
A grab sample is an individual sample of at least 100 milliliters
collected at a randomly chosen time over a period not exceeding
15 minutes.
A composite sample is a combination of at least eight sample
aliquots of at least 100 milliliters, collected at periodic intervals
during the operating hours of a facility over a 24-hour period. The
composite must be flow proportional; either the time interval
between each aliquot or the volume of each aliquot must be
proportional to either the stream flow at the time of sampling or the
total stream flow since the collection of the previous aliquot.
Aliquots may be collected manually or automatically. For "GC/MS
Fraction —Volatile Compounds" in Table B, aliquots must be
combined in the laboratory immediately before analysis. Four
(rather than eight) aliquots or grab samples should be collected for
this fraction. These four samples should be collected during actual
hours of discharge over a 24-hour period and need not be flow
proportioned. Only one analysis is required.
Use of Historical Data
Existing data may be used, if available, in lieu of sampling
conducted solely for the purposes of this application, provided that:
all data requirements are met; sampling was performed, collected,
and analyzed no more than 4.5 years prior to submission; all data
are representative of the discharge; and all available representative
data are considered in the values reported.
Analysis
Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical
methods approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or 0. A method is "sufficiently sensitive"
when:
• The method minimum level (ML) is at or below the level of the
applicable water quality criterion for the measured pollutant or
pollutant parameter.
• The method ML is above the water quality criterion, but the
amount of the pollutant or pollutant parameter in the facility's
discharge is high enough that the method detects and
quantifies the level of the pollutant or pollutant parameter in
the discharge.
• The method has the lowest ML of the analytical methods
approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or 0 for the measured pollutant or
pollutant parameter.
Consistent with 40 CFR 136, you may provide matrix- or sample -
specific MLs rather than the published levels. Further, where you
can demonstrate that, despite a good faith effort to use a method
that would otherwise meet the definition of "sufficiently sensitive,"
the analytical results are not consistent with the quality assurance
(QA)/quality control (QC) specifications for that method, then the
NPDES permitting authority may determine that the method is not
performing adequately and the NPDES permitting authority should
select a different method from the remaining EPA -approved
methods that is sufficiently sensitive consistent with 40 CFR
122.21(e)(3)(i). Where no other EPA -approved methods exist, you
must select a method consistent with 40 CFR 122.21(e)(3)(ii).
When there is no analytical method that has been approved under
40 CFR 136; required under 40 CFR chapter I, subchapter N or 0,
and is not otherwise required by the NPDES permitting authority,
you may use any suitable method but shall provide a description of
the method. When selecting a suitable method, other factors such
as a method's precision, accuracy, or resolution, may be
considered when assessing the performance of the method.
2C-6

FORM 2C—INSTRUCTIONS CONTINUED
Section 8. Used or Manufactured Toxics
Item 8.1. Indicate if any pollutant listed in Table B is used or
manufactured in your facility as an intermediate or final product or
byproduct. If yes, continue to Item 8.2. If no, skip to Section 9.
Item 8.2. List the applicable toxic pollutants. Note that the NPDES
permitting authority may waive or modify the requirement if you
demonstrate that it would be unduly burdensome to identify each
toxic pollutant and the permitting authority has adequate
information to issue you a permit. You may not claim this
information as confidential. Note that you do not need to distinguish
between use or production of the pollutants or list amounts.
Section 9. Biological Toxicity Tests
Item 9.1. Indicate if you have any knowledge or reason to believe
that any biological test for acute or chronic toxicity has been made
on any of your discharges or on a receiving water in relation to your
discharge within the last three years. If yes, continue to Item 9.2. If
no, skip to Section 10.
Item 9.2. Identify the tests known to have been performed and the
purposes of each. For each test, check "Yes" or "No" to indicate if
you have submitted the test results to the NPDES permitting
authority and the date the results were submitted. The NPDES
permitting authority may ask you to provide additional details after
reviewing your application.
Section 10. Contract Analyses
Item 10.1. Indicate if any of the analyses reported in Section 7 were
performed by a contract laboratory or consulting firm. If yes,
continue to Item 10.2. If no, skip to Section 11.
Item 10.2. Identify each laboratory or firm used in the table
provided. For each, provide the name, address, and phone number
of the laboratory or firm and the pollutants analyzed.
Section 11. Additional Information
Item 11.1. In addition to the information reported on the application
form, the NPDES permitting authority may request additional
information reasonably required to assess the discharges of the
facility and to determine whether to issue an NPDES permit. The
additional information may include additional quantitative data and
bioassays to assess the relative toxicity of discharges to aquatic life
and requirements to determine the cause of the toxicity. Indicate
under Item 11,1 whether the NPDES permitting authority has
requested additional information from you. If yes, continue to Item
11.2. If no, skip to Section 12.
Item 11.2. List the items requested and attach the required
information to the application.
Section 12. Checklist and Certification Statement
Item 12.1. Review the checklist provided. In Column 1, mark the
sections of Form 2C that you have completed and are submitting
with your application. In Column 2, indicate for each section
whether you are submitting attachments.
Item 12.2. The CWA provides for severe penalties for submitting
false information on this application form. Section 309(c)(2) of the
CWA provides that "Any person who knowingly makes any false
statement, representation, or certification in any application, ...shall
upon conviction, be punished by a fine of no more than $10,000 or
by imprisonment for not more than six months or both."
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A. For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) a president, secretary, treasurer, or vice-president of the
corporation in charge of a principal business function, or any
other person who performs similar policy- or decision -making
functions for the corporation, or (2) the manager of one or
more manufacturing, production, or operating facilities,
provided the manager is authorized to make management
decisions which govern the operation of the regulated facility
including having the explicit or implicit duty of making major
capital investment recommendations, and initiating and
directing other comprehensive measures to assure long term
environmental compliance with environmental laws and
regulations; the manager can ensure that the necessary
systems are established or actions taken to gather complete
and accurate information for permit application requirements;
and where authority to sign documents has been assigned or
delegated to the manager in accordance with corporate
procedures.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END
2C-7
Submit your completed Form 1, Form 2C, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

Exhibit 2C-1. Example Line Drawing
Blue River
Municipal
90,000 GPD Water Supply Blue River
10,000 GPD
45,000 GPD
J30,000 GPD
Cooling Water
Raw Materials�rNeutralization
Washing
10 000
5,000 GPD
10,000 GPD
GPD
To Atnrospt
f4O
40,000 10,000
To Product
GPD GPD
5,000 GPD
Solid WasteWaste
4,000 GPD
TreatmentD
Plant �2
36,000 GPD
34,000 GPD Ourfall 002
50,000 GPD
Waste
V
Outfa11001
y�tamrwarer
Treatment
70,000 GPD + Stormwa�er
Mai- 7n om GPr]
Plant =1
Schematic of Water Flow
Brown Mills, Inc.
City, County, State
2C-8

Exhibit 2C-2. Codes for Treatment Units and Disposal of Wastes Not Discharged
1—A ................Ammonia stripping
1—B ................ Dialysis
1—C ................ Diatomaceous earth filtration
1—D ................ Distillation
1—E ................ Electrodialysis
1—F................. Evaporation
1—G ................ Flocculation
1—H ................ Flotation
1-1.................. Foam fractionation
1—J ................. Freezing
1—K ................ Gas —phase separation
1—L................. Grinding (comminutors)
2—A ................
Carbon adsorption
2—B ................
Chemical oxidation
2—C ................
Chemical precipitation
2—D ................
Coagulation
2—E ................
Dechlorination
2—F.................
Disinfection (chlorine)
3—A ................Activated
sludge
3—B ................Aerated
lagoons
3—C ................
Anaerobic treatment
3—D ................
Nitrification—denitrification
4—A ................ Discharge to surface water
4—B ................Ocean discharge to outfall
5—A ................ Aerobic digestion
5-13 ................Anaerobic digestion
5—C ................ Belt filtration
5—D ................
Centrifugation
5—E ................Chemical
conditioning
5—F.................
Chlorine treatment
5—G ................
Composting
5—H ................
Drying beds
5-1..................
Elutriation
5—J .................
Flotation thickening
5—K ................
Freezing
5—L.................
Gravity thickening
1. PHYSICAL TREATMENT PROCESSES
1—M................Grit
removal
1—N ................Microstraining
1-0 ................
Mixing
1—P.................Moving
bed filters
1—Q ................
Multimedia filtration
1—R ................Rapid
sand filtration
1—S.................Reverse
osmosis (hyperfiltration)
1—T.................
Screening
1—U ................Sedimentation
(settling)
1—V.................
Slow sand filtration
1—W................
Solvent extraction
1—X.................
Sorption
2. CHEMICAL TREATMENT PROCESSES
2—G ................
Disinfection (ozone)
2—H ................Disinfection
(other)
2-1..................Electrochemical
treatment
2—J .................Ion
exchange
2—K.................
Neutralization
2—L .................
Reduction
3. BIOLOGICAL TREATMENT PROCESSES
3—E................. Pre -aeration
3—F.................Spray irrigation/land application
3—G ................ Stabilization ponds
3—H ................Trickling filtration
4. WASTEWATER DISPOSAL PROCESSES
4—C ................ Reuse/recycle of treated effluent
4—D ................Underground injection
5. SLUDGE TREATMENT AND DISPOSAL PROCESSES
2C-9
5—M ................
Heat drying
5—N ................
Heat treatment
5-0 ................
Incineration
5—P.................Land
application
5—Q ................
Landfill
5—R ................Pressure
filtration
5—S.................
Pyrolysis
5—T.................Sludge
lagoons
5—U ................Vacuum
filtration
5—V.................
Vibration
5—W................Wet
oxidation

Exhibit 2C-3. Testing Requirements for Organic Toxic Pollutants Industry Categories*
INDUSTRY CATEGORY
Volatile
GC/MS FRACTION?
Acid Base/Neutral
Pesticide
Adhesives and sealants........................................................
X
X
X
E
Aluminum forming.................................................................
X
X
X
❑
Auto and other laundries.......................................................
X
X
X
X
Battery manufacturing...........................................................
X
i i
X
❑
Coalmining...........................................................................
❑
Ci
❑
❑
Coilcoating...........................................................................
X
X
X
❑
Copperforming.....................................................................
X
X
X
❑
Electric and electronic compounds .......................................
X
X
X
X
Electroplating........................................................................
X
X
X
❑
Explosives manufacturing.....................................................
❑
X
X
❑
Foundries..............................................................................
X
X
X
❑
Gum and wood chemicals (all subparts except D and F) .....
X
X
❑
❑
Gum and wood chemicals, Subpart D (tall oil rosin) .............
X
X
X
❑
Gum and wood chemicals, Subpart F (rosin -based
X
X
X
❑
derivatives)...........................................................................
Inorganic chemicals manufacturing ......................................
X
X
X
❑
Iron and steel manufacturing ................................................
X
X
X
❑
Leather tanning and finishing
X
X
X
❑
Mechanical products manufacturing .....................................
X
X
X
❑
Nonferrous metals manufacturing .........................................
X
X
X
X
Ore mining, Subpart B (base and precious metals) ..............
❑
X
❑
❑
Organic chemicals manufacturing ........................................
X
X
X
X
Paint and ink formulation......................................................
X
X
X
❑
Pesticides.............................................................................
X
X
X
X
Petroleum refining.................................................................
X
11
❑
❑
Pharmaceutical preparations ................................................
X
X
X
❑
Photographic equipment and supplies ..................................
X
X
X
❑
Plastic and synthetic materials manufacturing ......................
X
X
X
X
Plastic processing.................................................................
X
❑
❑
❑
Printing and publishing.........................................................
X
X
X
X
Pulp and paperboard mills ....................................................
X
X
X
X
Rubber processing................................................................
X
X
X
❑
Soap and detergent manufacturing ......................................
X
X
X
❑
Steam electric power plants ..................................................
X
X
❑
❑
Textile mills (except Subpart C, Greige Mills) .......................
X
X
X
Ij
Timber products processing .................................................
X
X
X
X
* See note at conclusion of 40 CFR 122, Appendix D (1983) for explanation of effect of suspensions on testing requirements
for primary
industry categories.
t The pollutants in each fraction are listed in Table B.
X = Testing is required.
= Testing is not required.
2C-10

Exhibit 2C-4. Hazardous Substances
1. Acetaldehyde
73. Captan
144. Ferrous sulfate
2. Acetic acid
74. Carbaryl
145. Formaldehyde
3. Acetic anhydride
75. Carbofuran
146. Formic acid
4. Acetone cyanohydrin
76. Carbon disulfide
147. Fumaric acid
5. Acetyl bromide
77. Carbon tetrachloride
148. Furfural
6. Acetyl chloride
78. Chlordane
149. Guthion
7. Akxolein
79. Chlorine
150. Heptachlor
8. Acrylonitrile
80. Chlorobenzene
151. Hexachlorocyclopentadiene
9. Adipic acid
81. Chloroform
152. Hydrochloric acid
10. Aldrin
82. Chloropyrifos
153. Hydrofluoric acid
11. Allyl alcohol
83. Chlorosulfonic add
154. Hydrogen cyanide
12. Allyl chloride
84. Chromic acetate
155. Hydrogen sulfide
13. Aluminum sulfate
85. Chromic add
156. Isoprene
14. Ammonia
86. Chromic sulfate
157. Isopropanolamine dodecylbenzenesulfonate
15. Ammonium acetate
87. Chromous chloride
158. Kelthane
16. Ammonium benzoate
88. Cobaltous bromide
159. Kepone
17. Ammonium bicarbonate
89. Cobaltous formate
160. Lead acetate
18. Ammonium bichromate
90. Cobaltous sulfamate
161. Lead arsenate
19. Ammonium bifluoride
91. Coumaphos
162. Lead chloride
20. Ammonium bisulfite
92. Cresol
163. Lead fluoborate
21. Ammonium carbamate
93. Crotonaldehyde
164. Lead fluorite
22. Ammonium carbonate
94. Cupric acetate
165. Lead iodide
23. Ammonium chloride
95. Cupric acetoarsenite
166. Lead nitrate
24. Ammonium chromate
96. Cupric chloride
167. Lead stearate
25. Ammonium citrate
97. Cupric nitrate
168. Lead sulfate
26. Ammonium fluoroborate
98. Cupric oxalate
169. Lead sulfide
27. Ammonium fluoride
99. Cupric sulfate
170. Lead thiocyanate
28. Ammonium hydroxide
100. Cupric sulfate ammoniated
171. Lindane
29. Ammonium oxalate
101. Cupric tartrate
172. Lithium chromate
30. Ammonium silicofluodde
102. Cyanogen chloride
173. Malathion
31. Ammonium sulfamate
103. Cydohexane
174. Maleic add
32. Ammonium sulfide
104.2,4-D acid (2,4-dichlorophenoxyacetic acid)
175. Maleic anhydride
33. Ammonium sulfite
105. 2,4-D esters (2,4-dichlorophenoxyacetic acid esters)
176. Mercaptodimethur
34. Ammonium tartrate
106. DDT
177. Mercuric cyanide
35. Ammonium thiocyanate
107. Diazinon
178. Mercuric nitrate
36. Ammonium thiosulfate
108. Dicamba
179. Mercuric sulfate
37. Amyl acetate
109. Dichlobenil
180. Mercuric thiocyanate
38. Aniline
110. Dichlone
181. Mercurous nitrate
39. Antimony pentachloride
111. Dichlorobenzene
182. Methoxychlor
40. Antimony potassium tartrate
112. Dichloropropane
183. Methyl mercaptan
41. Antimony tribromide
113. Dichloropropene
184. Methyl methacrylate
42. Antimony trichlorde
114. Dichloropropene-dichloproropane mix
185. Methyl parathion
43. Antimony trifluoride
115.2,2-dichloropropionic acid
186. Mevinphos
44. Antimony trioxide
116. Dichlorvos
187. Mexacarbate
45. Arsenic disulfide
117. Dieldrin
188. Moncethylamine
46. Arsenic pentoxide
118. Diethylamine
189. Monomethylamine
47. Arsenic tchlodde
119. Dimethylamine
190. Naled
48. Arsenic trioxide
120. Dinitrobenzene
191. Naphthalene
49. Arsenic tsulfide
121. Dinitrophenol
192. Naphthenic add
50. Barium cyanide
122. Dinitrotoluene
193. Nickel ammonium sulfate
51. Benzene
123. Diquat
194. Nickel chloride
52. Benzoic acid
124. Disulfoton
195. Nickel hydroxide
53. Benzonitrile
125. Diuron
196. Nickel nitrate
54. Benzoyl chloride
126. Dodecylbenzesulfonic acid
197. Nickel sulfate
55. Benzyl chloride
127. Endosulfan
198. Nitric acid
56. Beryllium chloride
128. Enddn
199. Nitrobenzene
57. Beryllium fluoride
129. Epichlorohydrin
200. Nitrogen dioxide
58. Beryllium nitrate
130. Ethion
201. Nitrophenol
59. Butylacetate
131. Ethylbenzene
202. Nitrotoluene
60. n-butylphthalate
132. Ethylenediamine
203. Paraformaldehyde
61. Butylamine
133. Ethylene dibromide
204. Parathion
62. Butyric acid
134. Ethylene dichloride
205. Pentachlorophenol
63. Cadmium acetate
135. Ethylene diaminetetracetic acid (EDTA)
206. Phenol
64. Cadmium bromide
136. Ferric ammonium citrate
207. Phosgene
65. Cadmium chloride
137. Ferric ammonium oxalate
208. Phosphoric acid
66. Calcium arsenate
138. Ferric chloride
209. Phosphorus
67. Calcium arsenite
139. Ferric fluoride
210. Phosphorus oxychloride
68. Calcium carbide
140. Ferric nitrate
211. Phosphorus pentasulfide
69. Calcium chromate
141. Ferric sulfate
212. Phosphorus trichloride
70. Calcium cyanide
142. Ferrous ammonium sulfate
213. Polychlorinated biphenyls (PCB)
71. Calcium dodecylbenzenesulfonate
143. Ferrous chloride
214. Potassium arsenate
72. Calcium hypochlorite
215. Potassium arsenite
2C-11

Exhibit 2C-4. Hazardous Substances
216. Potassium bichromate
245. Sodium phosphate (dibasic)
271. Uranyl acetate
217. Potassium chromate
246. Sodium phosphate (tribasic)
272. Uranyl nitrate
218. Potassium cyanide
247. Sodium selenite
273. Vanadium penoxide
219. Potassium hydroxide
248. Strontium chromate
274. Vanadyl sulfate
220. Potassium permanganate
249. Strychnine
275. Vinyl acetate
221. Propargite
250. Styrene
276. Vinylidene chloride
222. Propionic acid
251. Sulfuric acid
277. Xylene
223. Propionic anhydride
252. Sulfur monochloride
278. Xylenol
224. Propylene oxide
253.2,4,5-T acid (2,4,5-trichlorophenoxyacetic acid)
279. Zinc acetate
225. Pyrethrins
254. 2,4,5-T amines (2,4,5-tdchlorophenoxy acetic acid
280. Zinc ammonium chloride
226. Quinoline
amines)
281. Zinc borate
227. Resorcinol
255. 2,4,5-T esters (2,4,5-tdchlorophenoxy acetic acid
282. Zinc bromide
228. Selenium oxide
esters)
283. Zinc carbonate
229. Silver nitrate
256. 2,4,5-T salts (2,4,54dchlorophenoxy acetic acid salts)
284. Zinc chloride
230. Sodium
257.2,4,5-TP acid (2,4,5-trichlorophenoxy propanoic acid)
285. Zinc cyanide
231. Sodium arsenate
258. 2,4,5-TP acid esters (2,4,5-tdchlorophenoxy propanoic
286. Zinc fluoride
232. Sodium arsenite
acid esters)
287. Zinc formate
233. Sodium bichromate
259. TDE (tetrachlorodiphenyl ethane)
288. Zinc hydrosulfite
234. Sodium bifluoride
260. Tetraethyl lead
289. Zinc nitrate
235. Sodium bisulfite
261. Tetraethyl pyrophosphate
290. Zinc phenolsulfonate
236. Sodium chromate
262. Thallium sulfate
291. Zinc phosphide
237. Sodium cyanide
263. Toluene
292. Zinc silicofluoride
238. Sodium dodecylbenzenesulfonate
264. Toxaphene
293. Zinc sulfate
239. Sodium fluoride
265. Trichlorofon
294. Zirconium nitrate
240. Sodium hydrosulfide
266. Trichloroethylene
295. Zirconium potassium fluoride
241. Sodium hydroxide
267. Trichlorophenol
296. Zirconium sulfate
242. Sodium hypochlorite
268. Triethanolamine dodecylbenzenesulfonate
297. Zirconium tetrachloride
243. Sodium methylate
269. Triethylamine
244. Sodium nitrite
270. Trimethylamine
2C-12

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 Kershaw WTP OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C 801 EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIO 1. OUTFALL LOCATIONi
1.1 Provide information on each of the facility's outfalls in the table below.
Outfa
Number Receiving Water Name Latitude Longitude
o o o
J
O
SECTIOND' 1
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• i
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number**
Operations
Operation Average Flow
mgd
mgd
is
mgd
c
y mgd
Treatment Units
0
U—
R 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
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110012909843
Kershaw 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 Dischar e
d
_
0
v
_
m
E
io
d
**Outfall Number**
Operations
0
Operation Average Flow
U-
a,
mgd
R
<
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 Dischar e
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d
❑ Yes ❑ No -* SKIP to Section 4.
�
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

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 Kershaw 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-* SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if n cessary.
Frequency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Days/We k
Months/Year
Average
Dail
days/week
months/year
mgd
mgd
days
odays/week
months/year
mgd
mgd
days
U_
days/week
months/year
mgd
mgd
days
w
E
days/week
months/year
mgd
mgd
days
m
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 daysSECTION
5. •'•D
• 1
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑ No -* SKIP to Section 6.
U)
5.2
Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory
Regulatory Citation
w
a�
m
Q
o.
Q
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
Cn
ElYes ❑ No -+ SKIP to Section 6.
a
0
;a
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
a
Number
Measure
a)
M
m
0
0
U
3
0
i
d
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 Kershaw WTP OMB No. 2040-0004
SECTIO 6. IMPROVEMENTS1
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 ouffall
Discharge
Required
Projected
o-
number
E
c
v,
d
CL
o.
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
;
requested and attached the results to this application package?
d
No; a waiver has been requested from my NPDES
❑ Yes ❑permitting
authority for all pollutants at all outfalls.
R
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
Y
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.)
-a
❑ 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?
UJ
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

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110012909843
Kershaw 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,
pollutants you have indicated are "Believed Present' in your discharge?
❑ Yes ❑ No
4)
Table C. Certain Conventional and Non -Conventional Pollutants
2
7.12
Have you indicated whether pollutants are 'Believed Present' or `Believed Absent' for all pollutants listed on Table C
for all outfalls?
U
•+
Y
❑
Yes ❑ No
c
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'?
c
❑ 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 TOXICSi
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?
❑ Yes ❑ No 4 SKIP to Section 9.
c
8.2
List the pollutants below.
0
1. 4. 7.
0
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 Kershaw WTP OMB No. 2040-0004
SECTION• •TOXICITY
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.
U
9.2
Identify the tests and their
3urposes below.
Test(s)
Purpose of Test(s)
Submitted to NPDES
Date Submitted
x
Permitting Authority?
0
f-
R
❑ Yes ❑ No
0
0
'm
❑ Yes ❑ No
❑ Yes ❑ No
SECTION•
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
10.1
❑ Yes ❑ No -+ 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
2,
Laboratory address
R
_
a
R
_
o
U
Phone number
Pollutant(s) analyzed
SECTIONDD
• •- • i
Has the NPDES permitting authority requested additional information?
11.1
_
❑ Yes ❑ No SKIP to Section 12.
0
11.2
List the information requested and attach it to this application.
0
1. 4.
0
2. 5.
-a
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No. 2040-0004
SECTION•
1
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 ❑ wl additional attachments
w/ list of each user of
Section 3: Average Flows and
❑
❑ 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
d
w/ small business exemption w/ other attachments
❑ ❑
request
in
❑ Section 7: Effluent and Intake
❑ w/ Table A ❑ w/ Table B
r-
Characteristics
❑ w/ Table C ❑ w/ Table D
U
w/ analytical results as an
❑ w/ Table E ❑
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
❑ Section 9: Biological Toxicity
❑ w/ attachments
s
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
Signature
Date signed
EPA Form 3510-2C (Revised 3-19) Page 7

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Oudall Number Form Approved 03I05/19
110012909843 1 NCO088331 Kershaw WTP 001 OMB No 204OMN
Effluent
Intake
(Opt nai
Waiver
Units
Maximum
Maximum
Long -Term
Pollutant
Requested
(may)
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
N/A
Mass
N/A
(BODa)
2.
Chemical oxygen demand
❑
Concentration
N/A
Mass
N/A
(COD)
Concentration
N/A
3.
Total organic carbon (TOC)
❑
Mass
N/A
Concentration
mg/L
19.9
N/A
2.1
52
4.
Total suspended solids (TSS)
❑
Mass
N/A
Concentration
mg/L
3.5
N/A
0.5
12
5.
Ammonia (as N)
❑
Mass
N/A
6.
Flow
❑
Rate
MGD
0.2
N/A
0.05
365
Temperature (winter)
❑
°C
°C
20.2
N/A
19.5
24
7.
Temperature (summer)
❑
°C
°C
25.9
N/A
19.5
24
pH (minimum)
❑
Standard units
S.U.
6.5
8.
pH (maximum)
❑
Standard units
s.u.
8.0
r Sampling shall be conducted acrxxdIng to sumciently sensitive test procedures (i.e., metnoss) approves under au t,rm uo Tor me anarysis or pomutants a punutdnt pdrdnretab ur
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03I05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
TOXICTABLE B.
1E,
TOTAL PHENOLS,1
ORGANIC TOXIC'
Presence or Absence
• • 1
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(andCAS Number, ifavailable)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Long-
Term
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
(rfavalable)
Discharge
g
Analyses
Value
Analyses
if 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
El
IZI
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
❑
❑
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
❑
❑❑
Concentration
Mass
(744041-7)
14
Cadmium, total
❑
O
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
❑
❑
❑
Concentration
Mass
(7440-47-3)
1.6
Copper, total
❑�
Concentration
ug/L
13
N/A
0.5
12
Mass
(7440-50-8)
1.7
Lead total
❑
El
❑
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
❑
❑❑
Concentration
Mass
(7439-97-6)
1 9
Nickel, total
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
El
❑❑
Concentration
Mass
(7782-49-2)
1.11
Silver, total
El
IZI
Concentration
1 Mass
(7440-224)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NC0088331 Kershaw WTP 001 OMB No 2040-0004
Units
(specify)
Effluent
Intake
Pollutant/Parameter
(and CAS Number. if available)
Testing
Required
Presence or Absence
check one
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Tenn
Average
Daily
Discharge
d available
Number
of
Analyses
Long -
Tenn
Average
Value
Number
of
Analyses
1.12
Thallium total
(7440-28-0)
Concentration
Mass
1.13
Zinc total
(7440 66 6)
�
❑
0
Concentration
ug/L
27
N/A
2.5
12
Mass
1.14
Cyanide, total
(57-12-5)
Concentration
Mass
1.15
Phenols, total
El
El
El
Concentration
Mass
Section 2.Organic Toxic Pollutants (GC/MS Fraction —Volatile Compounds)
21
Acrolein
(107-02-8)
❑
❑
❑�
Concentration
Mass
2.2
Acrylonitrile
(107-13-1)
©
Concentration
Mass
2.3
Benzene
(71-43-2)
Concentration
Mass
2.4
Bromoform
(75-25-2)
❑
❑
Concentration
Mass
2.5
Carbon tetrachloride
(�23-5)
El
©
Concentration
Mass
2.6
Chlorobenzene
(108.90-7)
Concentration
Mass
2.7
Chlorodibromomethane
(12448-1)
Concentration
Mass
2.8
Chloroethane
(75-00-3)
Concentration
Mass
EPA Form MUM (Revised 3-19) Page 12

EPA Idenfification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
• •
•UiL.
aellim-1011 •'
• '• •1Rujig
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/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
211
Dichlorobromomethane
❑
O
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
❑
❑
❑�
Concentration
Mass
(75-34-3)
213
12-dichlorcethane
Concentration
Mass
(107-06-2)
214
11-dichlorcethylene
[a
Concentration
Mass
(75.35-4)
215
12-dichloropropane
Concentration
Mass
(78-87-5)
216
13-dichloropropylene
Concentration
Mass
(542-75-6)
217
Ethylbenzene
Concentration
Mass
(100-41-4)
218
Methyl bromide
❑
❑❑
Concentration
Mass
(74-83-9)
219
Methyl chloride
❑
❑
O
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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number j Form Approved 03/05/19
110012909843 NCOO88331 Kershaw WTP 001 OMB No.2040-0004
TOXICTABLE B.
•E,
TOTAL PHENOLS,AND
ORGANIC TOXICPOLLUTANTSr
Intake
Presence or Absence
heckone
Effluent
(intak q
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number if available)
Required
o
Believed
Believed
(apeafy)
Daily
Monthly
Average
Number
Tenn
Number
Present
Absent
D(required) arge
Df
Daily
Discharge
Analyses
AYa
of
Analyses
aischarge vailable)
if available
uee
2.22
Tetrachloroethylene
Concentration
Mass
(127-18-4)
El
2.23
Toluene
❑
Concentration
Mass
(108-88-3)
2.24
1,2-trans-dichloroethylene
El
El
10
Concentration
Mass
(156-60-5)
225
1,1,1-trichloroethane
Concentration
Mass
(71-55-6)
2.26
1,1,2-trichloroethane
Concentration
Mass
(79-00-5)
2.27
Trichloroethylene
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
1
Concentration
Mass
(75-01-4)
Section 3. Organic Toxic Pollutants GCIMS Fraction —Acid Compounds
31
2-chlorophenol
❑
❑
Concentration
Mass
(95-57-8)
3.2
2,4-dichlorophenol
Concentration
Mass
(120-83-2)
3.3
2,4-dimethylphenol
❑
0
Concentration
Mass
(105-67-9)
3.4
4,6-dinitro-o-cresol
Concentration
(534-52-1)
3.5
2 4-dinitrophenol
❑
❑
IRtj
(51-28-5)
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NC0088331 Kershaw VJTP 001 OMB No.2040-0004
TOXICTABLE B. •E,
TOTAL PHENOLS,1
ORGANIC TOXIC•
• I
Presence or Absence
Intake
heck 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
D(required)
Daily
of
Average
of
ifavvailabllee)
Discharge
Analyses
Analyses
if available
3.6
2-nitrophenol
El
0
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
El
1:1
0
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
Concentration
Mass
(50-50-7)
3.9
Pentachlorophenol
Concentration
Mass
(87-86-5)
3.10
Phenol
0❑
Concentration
Mass
(108-95-2)
311
2,4,6-trichlorophenol
Ei
o
O
Concentration
Mass
(88-05-2)
Section 4. Organic Toxic Pollutants GCIMS Fraction —Base /Neutral Compounds)
4.1
Acenaphthene
11
El
El
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
El
El
❑�
Concentration
Mass
(208-96-8)
4.3
Anthracene
11
El
❑
Concentration
Mass
(120-12-7)
4.4
Benzidine
Concentration
Mass
(92-87-5)
4.5
Benzo (a) anthracene
❑
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
❑
0
❑
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outtall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
TOXICTABLE B.
1E,
TOTAL PHENOLS,1
ORGANIC TOXIC•
Presence or Absence
• 1
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(and CAS Number, rfavailable)
Testing
Required
Believed Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Long -
Term
Number
Present Absent
Daily
Discharge
Monthly
Discharge
Daily
of
Average
of
(required)
[if available)
Discharge
Analyses
Value
Analyses
davailable)
4.7
3,4-benzofluoranthene
❑
❑
❑�
Concentration
Mass
(205-99-2)
4.8
Benzo (ghi) perylene
Concentration
Mass
(191-24-2)
4.9
Benzo (k) fluoranthene
Concentration
Mass
(207-08-9)
4.10
Bis (2-chloroethoxy) methane
Concentration
Mass
(111-91-1)
411
Bis (2-chloroethyl) ether
Concentration
Mass
(111-444)
4 12
Bis (2-chloroisopropyl) ether
❑
❑
a
Concentration
Mass
(102-80-1)
4.13
Bis (2-ethylhexyl) phthalate
Concentration
Mass
(117-81-7)
4.14
4-bromophenyl phenyl ether
Concentration
Mass
(101-55-3)
4.15
Butyl benzyi phthalate
❑
❑
❑�
Concentration
Mass
(85-68-7)
4.16
2-chloronaphthalene
Concentration
Mass
(91-58-7)
4.17
4-chlorophenyl phenyl ether
Concentration
Mass
(7005-72-3)
418
Chrysene
Concentration
Mass
(218-01-9)
4 19
Dibenzo (a,h) anthracene
Concentration
Mass
(53-70-3)
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
1014 101
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, if available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Present
Absent
Discharge
Discharge
Daily
of
Average
of
(required)
(ae )
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
14-dichlorobenzene
❑
El
❑✓
Concentration
Mass
(106-46-7)
4.23
3 3-dichlorobenzidine
11
El
El
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
El
❑
❑✓
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
El
El
0
Concentration
Mass
(as azobenzene) (122-66-7)
4.31
Fluoranthene
❑
❑
121
Concentration
Mass
(20644-0)
4.32
Fluorene
El
❑
❑�
Concentration
Mass
(86-73-7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Idenfification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
• 1
•
•] It-w-j nelegeunI142•
' • • 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number. if available )
Required
q
Believed
Believed
(specify)
1 P r)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
of
Average
or
(required)
(if available)
Discharge
g
Analyses
Value
Analyses
if available
4.33
Hexachlorobenzene
❑
❑
❑
Concentration
Mass
(118-74-1)
4.34
Hexachlorobutadiene
❑
❑
Concentration
Mass
(87-68-3)
4.35
Hexachloro yclopentadiene
❑
❑
❑
Concentration
Mass
(77-474)
4.36
Hexachloroethane
❑
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno(1,2,3-cd) pyrene
El
❑
21
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
©
Concentration
Mass
(78-59-1)
4.39
Naphthalene
El
❑
El
Concentration
Mass
(91-20-3)
4.40
Nitrobenzene
ElMass
Concentration
(98-95-3)
4.41
N-nitrosodimethylarnme
❑
❑
❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑
❑✓
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑
Concentration
Mass
(86-30-6)
4
Phenanthrene
El
❑
©
Concentration
Mass
(85-01-8)
4.45
Pyrene
El
El
©1
Concentration
Mass
(129-00.0)
EPA Form 3510.2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCOO88331 Kershaw WTP 001 OMB No.2040-0004
• 1
•
• • • '
•ki [01240111HWINIZEE I1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
units
Maximum
Maximum
Long -Term
Long -
(and
(and CAS Number, N available)
Required
Believed
Believed
(��)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
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
❑
❑
❑�
Concentration
Mass
(319-84-6)
5.3
ji-BHC
El
El
❑
Concentration
Mass
(319.85-7)
5.4
y-BHC
El
ElMass
El
Concentration
(58-89-9)
5.5
b-BHC
❑
❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
El
Concentration
Mass
(57-74-9)
5.7
4 4'-DDT
❑
❑
Concentration
Mass
(50-29-3)
5.8
4 4'-DDE
❑
El
El
Concentration
Mass
(72-55-9)
5.9
4 4'-DDD
El
❑
IZI
Concentration
Mass
(72 54 8)
5.10
Dieldrin
ElMass
ID
Concentration
(60-57-1)
511
a-endosulfan
❑
❑
❑�
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)Average
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
5.12
j3-endosulfan
(115-29-7)
21
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
El
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)
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)
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
0
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑❑
Concentration
Mass
rPCB-1016
524
(12674-11-2)
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Perm t Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
• 1
•
• • • •
• • • - 1
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, rfavailable)
IToxaphene
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
d available
Concentration
001-35-2)
Mass
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 351D-2C (Revised 3-19) Page 21

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03105/19
110012909843 NCO088331 Kershaw WTP 001 OMB No. 2040MM
TWWR�,
M.
0Discharge
Qja���
Presence or Absence
Intake
chec one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Monthly
Long -Term
Average Daily
Nu
Long -Term
of
Present
Absent
Discharge
Discharge
Analyses
Analyses
Average
Analyses
Analyses
s
(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
ug/L
49
N/A
7.75
24
Mass
residual
3.
Color
❑
❑
Concentration
Mass
4.
Fecal coliform
El
❑�
Concentration
Mass
5
Fluoride
❑
❑
Concentration
Mass
(1698448-8)
6
Nitrate -nitrite
❑
Concentration
mg/L
1.82
N/A
1.13
4
Mass
7'
Nitrogen, total
El
El
Concentration
Concentration
mg/L
2.6
N/A
2.1
4
organic (as N)
8.
Oil and grease
❑
❑f
ConcentrationMass
9.
Phosphorus (as
❑
Concentration
mg/L
0.26
N/A
0.12
4
Mass
P), total (7723.14-0)
10
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
0
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Ouffall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
• •
Una
(specify)
Effluent
Intake
(Optional)
7P-l1ut,,t
Presence or Absence
check one
Believed
Present
Believed
Absent
Maximum DailyLong-Term
r9e
Discharge
(required)if
Maximum
Monthly
Discharge
available
Long -Term
Average Daily
Discharge
f available)
Number of
Analyses
Average
Value
Number of
Analyses
12
Sulfite (as S03)
(14265-45-3)
❑
❑
Concentration
Mass
13.
Surfactants
Concentration
Mass
14
Aluminum, total
(7429-90-5)
❑
❑
Concentration
Mass
15
Barium, total
(7440-39-3)
❑
❑
Concentration
Mass
16 Boron total
(7440-42-8)
❑
❑
Concentration
Mass
17 Cobalt, total
(7440-48-4)
❑
❑
Concentration
Mass
18.Iron, total
(7439-09-6)
El
El
Concentration
Mass
19 Magnesium, total
(7439-954)
❑
❑
Concentration
Mass
20•
Molybdenum,
total
7439-98-7
El
Concentration
Mass
21
Manganese, total
(7439-96-5)
❑
❑
Concentration
Mass
22
Tin total
(7440-31-5)
❑
❑
Concentration
Mass
23
Titanium, total
(7440-32-6)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Forth Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No. 2040-0004
Presence or Absence
Intake
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(speafy)
Maximum Daily
Maximum
Monthly
Long -Tenn
Average Daily
Number of
Long -Term
Number of
Present
Absent
Discharge
r9
Discharge
Discharge
Analyses
Average
Analyses
(squired)
d available
if available)Value
24. Radioactivity
Alpha, total
El
❑�
Concentration
Mass
Beta, total
❑
Concentration
Mass
Radium, total
❑
❑�
Concentration
Mass
Radium 226, total
❑
E]
Concentration
Mass
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 351042C (Revised 3-19) Page 25

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NC0088331 Kershaw WTP OMB No. 2040-0004
Pollutant
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Believed
Present
Believed
Absent
1.
Asbestos
❑
❑
2.
Acetaldehyde
❑
❑
3.
Ally] 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

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No.2040-0004
Pollutant
r2,4Drophenoxyacetic
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Believed
Present
Believed
Absent
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

EPA Identification Number NPOES Permit Number I Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No. 2040-0004
' 1 •
Pollutant
rGuthion
1 • IPresence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specdy units)
Believed
Present
Believed
Absent
❑
❑
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.
Monornethyl amine
❑
❑
54.
Naled
❑
❑
55.
Naphthenic acid
❑
❑
56.
Nitrotoluene
❑
❑
57.
Parathion
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No, 2040-0004
Pollutant
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Believed
Present
Believed
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-bichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑
72.
Triethanolamine
❑
❑
73.
Triethylamine
❑
❑
74.
Trimethylamine
❑
❑
75.
Uranium
❑
❑
76.
Vanadium
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Idenfification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No.2040-0004
Pollutant
rVinyl
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specifyurts)
Believed
Present
Believed
Absent
❑
❑
78. Xylene
❑
❑
79. Xylenol
❑
❑
80. 1 Zirconium
❑
❑
r 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

This page intentionally left blank.

110012909843
Pollutant
2,3,7,8-TCDD
NCO088331
TCDD Presence or
Congeners Absence
Used Or checkone
Manufactured Believed Believed
Present Absent
Kershaw WTP
Results of Screening Procedure
Form Approved 03/05/19
OMB No. 2040AN
EPA Form 3510-2C (Revised 3-19) Page 33

* : _,�, . _ ..- ' +►:' a - "ate: 'a► .,' j' -. = _=r _",. -� - _ - � . a;;y
Outfall 001 A.
- �.. -^ ,. •;.::alc_ �_,•.::.^.:•�K� •`�'�. �^ m. -!'^ (flows SOUth)`;w .
0 - " . Holt:a Chaff
`\� �•;
Tarkiln Creek
• [tidal]
i
r
a
dM Janiero Rd
Kershaw Rd
St 8teph Ch
Dawson Creek
" 7
q "•� �Sr.. .�.� [tidal] �_ - � � _ o
4.
Pamlico County Water System
Kershaw Water Treatment Plant (WTP)
4116 Kershaw Road, Arapahoe 28S10
State Grid/USGS Quad: G31SE / Arapahoe, NC Stream Segment: 27-125-7
Drainage Basin: Neuse River Basin Sub -Basin: 03-04-10
Latitude: 35° 01' 53' Longitude: 76" 46' 10"
Stream Class: SC; NSW HUC: 030202040601
Receiving Stream: UT to Tarkiln Creek
Facility
Location No,«,u,k,
NPDES Permit NCO088331
North
Scale 1:24,000 Pamlico County

EPA Identification Number NPDES Permit Number Facility Name Outlall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
TABLE B. TOXIC METALS, CYANIDE,
TOTAL PHENOLS,
AND ORGANIC TOXIC
POLLUTANTS (40 CFR
122.21(g)(7)(v))'
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
(and CAS Number, K available)
Testing
Required
Believed
Believed
Units
(spec4)
Maximum
Maximum
Long -Term
Average
Average
Number
Long -
Tee
Number
Present
Absent
Daily
Discharge
aa
Monthly
Ddavilaiabllee)
of
Average
of
(required)
Discharge
Analyses
Value
Analyses
d available
Check here if you quality 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
Concentration
Mass
(744041-7)
1.4
Cadmium, total
11
El
ID
Concentration
Mass
(744043-9)
1.5
Chromium, total
❑
❑
Concentration
Mass
(7440.47-3)
1.6
Copper, total
Concentration
ug/L
13
N/A
0.5
12
Mass
(7440-50-8)
1.7
Lead total
❑
❑
El
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
❑
❑
0
Concentration
Mass
(7439-97-6)
1.9
Nickel, total
❑
❑
✓❑
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
11
El
El
Concentration
Mass
(7782-49-2)
1.11
Silver, total
❑
❑
❑
Concentration
Mass
(7440-22.4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permil Number Facility Name OutfaA Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No. 2040-0004
TOXICTABLE B.
•E,
TOTAL PHENOLS,ORGANIC
TOXIC••
41
Units
(specify)
Effluent
Intake
(optional)
PollutaMlParameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
ched one
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Tenn
Average
Daily charof
Discharge
d available
Number
Analyses
Long -
Tent
Average
Value
Number
Analpn
1.12
Thallium, total
(7440-28-0)
❑
❑
Concentration
Mass
1.13
Zinc total
(7440-66-6)
❑
O
Concentration
ug/L
n
N/A
2.5
12
Mass
1.14
Cyanide, total
(57-12-5)
Concentration
Mass
1.15
Phenols, total
Concentration
Mass
Section 2.Organic Toxic Pollutants (GCIMS Fraction —Volatile Compounds)
21
Acrolein
(107-02-8)
❑
❑
Concentration
Mass
2 2
Acrylonitrile
(107-13-1)
❑
❑
0
Concentration
Mass
2.3
Benzene
(71-43-2)
Concentration
Mass
2.4
Bromoform
(75-25-2)
Concentration
Mass
2.5
Carbon tetrachloride
(56-23-5)
Concentration
Mass
2.6
Chlorobenzene
(108-90-7)
Concentration
Mass
2.7
Chlorodibromomethane
(124-48-1)
Concentration
Mass
2.8
Chloroethane
(75-00-3)
❑
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 12

EPA identification Number NPDES Pennd Number Facility Name Outfall Number Form Approved 03/05119
110012909843 NC0088331 Kershaw WTP 001 OMB No. 2040-0004
1-2
miul
Intake
Presence or Absence
checi. one)
Effluent
(optional)
— --
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Believed
Believed
Units
(specify)
Maximum
Maximum
Long -Term
Average
Number
Lon
Tenn
Number
Present
Absent
Daily
Discharge
Monthly
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required)
(if available)
if available
Value
2 9
2-chloroethylvinyl ether
❑
❑
❑
Concentration
Mass
(110-75-8)
2.10
Chloroform (67-66 3)
❑
❑
Concentration
Mass
2.11
Dichlorobromomethane
❑
❑
Concentration
Mass
(75-27-4)
212
1,1-dichloroethane
❑
❑
❑
Concentration
Mass
(75-34-3)
213
1,2-dichloroethane
❑
❑
❑
Concentration
Mass
(107-06-2)
214
1,1-dichloroethylene
❑
❑
❑
Concentration
Mass
(75-35-4)
2.15
1,2-dichloropropane
❑
❑
❑
Concentration
Mass
(78-87-5)
216
1,3-dichloropropylene
❑
❑
El
Concentration
Mass
(542-75-6)
217
Ethylbenzene
❑
❑
❑
Concentration
Mass
(100-41-4)
218
Methyl bromide
❑
❑
❑
Concentration
Mass
(74-83-9)
219
Methyl chloride
❑
❑
✓❑
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

EPA Identificafion Number NPDES Permit Number Facility Name Outfall Number Form Approved 03105119
110012909843 NCO088331 Kershaw WTP 001 OMB No.204UN4
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long'
(and CAS Number, ifavailable)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
Daily
Discharge
g
of
Analyses
Average
of
Analyses
(required)
(if available)
able)
d available)
Value
2 22
Tetrachloroethylene
❑
❑
❑
Concentration
Mass
(127-18-4)
2.23
Toluene
El
ElMass
El
Concentration
(108-88-3)
2.24
1,2-trans-dichloroethylene
❑
❑
©
Concentration
Mass
(156-60-5)
2.25
11,1-trichloroethane
El
El
❑
Concentration
Mass
(71-55-6)
2.26
11 2-trichloroethane
❑
El
El
Concentration
Mass
(7300-5)
❑
2 27
Trichloroethylene
El
❑
Concentration
Mass
(79-01-6)
2.28
Vinyl chloride
❑
❑
❑
Concentration
Mass
(75-014)
Section 3. Organic Toxic Pollutants GCIMS Fraction —Acid Compounds)
31
2-chlorophenol
❑
❑
❑
Concentration
Mass
(95-57-8)
3.2
2 4-dichlorophenol
❑
❑
❑✓
Concentration
Mass
(120-83.2)
3.3
2 4-dimethylphenol
❑
ElMass
El
Concentration
(105-67-9)
3.4
4 6-dinitro-o-cresol
❑
❑
O
Concentration
Mass
(534-52-1)
3.5
24-dinitrophenol
❑
❑
©
Concentration
(51-28-5)
1
1Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 1 NCO088331 Kershaw WTP 001 OMB No. 2040-0004
Intake
Presence or Absence
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum Maximum
Long -Term
Long -
(and CAS Number, if available)
Required
Believed
Believed
(sperdvl
Daily Monthly
Average
Number
Term
Number
Present
Absent
Discharge Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
(required) (ifavailable)
if available
Value
3.6
2-nitrophenol
❑
❑
❑✓
Concentration
Mass
(88-75-5)
3.7
4-nitrophenol
11
El
El
Concentration
Mass
(100-02-7)
3.8
p-chloro-m-cresol
El
❑
El
Concentration
Mass
(59-50-7)
3.9
Pentachlorophenol
1:1
El
El
Concentration
Mass
(87-86-5)
3.10
Phenol
Concentration
Mass
(108-95-2)
3.11
2,4,6-tdchlorophenol
Concentration
Mass
(88-05-2)
Section 4. Organic Toxic Pollutants GCIMS Fraction —Base /Neutral Compounds)
4.1
Acenaphthene
El
11
Q
Concentration
Mass
(83-32-9)
4.2
Acenaphthylene
Concentration
Mass
(208-96.8)
4.3
Anthracene
El
El
Concentration
Mass
(120-12-7)
4.4
Benzidine
11
El
El
Concentration
Mass
(92-87-5)
4.5
Benzo(a) anthracene
11
El
El
Concentration
Mass
(56-55-3)
4.6
Benzo (a) pyrene
Concentration
Mass
(50-32-8)
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03105/19
110012909843 NCO088331 Kershaw WTP 001 OMB No. 2040-0004
• 11:0
fol
• g I 111w
Sm' • • r
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Tenn
Long•
(and CAS Number,Navalabie)
Required
Believed
Believed
(Sp")
Daily
Monthlye
Number
Tenn
Number
Present
Absent
Discharge
Dischargege
Analyses
AverageAnalyses
(required)
(if available)le
Value
4.7
3,4-benzofluoranthene
❑
❑
❑
Concentration
Mass
(205-99-2)
4.8
Benzo (ghi) perylene
❑
❑
❑✓
Concentration
Mass
(191-24-2)
4.9
Benzo (k) fluoranthene
❑
❑
Concentration
Mass
(207 08-9)
4.10
Bis (2-chloroethoxy) methane
❑
❑
❑
Concentration
Mass
(111-91-1)
411
Bis (2-chloroethyl) ether
❑
❑
❑✓
Concentration
Mass
(111-44-4)
4.12
Bis (2-chloroisopropyl) ether
❑
❑
Concentration
Mass
(102-80-1)
4.13
Bis (2-ethylhexyl) phthalate
❑
❑
❑✓
Concentration
Mass
(117-81-7)
4.14
4-bromophenyl phenyl ether
❑
❑
❑
Concentration
Mass
(101-55-3)
4.15
Butyl benzyl phthalate
❑
❑
❑
Concentration
Mass
(85-68-7)
4.16
2-chloronaphthalene
❑
❑
❑
Concentration
Mass
(91-58-7)
4.17
4-chlorophenyl phenyl ether
❑
❑
Q
Concentration
Mass
(7005-72-3)
418
Chrysene
❑
❑
❑
Concentration
Mass
(218-01-9)
4.19
Dibenzo (a,h) anthracene
❑
❑
❑
Concentration
Mass
(53-70-3)
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved D3/DS/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Tenn
Long-
(and CAS Number, if available )
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
chargavailable
Daily
Discharge
of
Analyses
A
of
Analyses
required)
d available
Va uee
4.20
12-dichlorobenzene
El
El
0
Concentration
Mass
(95-50-1)
4.21
1 3-dichlorobenzene
Concentration
Mass
(541-73-1)
422
114-dichlorobenzene
El
1:1
El
Concentration
Mass
(106-46-7)
4.23
3,3-dichlorobenzidine
El
El
El
Concentration
Mass
(91-94-1)
4.24
Diethyl phthalate
11
El
El
Concentration
Mass
(84-66-2)
4.25
Dimethyl phthalate
O
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
El
El
IZI
Concentration
Mass
(117-84-0)
4.30
1,2-Diphenylhydrazine
❑
El
❑
Concentration
Mass
(as azobenzene)(122-66-7)
4.31
Fluoranthene
❑
❑
Concentration
Mass
(20644-0)
4.32
Fluorene
Concentration
Mass
(86 73 7)
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 I Kershaw WTP 001 OMB No.2040-0004
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, rf available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Tenn
Number
Present
Absent
Discharge
Ddavailabble)
Daily
Discharge
of
Analyses
Average
of
Analyses
rf available)
4.33
Hexachlorobenzene
❑
❑
❑
Concentration
Mass
(118-74-1)
4' 34
Hexachlorobutadiene
El
❑
El
Concentration
Concentration
(87-68-3)
4.35
Hexachlorocyclopentadiene
❑
❑
❑
Concentration
Mass
(77-474)
4.36
Hexachloroethane
❑
❑
❑
Concentration
Mass
(67-72-1)
4.37
Indeno (1,2,3-cd) pyrene
❑
Cl
❑
Concentration
Mass
(193-39-5)
4.38
Isophorone
❑
❑
Q
Concentration
Mass
(78-59-1)
4.39
Naphthalene
❑
❑
Q
Concentration
Mass
(91-20.3)
4.40
Nitrobenzene
❑
❑
Concentration
Mass
(98-95-3)
4.41
N-nitrosodimethylamine
❑
❑
❑
Concentration
Mass
(62-75-9)
4.42
N-nitrosodi-n-propylamine
❑
❑
❑
Concentration
Mass
(621-64-7)
4.43
N-nitrosodiphenylamine
❑
❑
❑
Concentration
Mass
(86-30-6)
4
Phenanthrene
El
❑
❑
Concentration
(85-01-8)
4.45
❑
❑
El
LMassPyrene entration
(129-00-0)
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Ouffall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
TOXICTABLE B.
•PHENOLS,AND
ORGANIC
• • r
Presence or Absence
Intake
check one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Terre
Long -
(and CAS Number, 4 available)
Required
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Terre
Number
Present
Absent
Discharge
Discharge
aily
Discharge harge
of
Analyses
Average
Of
Analyses
(required)
(if available)
if available
Value
1,2,4-fichlorobenzene
4.46
El
El
❑
Concentration
Mass
(120 82 1)
Section 5. Organic Toxic Pollutants GCIMS Fraction —Pesticides
5.1
Aldrin
❑
❑
Concentration
Mass
(309-00-2)
5.2
a-BHC
El
❑
El
Concentration
Mass
(319-84-6)
5.3
Q-BHC
❑
❑
❑
Concentration
Mass
(319-85.7)
5.4
y-BHC
El
❑
El
Concentration
Mass
(58-89-9)
5.5
6-BHC
❑
❑
❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
ElMass
El
Concentration
(57-74-9)
5.7
4,4'-DDT
❑
❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
ElMass
ID
Concentration
(72-55-9)
5.9
4,4'-DDD
❑
El
El
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
❑
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
El
ElMass
El
Concentration
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Numher Form Approved 03105/19
110012909843 NCO088331 Kershaw VJTP 001 OMB No.2040-0004
[7(.
•
Testing
Required
• 1 •'
Presence or Absence
check one
• '•1
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long•TerrnMaximum
Average
Daily
Discharge
if available
Number
of
Analyses
Long -
Term
Average
Value
Number
of
Analyses
512
R-endosulfan
(115-29-7)
El
11
El
Concentration
Mass
5.13
Endosulfan sulfate
(1031-07-8)
El
El
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)
�❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
❑
❑❑
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
❑
❑
E✓
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
❑
❑
0
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
El
El
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
❑
❑
❑�
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)
❑
0
❑✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw V✓TP 001 OMB No.2040-OW4
Intake
Presence or Absence
heck one
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number, if available)
(and
Required
Believed
Believed
(speciry)
Daily
Monthlyof
Average
Number
Term
Number
Present
Absent
Discharge
Discharge)
aily
DisDcharge
of
Analyses
Average
Analyses
(required)
(if
d available
alue
Toxaphene
5.25
❑
❑
Concentration
Mass
(8001-35-2)
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 GFR 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

EPA Identification Number NPDES Permit Number Facility Name Outrall Number Form Approved 03/05/19
110012909843 1 NC0088331 Kershaw WTP 1 001 OMB No. 2040-M
0Discharge
Intake
Presence or Absence
check one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum
Monthly
Long -Term
Average Daily
Number of
Long -Tenn
Number of
Present
Absent
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
❑
❑
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑✓
❑
Concentration
ug/L
49
N/A
7.75
24
Mass
residual
3.
Color
❑
Concentration
Mass
4.
Fecal coliform
❑
0
ConcentrationMass
5
Fluoride
❑
❑
Concentration
Mass
(16984-48-8)
6
Nitrate
❑�
❑
Concentration
mg/L
1 82
N/A
1.13
4
Mass
nitrite
7'
Nitrogen, total
❑
Concentration
mg/L
2.6
N/A
2.1
4
Mass
organic (as N)
8.
Oil and grease
❑❑
ConcentrationMass
9'
Phosphorus (as
El
❑
Concentration
mg/L
0.26
N/A
0.12
4
Mass
P), total (7723.140)
10
Sulfate (as SO4)
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
❑✓
Concentration
Mass
EPA Form 3510.2C (Revised 3.19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No. 2040-0004
Pollutant
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(Optional)
Believed
Present
Believed
Absent
Maximum Daily
Discharge ry
(required)
Maximum
Monthly
Discharge
(available
Long -Term
Average Daily
Discharge
ifavaiable
Number of
Analyses
Long -Term
Average
Value
Number of
Analyses
12
Sulfite (as S03)
(1426545.3)
❑
❑�
Concentration
Mass
13.
Surfactants
0
Concentration
Mass
14
Aluminum, total
(7429-90 5)
Concentration
Mass
15
Barium, total
(7440-39.3)
Concentration
Mass
16
Boron total
(7440-42-6)
El
Concentration
Mass
17
Cobalt total
V44"")
Concentration
Mass
113
Iron total
(7439-89-6)
Concentration
Mass
19
Magnesium, total
V439-95-4)
❑✓
Concentration
Mass
20.
Molybdenum,
total
439.98-7
0
Concentration
Mass
21
Manganese, total
(7439.96-5)
El
El
Concentration
Mass
22
Tin total
(7440-31-5)
El
El
Concentration
Mass
23
Titanium, total
(744o-32-0)
El
IZI
Concentration
Mass
EPA Form 3510.2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05/19
110012909843
NCO088331
Kershaw WTP
001
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
24.
Radioactivity
Alpha, total
❑
❑✓
Concentration
Mass
Beta, total
El❑✓
Concentration
Mass
Radium, total
El
0
Concentration
Mass
Radium 226, total
Concentration
Mass
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 25

United States Office of Water EPA Form 3510-2E
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
� E�► Application Form 2E
Manufacturing, Commercial,
Mining, and Silvicultural
Facilities Which Discharge
Only Nonprocess Wastewater
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is a new or existing manufacturing, commercial,
mining, and silvicultural facility that discharges only nonprocess wastewater.

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to collect and complete
Form 2E to be 13.5 hours. This estimate includes time for reviewing instructions, searching existing data
sources, gathering and maintaining the needed data, and completing and reviewing the collection of
information. Send comments about the burden estimate or any other aspect of this collection of
information to the Chief, Information Policy Branch (PM-223), U.S. Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17th Street, Washington, DC 20503, marked
"Attention: Desk Officer for EPA."

FORM 2E—INSTRUCTIONS
General Instructions
Who Must Complete Form 2E?
You must complete Form 2E if you answered "Yes" to Item 1.2.4 on
Form 1—that is, if you are a new or existing facility (including
manufacturing, commercial, mining, and silvicultural facilities) that
discharges only nonprocess wastewater.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2E) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1-1 of Form 1's "General
Instructions" to identify your NPDES permitting authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2E (or related attachments) as
confidential.
You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2E. Note that NPDES permitting authorities will deny claims for
treating any effluent data as confidential. If you do not assert a
claim of confidentiality at the time you submit your information to
the NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will handle
claims of confidentiality in accordance with the Agency's business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).
Completion of Forms
Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.
Provide your EPA Identification Number from the Facility Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 2E and any attachments. If you do not know
your EPA Identification Number, contact your NPDES permitting
authority. See Exhibit 1-1 of Form 1's "General Instructions" for
contact information.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter "NA" for "not applicable" to
demonstrate that you considered the item and determined a
response was not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority's satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
Definitions
The legal definitions of all key terms used in these instructions and
Form 2E are in the "Glossary" at the end of the "General
Instructions" in Form 1.
Follow-up Requirements for New Dischargers
Note that no later than 24 months after commencement of
discharge from the proposed facility, you must complete and
submit Section 4 of this form. At that time you must test and report
actual rather than estimated data for the pollutants or parameters
listed, unless waived by the NPDES permitting authority.
Line -by -Line Instructions
If you have multiple outfalls, you must submit a separate Form 2E
for each (Sections 1, 3, and 4 only).
Section 1.Outfall Location
Item 1.1. Complete sections 1 through 6 for each outfall. Provide
the latitude and longitude to the nearest 15 seconds for the outfall.
Latitude and longitude coordinates may be obtained in a variety of
ways, including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.Iarc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS). The
location of each outfall (i.e., where the coordinates are collected)
shall be the point where the discharge is released into a water of
the United States. If you need further guidance in responding to
Item 1. 1, refer to htto://www.epa.ciov/geosl)atial/latitudelongitude-
data-standard.
Section 2. Discharge Date
Item 2.1. Indicate whether you are a new or an existing discharger.
If you are an existing discharger, skip to Section 3 after completing
this item.
Item 2.2. Indicate the date on which the facility will or is estimated
to commence discharge.
Section 3. Waste Types
Item 3.1. Indicate the general type(s) of wastes being discharged or
to be discharged, depending on whether you are an existing or new
discharger. If you mark the response "Other Nonprocess
Wastewater," specify the nature of your discharge.
Item 3.2. Indicate if the facility uses cooling water additives. If yes,
continue. If no, skip to Section 4.
Item 3.3. List the cooling water additives being used (or to be used)
and specify the composition of the additives, if such information is
available to you. You can generally find composition information on
product labels or from manufacturers' data sheets.
Section 4. Effluent Characteristics
Items 4.1 to 4.8. These items require you to collect and report data
for the parameters and pollutants listed in Section 4. The
instructions are distinct for applicants with existing discharges
versus applicants that are new.
Important note: Read the "General Instructions for Reporting,
Sampling, and Analysis" on pages 2E-3 and 2E-4 before
completing Section 4.
2E-1

FORM 2E—INSTRUCTIONS CONTINUED
Item 4.1. Indicate whether you have completed monitoring for all
parameters in the table under Item 4.2 and attached it to the
application package. If you answer "No" because you have
requested a waiver from your NPDES authority, skip to Section 5. If
"Yes," continue to Item 4.2.
Item 4.2. Provide the sampling data requested in the table per the
"General Instructions for Reporting, Sampling, and Analysis" for
biochemical oxygen demand (BOD), total suspended solids (TSS),
oil and grease, ammonia (as N), flow, pH, and temperature (winter
and summer).
Item 4.3. Answer whether you believe fecal coliform to be present
in your discharge or whether sanitary waste is discharged (or will be
discharged). If you answer "No," skip to Item 4.5. Otherwise,
continue to Item 4.4.
Item 4.4. Provide the sampling data requested in the table per the
"General Instructions for Reporting, Sampling, and Analysis" for
fecal coliform, Escherichia coli (E. colt), and enterococci.
Item 4.5. Indicate whether chlorine is used (or will be used). If no,
skip to Item 4.7. Otherwise, continue to Item 4.6.
Item 4.6. Provide the sampling data requested in the table per the
"General Instructions for Reporting, Sampling, and Analysis" for
total residual chlorine.
Item 4.7. Answer whether non -contact cooling water is (or will be)
discharged from your facility. If no, skip to Section 5. If yes,
continue to Item 4.8.
Item 4.8. Provide the sampling data requested in the table per the
"General Instructions for Reporting, Sampling, and Analysis" for
chemical oxygen demand (COD), and total organic carbon (TOC).
Section 5. Flow
Item 5.1. Indicate whether any of the discharges that you described
in Sections 1 and 3 (except for stormwater runoff, leaks, or spills)
are intermittent or seasonal. If yes, continue to Item 5.2. If no, skip
to Section 6.
Item 5.2. Describe the average frequency of flow and duration of
any intermittent or seasonal discharge (except for stormwater
runoff, leaks, or spills) in gallons or million gallons per day (gpd or
mgd), whichever is appropriate. The frequency of flow is the
number of days or months per year there is an intermittent
discharge. Duration is the number of days or hours per discharge.
For new dischargers, report your best estimate.
Section 6. Treatment System
Item 6.1. Briefly describe any treatment system(s) used (or to be
used for new dischargers), indicating whether the treatment system
is physical, chemical, biological, sludge and disposal, or other. Also
give the particular type(s) of process(es) used (or to be used). For
example, if a physical treatment system is used (or will be used),
specify the processes applied (or to be applied), such as grit
removal, ammonia stripping, dialysis, etc.
Section 7.Other Information
Item 7.1. OPTIONAL ITEM. Report any additional information or
data (such as sampling results) that you believe the NPDES
permitting authority should consider when establishing permit
limitations. If you wish to demonstrate your eligibility for a "net'
effluent limitation (i.e., an effluent limitation adjusted to provide
credit for the pollutant(s) present in your intake water) add a short
statement as to why you believe you are eligible. See also 40 CFR
122.45(g). You will be contacted by the NPDES permitting authority
with further instructions.
Section 8. Checklist and Certification Statement
Item 8.1. Review the checklist provided on the application. In
Column 1, mark the sections of Form 2E that you have completed
and are submitting with your application. For each section in
Column 2, indicate whether you are submitting attachments.
Item 8.2. The Clean Water Act (CWA) provides for severe penalties
for submitting false information on this application form. CWA
Section 309(c)(2) provides that "Any person who knowingly makes
any false statement, representation, or certification in any
application, ...shall upon conviction, be punished by a fine of no
more than $10,000 or by imprisonment for not more than six
months, or both."
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A. For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) a president, secretary, treasurer, or vice-president of the
corporation in charge of a principal business function, or any
other person who performs similar policy- or decision -making
functions for the corporation, or (2) the manager of one or
more manufacturing, production, or operating facilities,
provided the manager is authorized to make management
decisions which govern the operation of the regulated facility
including having the explicit or implicit duty of making major
capital investment recommendations, and initiating and
directing other comprehensive measures to assure long term
environmental compliance with environmental laws and
regulations; the manager can ensure that the necessary
systems are established or actions taken to gather complete
and accurate information for permit application requirements;
and where authority to sign documents has been assigned or
delegated to the manager in accordance with corporate
procedures.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END
Submit your completed Form 1, Form 2E, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.
2E-2

General Instructions for Reporting, Sampling, and Analysis
Important note: Read these instructions before completing Section
4 of Form 2E.
General Items
Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit number,
facility name, and applicable outfall number at the top of each page
of any associated attachments.
You may report some or all of the required data by attaching
separate sheets of paper instead of completing Section 4 for each
of your outfalls so long as the sheets contain all of the required
information and are similar in format to Section 4.
Reporting of Effluent Data
Report pollutant levels for all pollutants in Section 4 as
concentration and total mass, with the exception of flow, pH, and
temperature. Total mass is the total weight of pollutants
discharged over a day.
Flow, temperature, pH, and fecal coliform organisms must be
reported as mgd, degrees Celsius (°C), standard units, and most
probable number per 100 milliliters (MPN/100 mL), respectively.
Use the following abbreviations in the columns requiring "units" in
Section 4.
Concentration
Mass
ppm = parts per million
Ibs = pounds
mg/L = milligrams per liter
ton = tons (English tons)
ppb = parts per billion
mg = milligrams
Ng/L = micrograms per liter
g = grams
MPN = most probable number per
kg = kilograms
100 milliliters
T = tonnes (metric tons)
Existing Dischargers
You must provide at least one analysis for each parameter or
pollutant, including the following: BOD, TSS, oil and grease,
ammonia (as N), fecal coliform including E. coli and enterococci (if
believed present or if sanitary waste is or will be discharged), total
residual chlorine (if chlorine is or will be used), COD, and TOC (if
non -contact cooling water is or will be discharged), discharge flow,
pH, and temperature (winter and summer).
You may report quantitative data that you have collected over the
past 365 days if they are representative of your current operations.
The data reported must include maximum daily discharge, average
daily discharge, and number of analyses. Most existing facilities
routinely monitor the pollutants and parameters listed in Section 4
as part of their existing NPDES permit requirements.
You must collect and analyze samples in accordance with 40 CFR
136. Grab samples must be used for analyses of pH, temperature,
total residual chlorine, oil and grease, fecal coliform (including E.
coli), and enterococci (previously known as fecal streptococcus)
and volatile organic compounds. Twenty -four-hour composite
samples must be used for all other pollutants, using at least four
grab samples unless otherwise specified at 40 CFR 136. For a
composite sample, only one analysis of the composite of aliquots is
required.
If you have sampling and analysis questions, direct them to your
NPDES permitting authority. The authority may request that you do
additional testing, if appropriate, on a case -by -case basis under
CWA Section 308.
New Dischargers
You must provide maximum daily and average daily discharge
estimates for the parameters or pollutants listed in Section 4, unless
specifically indicated on the form. Note that if you have the results
of actual analyses for the listed parameters or pollutants, you are
required to report those results rather than submit estimates.
Report or estimate all parameter or pollutant levels as concentration
and as total mass, except for flow, pH, and temperature. Indicate
the source of all estimates in the appropriate column in the
Section 4 tables using the engineering study codes below. Note
that you are required to conduct follow-up testing and reporting no
later than two years once your facility commences discharge.
Engineering Report Codes
Actual data from pilot plants....................................1
Estimates from other engineering reports ..............2
Data from other similar plants.................................3
Best professional estimates....................................4
Others ..........................................specify on the form
Base your determination of whether a pollutant will be present in
your discharge on your knowledge of the proposed facility's use of
maintenance chemicals and any analyses of your effluent or of any
similar effluent. You may also provide the estimates based on
available in-house or contractor engineering reports or any other
studies performed on the proposed facility.
Pollutants Solely in Intake Water
If you expect a pollutant to be present solely because of its
presence in your intake water, you must still provide an estimate or
analytical result in Section 4; however, you should indicate in
Section 7 in Item 7.1 that you believe the pollutant or parameter to
be present only due to its presence in your source water. See the
instructions under Item 7.1.
Testing Waivers
The NPDES permitting authority may waive the testing and
reporting requirements for flow or any of the pollutants listed in
Section 4 if you submit a written request for such a waiver before
or with your application. Contact your NPDES permitting authority
for more information.
Sampling
The collection of samples for the reported analyses should be
supervised by a person experienced in performing sampling of
industrial wastewater. You may contact your NPDES permitting
authority for detailed guidance on sampling techniques and for
answers to specific questions. See Exhibit 1-1 of Form 1 for
contact information. Any specific requirements in the applicable
analytical methods —for example, sample containers, sample
preservation, holding times, and the collection of duplicate
samples —must be followed.
2E-3

General Instructions for Reporting, Sampling, and Analysis Continued
The time when you sample should be representative of your normal
• The method has the lowest ML of the analytical methods
operation, to the extent feasible, with all processes that contribute
approved under 40 CFR 136 or required under 40 CFR
wastewater in normal operation, and with your treatment system
chapter I, subchapter N or 0 for the measured pollutant or
operating properly with no system upsets. Collect samples from the
pollutant parameter.
center of the flow channel, where turbulence is at a maximum, at a
site specified in your present NPDES permit, or at any site
Consistent with 40 CFR 136, you may provide matrix- or sample -
adequate for the collection of a representative sample.
specific MLs rather than the published levels. Further, where you
can demonstrate that, despite a good faith effort to use a method
Analysis
that would otherwise meet the definition of "sufficiently sensitive,"
Except as specified below, all required quantitative data shall be
the analytical results are not consistent with the quality assurance
collected in accordance with sufficiently sensitive analytical
(QA)/quality control (QC) specifications for that method, then the
methods approved under 40 CFR 136 or required under 40 CFR
NPDES permitting authority may determine that the method is not
chapter I, subchapter N or 0. A method is "sufficiently sensitive"
performing adequately and the NPDES permitting authority should
when:
select a different method from the remaining EPA -approved
methods that is sufficiently sensitive consistent with 40 CFR
• The method minimum level (ML) is at or below the level of the
122.21(e)(3)(i). Where no other EPA -approved methods exist, you
applicable water quality criterion for the measured pollutant or
must select a method consistent with 40 CFR 122.21(e)(3)(ii).
pollutant parameter.
When there is no analytical method that has been approved under
• The method ML is above the water quality criterion, but the
40 CFR 136; required under 40 CFR chapter 1, subchapter N or 0,
amount of the pollutant or pollutant parameter in the facility's
and is not otherwise required by the NPDES permitting authority,
discharge is high enough that the method detects and
you may use any suitable method but shall provide a description of
quantifies the level of the pollutant or pollutant parameter in
the method. When selecting a suitable method, other factors such
the discharge.
as a method's precision, accuracy, or resolution, may be
considered when assessing the performance of the method.
2E-4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110012909843
NCO088331
Kershaw WTP
OMB No. 2040-0004
U.S. Environmental Protection Agency
FORM
n
PA
Application for NPDES Permit to Discharge Wastewater
NPDES
MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURAL FACILITIES WHICH
DISCHARGE ONLY NONPROCESS WASTEWATER
SECTIONOUTFALL
LOCATION1
1.1 Provide information
on each of the facilit 's outfalls in the table below.
o
—
Outfall
Number
Receiving Water Name
Latitude
Longitude
R
V
0
001
LIT to Tarkiln Creek
35' Ole 53" N
76' 46' 10" w
J
7
0
SECTION1
Are you a new or existing discharger? (Check only one response.)
2.1
s
❑ New discharger ❑✓ Existing discharger 4 SKIP to Section 3.
y
2.2
Specify your anticipated discharge date:
0
SECTION1
3.1
What types of wastes are currently being discharged if you are an existing discharger or will be discharged if you are a
new discharger? (Check all that apply.)
❑ Sanitary wastes ❑✓ Other nonprocess wastewater (describe/explain
❑ Restaurant or cafeteria waste directly below)
aU)
Backwash from Sand Filters and Ion Exchange
❑ Non contact cooling water
a
3.2
Does the facility use cooling water additives?
d
❑ Yes ❑✓ No 4 SKIP to Section 4.
3.3
List the cooling water additives used and describe their com Dosition.
Cooling Water Additives
Composition of Additives
list
if available toyou)
SECTION1
Have you completed monitoring for all parameters in the table below at each of your outfalls and attached the results to
4.1
this application package?
❑✓ Yes ❑ No; a waiver has been requested from my NPDES permitting authority
attach waiver request and additional information 4 SKIP to Section 5.
4.2
Provide data as requested in the table below.t See instructions forspecifics.)
U)
Number of
Maximum Daily
Average Daily
Source
Parameter or Pollutant
Analyses
Discharge
Discharge
(use codes
(if actual data
s eci units
s ecif units
per
Mass
Conc.
Mass
Conc.
reported)
instructions)
a
s
Biochemical oxygen demand (BOD5)
N/A
0
c
Total suspended solids (TSS)
52
19.9
mg/L
2.1
mg/L
Oil and grease
N/A
w
Ammonia (as N)
12
3.5
mg/L
0.5
1 mg/L
Discharge flow
365
0.2 MGD
j
pH (report as range)
24
6.5 - 8.0 s.u.
Temperature (winter)
6
20.2 deg. C
Temperature (summer)
6
25.9 deg. C
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 3510-2E (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name i
Form Approved 03/05/19
110012909843
NCO088331
Kershaw WTP
OMB No. 2040-0004
4.3
Is fecal coliform believed present, or is sanitary waste discharged (or will it be discharged)?
❑ Yes ❑✓ No 4 SKIP to Item 4.5.
4.4
Provide data as requested in the table below.[
See instructions forspecifics.)
Number of
Maximum Daily
Average Daily
Source
Parameter or Pollutant
Analyses
Discharge
Discharge
(use codes
(if actual data
sea units
(specify units
per
Mass
Conc.
Mass
Conc.
reported)
Instructions.)
Fecal coliform
E. coli
Enterococci
0
4.5
Is chlorine used (or will it be used)?
❑✓ Yes ❑ No 4 SKIP to Item 4.7.
4.6
Provide data as requested in the table below.[
See instructions forspecifics.)
Number of
Maximum Daily
Average Daily
Source
Parameter or Pollutant
Analyses
Discharge
Discharge
(use codes
Alls
(if actual data
sea f units
sea units
per
Mass
Conc.
Mass
Conc.
reported)
instructions)
c
Total Residual Chlorine
52
49
ug/L
7.8
ug/L
w
4.7
Is non -contact cooling water discharged (or will it be discharged)?
❑ Yes 0 No -* SKIP to Section 5.
4.8
Provide data as requested in the table below.[ See instructions forspecifics.)
Number of
Maximum Daily
Average Daily
Source
Parameter or Pollutant
Analyses
Discharge
Discharge
(use codes
(if actual data
sea units
sea units
per
Mass Conc.
Mass Conc.
reported)
instructions)
Chemical oxygen demand (COD)
Total organic carbon (TOC)
SECTION•
r
Except for stormwater water runoff, leaks, or spills, are any of the discharges you described in Sections 1 and 3 of this
5.1
application intermittent or seasonal?
❑ Yes 4 Complete this section. ❑✓ No 4 SKIP to Section 6.
30
5.2
Briefly describe the frequency and duration of flow.
LL
SECTION1
Briefly describe any treatment system(s) used (or to be used).
6.1
E
Groundwater treatment from 2 wells in the Castle Hayne Aquifer. Backwash water from 2 sand filters and 2 ion
vim)
exchange water softeners. Backwash water is dechlorinated before discharge with 502.
c
ar
E
io
a�
'Sampling shall be conducted according to sufficiently sensitive test proceaures (re., metnoas) approvea under 4u ut-K iao Tor me anarysis or powtams or pouutant
parameters or required under 40 CFR chapter I, subchapter Nor 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2E (revised 3-19) Page 2

EPA
Identification
Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843
NCO088331 Kershaw WTP OMB No. 2040-0004
SECTIONOTHER
INFORMATION1
7.1
Use the space below to expand upon any of the above items. Use this space to provide any information you believe the
reviewer should consider in establishing permit limitations. Attach additional sheets as needed.
c
0
cc :
c
m
O
SECTION•
1
In Column 1 below, mark the sections of Form 2E that you have completed and are submitting with your application.
8.1
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 provide attachments.
Column 1
Column 2
❑� Section 1: Outfall Location
❑ w/ attachments (e.g., responses for additional outfalls)
❑✓ Section 2: Discharge Date
❑ w/ attachments
❑✓ Section 3: Waste Types
❑ w/ attachments
d
❑✓ Section 4: Effluent Characteristics
❑ w/ attachments
d
❑✓ Section 5: Flow
❑ w/ attachments
�
.r
N
c
❑✓ Section 6: Treatment System
❑ w/ attachments
cc
w
❑ Section 7: Other Information
❑ wl attachments
-a
❑✓ Section 8: Checklist and Certification Statement
❑ w/ attachments
c
8.2
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 fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Timothy Buck
County Manager
Signa a
Date signed
EPA Form 3510-2E (revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP 001 OMB No.2040-0004
TABLE A. CONVENTIONAL AND NON
CONVENTIONAL•
r
Effluent
Intake
i0 tional'
Waiver
Units
Maximum
Maximum
Long -Term
Pollutant
k[F31Cherk
Requested
(specify)
Daily
Monthly
Average Daily Number of
Long -Term
Number of
(if applicable)
Discharge
Discharge
Discharge Analyses
Average Value
Analyses
(requir
d available
it available
have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
hee if you h
Biochemical oxygen demand
�'
El
Concentration
Concentration
N/A
N/A
(BOD5)
Chemical oxygen demand
2.
❑
Concentration
N/A
Mass
N/A
(COD)
Concentration
N/A
3.
Total organic carbon (TOC)
Cl
Mass
N/A
Concentration
mg/L
19.9
N/A
2.1
52
4.
Total suspended solids (TSS)
❑
Mass
N/A
Concentration
mg/L
3.5
N/A
0.5
12
5.
Ammonia (as N)
❑
Mass
N/A
6.
Flow
❑
Rate
MGD
0.2
N/A
0.05
365
Temperature (winter)
❑
°C
°C
20.2
N/A
19.5
24
7.
Temperature (summer)
❑
°C
°C
25.9
N/A
19.5
24
pH (minimum)
❑
Standard units
S.U.
6.5
8.
pH (maximum)
❑
Standard units
s.U.
8.0
Sampling shall be conducted according to suttmclently sensitive test proceaures p.e., memoos) approves unaer 4u t Fm I ao 1UI ❑le dndrysw UI PUnutdnrs u1 yUourdnL pdrdniereia vi
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

United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
VEPA Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 213, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to collect information
and complete Form 1 to be 2.9 hours for new applicants and 0.9 hours for applicants renewing
existing permits. This estimate includes time to review instructions, search existing data sources,
gather and maintain the needed data, and complete and review the collection of information.
New respondents must also prepare a topographic map. Send comments about the burden
estimate or any other aspect of this collection of information to the Chief, Information Policy
Branch (PM-223), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW,
Washington, DC 20460, and to the Office of Information and Regulatory Affairs, Office of
Management and Budget, 725 17th Street, NW, Washington, DC 20503, marked "Attention:
Desk Officer for EPA."

DESCRIPTION OF NPDES PERMIT APPLICATION FORMS
The application forms for individual National Pollutant Discharge
Elimination System (NPDES) permits include the following:
Form 1—General Information (included in this package).
Form 2—Forms Based on Facility or Activity Type (not included
in this package):
2A. New and Existing Publicly Owned Treatment Works
2B. Concentrated Animal Feeding Operations and
Concentrated Aquatic Animal Production Facilities
2C. Existing Manufacturing, Commercial, Mining, and
Silvicultural Operations
2D. New Manufacturing, Commercial, Mining, and Silvicultural
Operations That Have Not Yet Commenced Discharge of
Process Wastewater
2E. Manufacturing, Commercial, Mining, and Silvicultural
Facilities Which Discharge Only Nonprocess Wastewater
2F. Stormwater Discharges Associated with Industrial Activity
2S. New and Existing Treatment Works Treating Domestic
Who Must Apply for an NPDES Permit?
CONTENTS OF FORM 1 PACKAGE
Form 1—General Instructions
Form 1—Line-by-Line Instructions
Form 1—Activities That Do Not Require Permits
Form 1—Glossary
Form 1—Application
FORM 1—GENERAL INSTRUCTIONS
With the exceptions described in "Form 1—Activities That Do Not
Require Permits," the federal Clean Water Act (33 U.S.C. 1251 et
seq.) prohibits any person from discharging pollutants into waters
of the United States without first having been issued a permit
under the NPDES program.
Who Must Complete Form 1?
All applicants, other than publicly owned treatment works
(POTWs) and treatment works treating domestic sewage
(TWTDS), must submit Form 1. If you operate one of the
following facilities, you must submit Form 1: concentrated animal
feeding operations and aquatic animal production facilities;
manufacturing, commercial, mining, and silvicultural operations;
or other industrial facilities.
At the state level, either the U.S. Environmental Protection
Agency (EPA) or an approved state agency administers the
NPDES permit program. If you are located in a jurisdiction in
which an EPA regional office administers the NPDES permit
program, you should use Form 1 and all other applicable forms
described in these instructions. If you are located in a jurisdiction
where a state administers the NPDES permit program, contact
the state to determine the forms you should complete. States
often develop their own application forms rather than use the
federal forms. See hftp://www.epa.gov/npdes/npdes-state-
program-information for a list of states that have approved
NPDES permit programs and those that do not.
Exhibit 1-1 (see end of this section) provides contact information
for each of EPA's 10 regional offices. Since the exhibit's content is
subject to change, consult EPA's website for the latest information:
hftp://www.epa.gov/aboutepa#regional.
1-1
Upon your request, and based on information supplied by you,
EPA or the authorized NPDES state will determine whether you
are required to obtain a permit for a particular facility or activity.
Be sure to contact EPA or your state if you have a question.
Form 1 collects general information only. You must also complete
a more detailed application based on your proposed discharge
activity, as follows:
• If your facility is a concentrated animal feeding operation
or a concentrated aquatic animal production facility, you
must also complete Form 2B.
• If your facility is an existing manufacturing, commercial,
mining, or silvicultural facility that currently discharges
process wastewater, you must also complete Form 2C.
• If your facility is a new manufacturing, commercial, mining,
or silvicultural facility that has yet to commence discharge of
process wastewater, you must also complete Form 2D.
• If your facility is a new or existing facility (including
manufacturing, commercial, mining, and silvicultural
facilities) that discharges only nonprocess wastewater,
you must also complete Form 2E.
• If your facility is a new or existing facility whose discharge
is composed entirely of stormwater associated with industrial
activity —excluding discharges from construction activity
under 122.26(b)(14)(x) or (b)(15)—you must also complete
Form 2F. If the discharge is composed of stormwater and
non-stormwater, you must complete Form 2F and you must
also complete Forms 2C, 2D, and/or 2E, as appropriate. See
Form 2F's instructions for further details.

FORM 1—GENERAL INSTRUCTIONS CONTINUED
Where to File Your Completed Form
• If you are in a jurisdiction with an approved state NPDES
permit program, file according to the instructions on the state
forms.
• If you are in a jurisdiction where EPA is the NPDES
permitting authority (i.e., the state is not an NPDES-
authorized state), mail the completed application forms to the
EPA regional office that covers the state in which your facility
is located (see Exhibit 1-1).
When to File Your Completed Form
Because of statutory and regulatory requirements, the deadlines
for filing applications vary according to your facility or activity type
and the type of permit you need. The various permit application
deadlines are listed in Exhibit 1-2 at the end of this section.
Fees
EPA does not require applicants to pay a fee for applying for
NPDES permits. However, states that administer the NPDES
permit program may charge fees. Consult with state officials for
further information.
Public Availability of Submitted Information
EPA will make information from NPDES permit application forms
available to the public for inspection and copying upon request.
You may not claim any information on Form 1 (or related
attachments) as confidential.
You may make a claim of confidentiality for any information that
you submit to EPA that goes beyond the information required by
Form 1. If you do not assert a claim of confidentiality at the time
you submit your information to the NPDES permitting authority,
EPA may make the information available to the public without
further notice to you. EPA will handle claims of confidentiality in
accordance with the Agency's business confidentiality regulations
at Part 2 of Title 4 of the Code of Federal Regulations (CFR).
Completion of Forms
Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.
The NPDES permitting authority could consider your application
incomplete if you do not provide an answer (or indicate "NA" for
"not applicable") for all questions on Form 1 and the applicable
Form 2.
Provide your EPA Identification Number from the Facility Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 1 and any attachments. If your facility is new
(i.e., not yet constructed), write or type "New Facility" in the space
provided for the EPA Identification Number and NPDES number.
If you do not know your EPA Identification Number, contact your
NPDES permitting authority. See Exhibit 1-1 for contact
information.
Do not leave any response areas blank unless the form directs
you to skip them. If the form directs you to respond to an item that
does not apply to your facility or activity, enter "NA" for "not
applicable" to show that you considered the item and determined
a response was not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received
and completed according to the authority's satisfaction. The
NPDES permitting authority will judge the completeness of any
application independently of the status of any other permit
application or permit for the same facility or activity.
1-2

FORM 1—GENERAL INSTRUCTIONS CONTINUED
Exhibit 1-1. Addresses of EPA Regional Contacts and Covered States
REGION 1
REGION 6
U.S. Environmental Protection Agency, Region 1
U.S. Environmental Protection Agency, Region 6
5 Post Office Square, Suite 100, Boston, MA 02109-3912
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733
Phone: [phone]; toll free: [phone]
Phone: [phone]; toll free: [phone]
Fax: [phone]
Fax: [phone]
Website: http://www.epa.gov/aboutepa/epa-region-l-new-england
Website: http://www.eya.gov/aboutepa/epa-region-6-south-central
Covered states: Connecticut, Maine, Massachusetts, New Hampshire, Rhode
Covered states: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
Island, and Vermont
REGION 2
REGION 7
U.S. Environmental Protection Agency, Region 2
U.S. Environmental Protection Agency, Region 7
290 Broadway, New York, NY 10007-1866
11201 Renner Boulevard, Lenexa, KS 66219
Phone: [phone]; toll free: (877) 2514575
Phone: [phone]; toll free: [phone]
Fax: [phone]
Website: http://www.epa.qov/aboutepa/epa-region-7-midwest
Website: http://www.epa.gov/aboutepa/epa-region-2
Covered states: Iowa, Kansas, Missouri, and Nebraska
Covered states: New Jersey, New York, Virgin Islands, and Puerto Rico
REGION 3
REGION 8
U.S. Environmentai Protection Agency, Region 3
U.S. Environmental Protection Agency, Region 8
1650 Arch Street, Philadelphia, PA 19103-2029
1595 Wynkoop Street, Denver, CO 80202-1129
Phone: [phone]; toll free: [phone]
Phone: [phone]; toll free: [phone]
Fax: [phone]
Fax: [phone]
Website: http://www.epa.gov/aboutepa/epa-region-3-mid-atlantic
Website: http://www.epa.gov/aboutepa/epa-region-8-mountains-and-plains
Covered states: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia,
Covered states: Colorado, Montana, North Dakota, South Dakota, Utah, and
and West Virginia
Wyoming
REGION 4
REGION 9
U.S. Environmental Protection Agency, Region 4
U.S. Environmental Protection Agency, Region 9
Sam Nunn Atlanta Federal Center
75 Hawthorne Street, San Francisco, CA 94105
61 Forsyth Street, SW, Atlanta, GA 30303-8960
Phone: [phone]; toll free: (866) EPA -WEST
Phone: [phone]; toll free: [phone]
Fax: [phone]
Fax: [phone]
Website: http://www.epa.gov/aboutepa/about-epa-region4-southeast
Website: http://www.epa.gov/aboutepa/epa-region-9-pacific-southwest
Covered states: Arizona, California, Hawaii, Nevada, Guam, American Samoa,
Covered states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina,
and Trust Territories
South Carolina, and Tennessee
REGION 5
REGION 10
U.S. Environmental Protection Agency, Region 5
U.S. Environmental Protection Agency, Region 10
77 West Jackson Boulevard, Chicago, IL 60604-3507
1200 Sixth Avenue, Suite 900, Seattle, WA 98101
Phone: [phone]; toll free: [phone]
Phone: [phone]; toll free: (800) 4244372
Fax: [phone]
Fax: [phone]
Website: http://www.el)a.gov/aboutepa/epa-region-5
Website: http://www.epa.qov/aboutepa/epa-region-10-pacific-northwest
Covered states: Alaska, Idaho, Oregon, and Washington
Covered states: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin
Exhibit 1-2. Filing Dates for NPDES Permit Applications
File
Permit Application
When to
180 days before your present NPDES permit expires or, if you are a
2A
new discharger, 180 days before the date on which the discharge is
to commence unless the NPDES permitting authority has granted
permission for a later date.
2B
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.
2C
180 days before your present NPDES permit expires.
2D
180 days prior to startup.
2E
180 days before your present NPDES permit expires, or 180 days
prior to startup if you are a new facility.
Construction: 90 days prior to date construction is to commence.
2F
Nonconstruction: 180 days before your present NPDES permit
expires or 180 days prior to startup if you are a new facility.
2S
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.
1-3

FORM 1—LINE-BY-LINE INSTRUCTIONS
Section 1. Activities Requiring an NPDES Permit
Item 1.1. Review the questions in Item 1.1 to determine if you are
required to submit Form 1. Be sure to check the Form 1—
Glossary for the legal definitions of any key terms.
If you answer "Yes" to a question in Item 1.1, then you do not
need to complete Form 1, but you must comply with the
application requirements specified.
Item 1.2. Respond to the questions in Items 1.2.1 to 1.2.5. If you
answer "Yes" to any question, you must complete Form 1 and the
Form 2 application specified. See Exhibit 1-2 for filing deadlines.
If you answer "No" to every question in Items 1.1 and 1.2, then
you do not need an NPDES permit, and you do not need to
complete and return any of the NPDES application forms.
Section 2. Name, Mailing Address, and Location
Item 2.1. Enter the facility's official or legal name. Do not use a
colloquial name.
Item 2.2. Provide your EPA Identification Number from the
Facility Registry Service if you have an existing facility. If you do
not know your EPA Identification Number, contact your NPDES
permitting authority. If your facility is new (i.e., not yet
constructed), write or type "New Facility."
Item 2.3. Give the name (first and last), title, work telephone
number, and email address of the person who is thoroughly
familiar with the operation of the facility and with the facts
reported in this application. The NPDES permitting authority will
contact the person listed if they have questions on the material
submitted.
Item 2.4. Give the complete mailing address of the office to which
the NPDES permitting authority should send correspondence.
This often is not the address used to designate the location of the
facility or activity.
Item 2.5. Give the address or location of the facility identified
under Item 2.1. If the facility lacks a street name or route number,
give the most accurate, alternative geographic information (e.g.,
section number or quarter section number from county records or
"at intersection of Routes 425 and 22"). Also provide the county
name, county code (if known), city or town, state, and zip code.
For concentrated aquatic animal production facilities, provide the
address or location of the production area (i.e., the location where
the animals are contained, grown, or held).
Section 3. SIC and NAICS Codes
Items 3.1 and 3.2. List, in descending order of significance, up to
four 4-digit standard industrial classification (SIC) codes and
North American Industrial Classification System (NAICS) codes
that best describe your facility in terms of the principal products or
services it produces or provides. If the SIC or NAICS codes do
not adequately describe your facility's products or services, you
have the option to provide additional descriptive information.
You can find SIC code numbers and descriptions in the
1987 Standard Industrial Classification Manual, prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the Government Printing
Office, Washington, D.C. An online version of the manual is also
available courtesy of the Occupational Safety and Health
Administration at hfti)://www.osha.gov/i)ls/imis/sic manual.html.
You can find NAICS code numbers and descriptions in the North
American Industrial Classification System Manual prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the National Technical
Information Service (NTIS) in Alexandria, Virginia. It is also
available online at http://www.census.gov/eos/www/naics/.
Use the latest edition of the manuals. If you have any questions
about the appropriate SIC or NAICS codes for your facility,
contact your NPDES permitting authority.
Section 4.Operator Information
Item 4.1. Give the legal name of the person, firm, public
organization, or other entity that operates the facility described in
this application. This may or may not be the same as the facility's
name. The operator of the facility is the legal entity that controls
the facility's operation rather than the plant or site manager. Do
not use a colloquial name.
Item 4.2. Indicate whether the entity listed in response to Item 4.1
also owns the facility by marking the appropriate box.
Item 4.3. Indicate the ownership status of the operator of the
facility by marking the appropriate box. If the facility is a federal
facility (i.e., owned by the U.S. government), check the box for
"Public —federal." If the facility is owned by a state government,
check the box for "Public —state." If the facility is owned by a
county government, municipal (e.g., city or town) government,
tribal government, school district, water district, or other local
government entity, check the box for "Other public" and specify
the type of government entity. If the facility is owned by a
corporation or other private entity, check the box for "Private." If
the facility has mixed ownership (e.g., public/private) or is not
owned by an entity of the types previously listed, check the box
for "Other" and specify the type of entity.
Items 4.4 to 4.6. Enter the telephone number, address, and email
address of the operator identified in Item 4.1.
Section 5. Indian Land
Item 5.1. Indicate whether the facility is located on Indian Land.
Section 6. Existing Environmental Permits
Item 6.1. Check the appropriate boxes and provide the permit
numbers for all relevant federal, state, and local environmental
permits or construction approvals received or applied for under
any of the programs listed below. If you have more than one
currently effective permit under a particular permit program for
your facility, list the additional permit numbers on the application
form or on a separate sheet of paper.
1-4

FORM 1—LINE-BY-LINE INSTRUCTIONS CONTINUED
• Hazardous waste management program under the Resource
Conservation and Recovery Act (RCRA).
• Underground Injection Control (UIC) program under the Safe
Drinking Water Act (SDWA).
• NPDES program under the Clean Water Act (CWA).
• Prevention of Significant Deterioration (PSD) program under
the Clean Air Act (CAA).
• Nonattainment program under the CAA.
• National Emission Standards for Hazardous Pollutants
(NESHAPs) preconstruction approval under the CAA.
• Ocean dumping permits under the Marine Protection
Research and Sanctuaries Act (MPRSA).
• Dredge or fill permits under Section 404 of the CWA.
• Other federal, state, or local environmental permits.
Section 7. Map
Unless the facility is a concentrated animal feeding operation,
provide a topographic map(s) of the area extending at least one
mile beyond the property boundaries of the facility that clearly
shows the following:
• The legal boundaries of the facility.
• The location and serial number of each of your existing and
proposed intake and discharge structures.
• All hazardous waste management, storage, and disposal
facilities.
• Each well where you inject fluids underground.
• All wells, springs, surface water bodies, and drinking water
wells that are in the public record or otherwise known to you
and that are located in the map area.
If the facility has associated water intakes, discharge structures,
hazardous waste disposal sites, or injection wells and these items
are located more than one mile from the facility, include them on
the map if possible. If you cannot, attach additional sheets
describing the location of the structures, disposal site(s), or well(s)
and identify the U.S. Geological Survey (USGS) or other map
corresponding to the location(s).
On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude to the nearest second. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., USGS).
On all maps of rivers, show the direction of the current. In tidal
waters, show the directions of ebb and flow tides.
You may develop your map by going to USGS's National Map
website at http://nationalmap.gov/. (For a map from this site, use
the traditional 7.5-minute quadrangle format. If none is available,
use a USGS 15-minute series map.) You may also use a plat or
other appropriate map. Briefly describe land uses in the map area
1-5
(e.g., residential, commercial). An example of an acceptable
location map is shown as Exhibit 1-3 at the end of these
instructions. Note: Exhibit 1-3 is provided for illustration only; it
does not show an actual facility.
If the facility is a concentrated animal feeding operation, you are
not required to provide the topographic map required by this
section of Form 1. Instead, you are required to provide a
topographic map as specified in Section 4 of Form 2B.
Item 7.1. Note that you have completed your topographic map
and attached it to the application.
Section 8. Nature of Business
Briefly describe the nature of your business (e.g., products
produced or services provided). See Examples 1 and 2.
Example 1
Facilities Subject to 40 CFR 426, Subparts F and G
Industry A is an auto tempered and auto laminated glass
manufacturing facility subject to effluent limitation guidelines
(ELGs) for the "Automotive Glass Tempering" and "Automotive
Glass Laminating" subcategories of the "Glass Manufacturing"
point source category at 40 CFR 426, subparts F and G. At the
facility, glass is cut and then passed through a series of
processes that grind and polish the edges, bend the glass, and
then temper the glass to produce side and back windows for
automobiles. Tempering involves heating the glass near the
melting point, then rapidly cooling it to increase its mechanical
and thermal endurance. The facility also produces automobile
windshields and undertakes processes that laminate a plastic
sheet between two layers of glass and that prepare the glass for
lamination (e.g., cutting, bending, and washing).
Example 2
Facility Not Subject to ELGs
Industry B undertakes batch -type resin manufacturing operations.
It has aboveground storage tanks for raw materials and finished
goods, resin loading operations, and warehouses for 55-gallon
drums of finished product. Industry B manufactures alkyd,
saturated and unsaturated polyester resins in batches using
reactor vessels and mix tanks. Most of the feedstock liquids are
pumped from storage tanks to the kettles and mixers via a closed
piping system. Additional feedstocks are added manually as
solids from bags and sacks via manways, which are located on
top of the kettles. The resin is then chemically reacted in the
kettles. After the reaction step finishes, the resin is transferred
from the kettles to the mix tanks, where solvents are added to
thin it. The primary byproduct of the reaction is water vapor
containing condensed soluble organics. The byproduct flows to
an isolation tank where the vapors are directed to an onsite
thermal oxidizer. The finished resin is then pumped through one
of three types of filtration systems into finished goods storage
tanks, 55-gallon drums, 350-gallon intermediate bulk container
totes, or directly into tanker trucks. A typical batch takes about 30
hours to complete.

FORM 1—LINE-BY-LINE INSTRUCTIONS CONTINUED
Section 9. Cooling Water Intake Structures
Item 9.1. Indicate whether the facility uses cooling water. If yes,
continue to Item 9.2. If no, skip to Item 10.1.
Item 9.2. Identify the source of the cooling water. For example,
indicate whether the cooling water is from a surface water,
groundwater well, public water system, or treated effluent that
would otherwise be discharged to a water of the U.S.
If the facility uses a cooling water intake structure as described in
40 CFR 125, Subparts I and J, the facility may have additional
application requirements under 40 CFR 122.21(r). Note that the
information required by 40 CFR 122.21(r) is not requested as part
of Form 1. Contact your NPDES permitting authority to determine
the specifics of what you should provide and when.
Section 10. Variance Requests
An applicant (other than a POTW) may request a variance from
otherwise applicable effluent limitations under certain conditions
described at 40 CFR 122.21(m).
Item 10.1. If known at the time of application, check all of the
authorized variances that you plan to request or renew. Note that
you are not being asked to submit any other information at this
time. Contact your NPDES permitting authority to determine the
specifics of what you should provide and when. The ability to
request a variance is not limited to the time of application, and an
applicant may request a variance consistent with statutory and
regulatory requirements.
Section 11. Checklist and Certification
Item 11.1. Review the checklist provided. In Column 1, mark the
sections of Form 1 that you have completed and are submitting
with your application. In Column 2, indicate for each section
whether you are submitting attachments.
Item 11.2. The Clean Water Act provides for severe penalties for
submitting false information on this application form. CWA Section
309(c)(2) provides that, "Any person who knowingly makes any
false statement, representation, or certification in any application,
...shall upon conviction, be punished by a fine of no more than
$10,000 or by imprisonment for not more than six months, or
both."
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A. For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer
means: (1) a president, secretary, treasurer, or vice-president
of the corporation in charge of a principal business function,
or any other person who performs similar policy- or decision -
making functions for the corporation, or (2) the manager of
one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management
decisions which govern the operation of the regulated facility
including having the explicit or implicit duty of making major
capital investment recommendations, and initiating and
directing other comprehensive measures to assure long term
environmental compliance with environmental laws and
regulations; the manager can ensure that the necessary
systems are established or actions taken to gather complete
and accurate information for permit application requirements;
and where authority to sign documents has been assigned or
delegated to the manager in accordance with corporate
procedures.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
1-6

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1-7

FORM 1—ACTIVITIES THAT DO NOT REQUIRE PERMITS
You are not required to obtain an NPDES permit if your discharge
is in one of the following categories, as provided by the CWA and
NPDES regulations at 40 CFR 122 to 125. (However, under CWA
Sections 510 and 312, some discharges exempted from the
federal NPDES requirements may still be regulated by a state
permitting authority.)
Any discharge of sewage from vessels and any effluent from
properly functioning marine engines, laundry, shower, and
galley sink wastes, or any other discharge incidental to the
normal operation of a vessel, including vessels of the Armed
Forces within the meaning of section 312 of the CWA and
recreational vessels within the meaning of section 502(25) of
the CWA. None of these exclusions apply to rubbish, trash,
garbage, or other such materials discharged overboard; nor
to other discharges when the vessel is operating in a
capacity other than as a means of transportation such as
when used as an energy or mining facility, a storage facility
or a seafood processing facility, or when secured to a
storage facility or a seafood processing facility, or when
secured to the bed of the ocean, contiguous zone or waters
of the United States for the purpose of mineral or oil
exploration or development.
• Discharges of dredged or fill material into waters of the
United States that are regulated under CWA Section 404.
The introduction of sewage, industrial wastes, or other
pollutants into publicly owned treatment works by indirect
dischargers. Plans or agreements to switch to this method of
disposal in the future do not relieve dischargers of the
obligation to have and comply with permits until all
discharges of pollutants to waters of the United States are
eliminated. (See also 40 CFR 122.47(b).) This exclusion
does not apply to the introduction of pollutants to privately
owned treatment works or to other discharges through pipes,
sewers, or other conveyances owned by a state, municipality,
or other party not leading to treatment works.
• Any discharge in compliance with the instructions of an On -
Scene Coordinator pursuant to 40 CFR 300 (The National Oil
and Hazardous Substances Pollution Contingency Plan) or
33 CFR 153.10(e) (Pollution by Oil and Hazardous
Substances).
Any introduction of pollutants from non point -source
agricultural and silvicultural activities, including stormwater
runoff from orchards, cultivated crops, pastures, range lands,
and forest lands, but not discharges from concentrated
animal feeding operations as defined in 40 CFR 122.23,
discharges from concentrated aquatic animal production
facilities as defined in 40 CFR 122.23, discharges from
concentrated aquatic animal production facilities as defined
in 40 CFR 122.24, discharges to aquaculture projects as
defined in 40 CFR 122.25, and discharges from silvicultural
point sources as defined in 40 CFR 122.27. Note: Per 40
CFR 122.26(b)(14)(ii), facilities classified within SIC 24,
Industry Group 241, that are rock crushing, gravel washing,
log sorting, or log storage facilities operated in connection
with silvicultural activities defined in 40 CFR 122.27(b)(2)—(3)
and Industry Groups 242 through 249; 26 (except 265 and
267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441,
and 373 (not included are all other types of silviculture
facilities) are considered stormwater discharges associated
with industrial activity, and are required to obtain an NPDES
permit.
• Return flows from irrigated agriculture.
• Discharges into a privately owned treatment works, except as
the NPDES permitting authority may otherwise require under
40 CFR 122.44(m).
• Discharges from a water transfer. "Water transfer" means an
activity that conveys or connects waters of the United States
without subjecting the transferred water to intervening
industrial, municipal, or commercial use. This exclusion does
not apply to pollutants introduced by the water transfer
activity itself to the water being transferred.
1-8

FORM 1—GLOSSARY
Note: This glossary includes terms used in the various NPDES application forms, including Form 1. The definitions are from the NPDES
regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms, contact
your NPDES permitting authority.
ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (other than an aquatic animal production facility) where the
following conditions are met;
• Animals (other than aquatic animals) have been, are, or will be stabled or confined and fed or maintained for a total of 45 days or
more in any 12-month period; and
• Crops, vegetation, forage growth, or post -harvest residues are not sustained in the normal growing season over any portion of the lot
or facility.
APPLICATION means the EPA standard national forms for applying for a permit, including any additions, revisions, or modifications to the
forms; or forms approved by EPA for use in approved states, including any approved modifications or revisions.
APPROVED PROGRAM or APPROVED STATE means a State or interstate program which has been approved or authorized by EPA
under part 123.
AQUACULTURE PROJECT (defined at § 122.25) means a defined managed water area which uses discharges of pollutants into that
designated area for the maintenance or production of harvestable freshwater, estuarine, or marine plants or animals. DESIGNATED
PROJECT AREA means the portions of the waters of the United States within which the permittee or permit applicant plans to confine the
cultivated species, using a method or plan or operation (including, but not limited to, physical confinement) which, on the basis of reliable
scientific evidence, is expected to ensure that specific individual organisms comprising an aquaculture crop will enjoy increased growth
attributable to the discharge of pollutants, and be harvested within a defined geographic area.
AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month,
calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured during that
month.
AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week,
calculated as the sum of all daily discharges measured during a calendar week divided by the number of daily discharges measured during
that week.
BEST MANAGEMENT PRACTICES (BMPs) means schedules of activities, prohibitions of practices, maintenance procedures, and other
management practices to prevent or reduce the pollution of waters of the United States. BMPs include treatment requirements, operation
procedures, and practices to control plant site runoff, spillage or leaks, sludge or waste disposal, or drainage from raw material storage.
BIOSOLIDS (see sewage sludge).
BYPASS (defined at § 122.41(m)) means the intentional diversion of waste streams from any portion of a treatment facility.
COMBINED SEWER OVERFLOW (CSO) means a discharge from a combined sewer system (CSS) at a point prior to the Publicly Owned
Treatment Works (POTW) Treatment Plant (defined at § 403.3(r)).
COMBINED SEWER SYSTEM (CSS) means a wastewater collection system owned by a State or municipality (as defined by section
502(4) of the CWA) which conveys sanitary wastewaters (domestic, commercial and industrial wastewaters) and storm water through a
single -pipe system to a Publicly Owned Treatment Works (POTW) Treatment Plant (as defined at § 403.3(r)).
CONCENTRATED ANIMAL FEEDING OPERATION (defined at § 122.23) means an animal feeding operation that is defined as a Large
CAFO or as a Medium CAFO by the terms of (A) or (B) below, or that is designated as a CAFO in accordance with 40 CFR 122.23(c). Two
or more AFOs under common ownership are considered to be a single AFO for the purposes of determining the number of animals at an
operation, if they adjoin each other or if they use a common area or system for the disposal of wastes.
A. LARGE CONCENTRATED ANIMAL FEEDING OPERATION (LARGE CAFO) means an AFO that stables or confines as many as or
more than the numbers of animals specified in any of the following categories:
1. 700 mature dairy cows, whether milked or dry;
1,000 veal calves;
1,000 cattle other than mature dairy cows or veal calves. Cattle includes but is not limited to heifers, steers, bulls and cow/calf
pairs;
4. 2,500 swine each weighing 55 pounds or more;
5. 10,000 swine each weighing less than 55 pounds;
1-9

FORM 1—GLOSSARY CONTINUED
6. 500 horses;
7. 10,000 sheep or lambs;
8. 55,000 turkeys;
9. 30,000 laying hens or broilers, if the AFO uses a liquid manure handling system;
10. 125,000 chickens (other than laying hens), if the AFO uses other than a liquid manure handling system;
11. 82,000 laying hens, if the AFO uses other than a liquid manure handling system;
12. 30,000 ducks (if the AFO uses other than a liquid manure handling system); or
13. 5,000 ducks (if the AFO uses a liquid manure handling system).
B. MEDIUM CONCENTRATED ANIMAL FEEDING OPERATION (MEDIUM CAFO) means any AFO with the type and number of
animals that fall within any of the ranges listed below and which has been defined or designated as a CAFO. An AFO is defined as a
Medium CAFO if:
1. The type and number of animals that it stables and confines falls within any of the following ranges:
a. 200 to 699 mature dairy cows, whether milked or dry;
b. 300 to 999 veal calves;
c. 300 to 999 cattle other than mature dairy cows or veal calves. Cattle includes but is not limited to heifers, steers, bulls and
cow/calf pairs;
d. 750 to 2,499 swine each weighing 55 pounds or more;
e. 3,000 to 9,999 swine each weighing less than 55 pounds;
f. 150 to 499 horses;
g. 3,000 to 9,999 sheep or Iambs;
h. 16,500 to 54,999 turkeys;
i. 9,000 to 29,999 laying hens or broilers, if the AFO uses a liquid manure handling system;
j. 37,500 to 124,999 chickens (other than laying hens), if the AFO uses other than a liquid manure handling system;
k. 25,000 to 81,999 laying hens, if the AFO uses other than a liquid manure handling system;
I. 10,000 to 29,999 ducks (if the AFO uses other than a liquid manure handling system); ore
m. 1,500 to 4,999 ducks (if the AFO uses a liquid manure handling system); and
2. Either one of the following conditions are met:
a. Pollutants are discharged into waters of the United States through a man-made ditch, flushing system, or other similar man-
made device; or
b. Pollutants are discharged directly into waters of the United States which originate outside of and pass over, across, or
through the facility or otherwise come into direct contact with animals confined in the operation.
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY (defined at § 122.24) means a hatchery, fish farm, or other facility which
contains, grows, or holds aquatic animals in either of the following categories, or which the Director designates as such on a case -by -case
basis:
A. Cold water fish species or other cold water aquatic animals including, but not limited to, the Salmonidae family of fish (e.g., trout and
salmon) in ponds, raceways, or other similar structures which discharge at least 30 days per year but does not include:
1. Facilities which produce less than 9,090 harvest weight kilograms (approximately 20,000 pounds) of aquatic animals per year;
and
2. Facilities which feed less than 2,272 kilograms (approximately 5,000 pounds) of food during the calendar month of maximum
feeding.
B. Warm water fish species or other warm water aquatic animals including, but not limited to, the Ameiuridae, Cetrarchiclae, and
Cyprinidae families of fish (e.g., respectively, catfish, sunfish, and minnows) in ponds, raceways, or other similar structures which
discharge at least 30 days per year, but does not include;
1. Closed ponds which discharge only during periods of excess runoff; or
2. Facilities which produce less than 45,454 harvest weight kilograms (approximately 100,000 pounds) of aquatic animals per year.
1-10

FORM 1—GLOSSARY CONTINUED
CWA means the Clean Water Act (formerly referred to as the Federal Water Pollution Control Act or Federal Water Pollution Control Act
Amendments of 1972) Public Law 92-500, as amended by Public Law 95-217, Public Law 95-576, Public Law 96-483 and Public Law
97-117, 33 U.S.C. 1251 et seq.
CWA AND REGULATIONS means the Clean Water Act (CWA) and applicable regulations promulgated thereunder. In the case of an
approved State program, it includes State program requirements.
DAILY DISCHARGE means the "discharge of a pollutant" measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling. For pollutants with limitations expressed in units of mass, the "daily discharge" is
calculated as the total mass of the pollutant discharged over the day. For pollutants with limitations expressed in other units of
measurement, the "daily discharge" is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the "discharge of a pollutant."
DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an authorized representative. When there
is no "approved State program," and there is an EPA administered program, "Director" means the Regional Administrator. When there is
an approved State program, "Director" normally means the State Director. In some circumstances, however, EPA retains the authority to
take certain actions even when there is an approved State program. (For example, when EPA has issued an NPDES permit prior to the
approval of a State program, EPA may retain jurisdiction over that permit after program approval, see § 123.1.) In such cases, the term
"Director" means the Regional Administrator and not the State Director.
DISCHARGE (OF A POLLUTANT) means:
• Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or
• Any addition of any pollutant or combination of pollutants to the waters of the contiguous zone or the ocean from any point source
other than a vessel or other floating craft which is being used as a means of transportation.
This definition includes discharges into waters of the United States from: surface runoff which is collected or channelled by man;
discharges through pipes, sewers, or other conveyances owned by a State, municipality, or other person which do not lead to a treatment
works; and discharges through pipes, sewers, or other conveyances, leading into privately owned treatment works. This term does not
include an addition of pollutants by any "indirect discharger".
DISCHARGE MONITORING REPORT means the EPA uniform national form, including any subsequent additions, revisions, or
modifications for the reporting of self -monitoring results by permittees. DMRs must be used by "approved States" as well as by EPA. EPA
will supply DMRs to any approved State upon request. The EPA national forms may be modified to substitute the state agency name,
address, logo, and other similar information, as appropriate, in place of EPA's.
DRAFT PERMIT means a document prepared under § 124.6 indicating the Director's tentative decision to issue or deny, modify, revoke
and reissue, terminate, or reissue a "permit." A notice of intent to terminate a permit, and a notice of intent to deny a permit, as discussed
in § 124.5, are types of "draft permits." A denial of a request for modification, revocation and reissuance, or termination, as discussed in
§ 124.5, is not a "draft permit." A "proposed permit" is not a "draft permit."
EFFLUENT LIMITATION means any restriction imposed by the Director on quantities, discharge rates, and concentrations of "pollutants"
which are "discharged" from "point sources" into "waters of the United States," the waters of the "contiguous zone," or the ocean.
EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administrator under section 304(b) of the CWA to adopt or
revise "effluent limitations."
ENVIRONMENTAL PROTECTION AGENCY (EPA) means the United States Environmental Protection Agency.
FACILITY or ACTIVITY means any NPDES "point source" or any other facility or activity (including land or appurtenances thereto) that is
subject to regulation under the NPDES program.
GENERAL PERMIT means an NPDES "permit" issued under § 122.28 authorizing a category of discharges under the CWA within a
geographical area.
HAZARDOUS SUBSTANCE means any substance designated under 40 CFR part 116 pursuant to section 311 of the CWA.
INDIAN COUNTRY (or INDAN LANDS) means:
• All land within the limits of any Indian reservation under the jurisdiction of the United States Government, notwithstanding the
issuance of any patent, and, including rights -of -way running through the reservation;
• All dependent Indian communities with the borders of the United States whether within the originally or subsequently acquired territory
thereof, and whether within or without the limits of a state; and
• All Indian allotments, the Indian titles to which have not been extinguished, including rights -of -way running through the same.

FORM 1—GLOSSARY CONTINUED
INDIAN TRIBE means any Indian Tribe, band, group, or community recognized by the Secretary of the Interior and exercising
governmental authority over a Federal Indian reservation.
INDIRECT DISCHARGE means a nondomestic discharger introducing "pollutants" to a "publicly owned treatment works."
LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(4)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census (Appendix F of 40 CFR 122); or
(ii) Located in the counties listed in appendix H of 40 CFR 122, except municipal separate storm sewers that are located in the
incorporated places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraphs (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(D) The nature of the receiving waters; and
(E) Other relevant factors; or
(iv) The Director may, upon petition, designate as a large municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii).
LOG SORTING AND LOG STORAGE FACILITIES (defined at § 122.27) means facilities whose discharges result from the holding of
unprocessed wood, for example, logs or roundwood with bark or after removal of bark held in self-contained bodies of water (mill ponds or
log ponds) or stored on land where water is applied intentionally on the logs (wet decking). (See 40 CFR 429, subpart I, including the
effluent limitations guidelines.)
MAJOR FACILITY means any NPDES "facility or activity" classified as such by the Regional Administrator, or, in the case of "approved
State programs," the Regional Administrator in conjunction with the State Director.
MAXIMUM DAILY DISCHARGE LIMITATION means the highest allowable "daily discharge."
MEDIUM MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(7)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 100,000 or more but less than 250,000, as determined by the 1990 Decennial
Census by the Bureau of the Census (appendix G of 40 CFR 122); or
(ii) Located in the counties listed in appendix I of 40 CFR 122, except municipal separate storm sewers that are located in the incorporated
places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraph (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraph (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(D) The nature of the receiving waters; or
(E) Other relevant factors; or
1-12

FORM 1—GLOSSARY CONTINUED
(iv) The Director may, upon petition, designate as a medium municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii) of this section.
MUNICIPALITY means a city, town, borough, county, parish, district, association, or other public body created by or under State law and
having jurisdiction over disposal of sewage, industrial wastes, or other wastes, or an Indian tribe or an authorized Indian tribal organization,
or a designated and approved management agency under section 208 of the CWA.
MUNICIPAL SEPARATE STORM SEWER (defined at § 122.26(b)(8)) means a conveyance or system of conveyances (including roads
with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels, or storm drains):
• Owned or operated by a State, city, town, borough, county, parish, district, association, or other public body (created by or pursuant to
State law) having jurisdiction over disposal of sewage, industrial wastes, stormwater, or other wastes, including special districts under
State law such as a sewer district, flood control district or drainage district, or similar entity, or an Indian tribe or an authorized Indian
tribal organization, or a designated and approved management agency under section 208 of the CWA that discharges to waters of the
United States.
• Designed or used for collecting or conveying stormwater.
• Which is not a combined sewer; and
• Which is not part of a POTW as defined at 40 CFR 122.2.
MUNICIPAL SLUDGE (see sewage sludge)
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) means the national program for issuing, modifying, revoking
and reissuing, terminating, monitoring and enforcing permits, and imposing and enforcing pretreatment requirements, under sections 307,
402, 318, and 405 of the CWA. The term includes an "approved program."
NEW DISCHARGER means any building, structure, facility, or installation:
• From which there is or may be a "discharge of pollutants;"
• That did not commence the "discharge of pollutants" at a particular "site" prior to August 13, 1979;
• Which is not a "new source;" and
• Which has never received a finally effective NPDES permit for discharges at that "site."
This definition includes an "indirect discharger" which commences discharging into "waters of the United States" after August 13, 1979. It
also means any existing mobile point source (other than an offshore or coastal oil and gas exploratory drilling rig or a coastal oil and gas
developmental drilling rig) such as a seafood processing rig, seafood processing vessel, or aggregate plant, that begins discharging at a
"site" for which it does not have a permit; and any offshore or coastal mobile oil and gas exploratory drilling rig or coastal mobile oil and gas
developmental drilling rig that commences the discharge of pollutants after August 13, 1979, at a "site" under EPA's permitting jurisdiction
for which it is not covered by an individual or general permit and which is located in an area determined by the Regional Administrator in
the issuance of a final permit to be an area of biological concern. In determining whether an area is an area of biological concern, the
Regional Administrator shall consider the factors specified in 40 CFR 125.122(a)(1) through (10).
An offshore or coastal mobile exploratory drilling rig or coastal mobile developmental drilling rig will be considered a "new discharger" only
for the duration of its discharge in an area of biological concern.
NEW SOURCE means any building, structure, facility, or installation from which there is or may be a "discharge of pollutants," the
construction of which commenced:
• After promulgation of standards of performance under section 306 of the CWA which are applicable to such source, or
• After proposal of standards of performance in accordance with section 306 of the CWA which are applicable to such source, but only
if the standards are promulgated in accordance with section 306 within 120 days of their proposal.
OWNER OR OPERATOR means the owner or operator of any "facility or activity" subject to regulation under the NPDES program.
PERMIT means an authorization, license, or equivalent control document issued by EPA or an "approved State" to implement the
requirements of this part and parts 123 and 124. "Permit" includes an NPDES "general permit" (§ 122.28). Permit does not include any
permit which has not yet been the subject of final agency action, such as a "draft permit" or a "proposed permit."
PESTICIDE DISCHARGES TO WATERS OF THE UNITED STATES FROM PESTICIDE APPLICATION means the application of
biological pesticides, and the application of chemical pesticides that leave a residue, from point sources to waters of the United States. In
the context of this definition of pesticide discharges to waters of the United States from pesticide application, this does not include
1-13

FORM 1—GLOSSARY CONTINUED
agricultural storm water discharges and return flows from irrigated agriculture, which are excluded by law (33 U.S.C. 1342(I); 33 U.S.C.
1362(14)).
PESTICIDE RESIDUE for the purpose of determining whether a NPDES permit is needed for discharges to waters of the United States
from pesticide application, means that portion of a pesticide application that is discharged from a point source to waters of the United
States and no longer provides pesticidal benefits. It also includes any degradates of the pesticide.
POINT SOURCE means any discernible, confined, and discrete conveyance, including but not limited to, any pipe, ditch, channel, tunnel,
conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, landfill leachate collection system, vessel or
other floating craft from which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff. (See § 122.3).
POLLUTANT means dredged spoil, solid waste, incinerator residue, filter backwash, sewage, garbage, sewage sludge, munitions,
chemical wastes, biological materials, radioactive materials (except those regulated under the Atomic Energy Act of 1954, as amended (42
U.S.C. 2011 et seq.)), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste
discharged into water. It does not mean:
• Sewage from vessels; or
• Water, gas, or other material which is injected into a well to facilitate production of oil or gas, or water derived in association with oil
and gas production and disposed of in a well, if the well used either to facilitate production or for disposal purposes is approved by
authority of the State in which the well is located, and if the State determines that the injection or disposal will not result in the
degradation of ground or surface water resources. Note: Radioactive materials covered by the Atomic Energy Act are those
encompassed in its definition of source, byproduct, or special nuclear materials. Examples of materials not covered include radium
and accelerator -produced isotopes. See Train v. Colorado Public Interest Research Group, Inc., 426 U.S. 1 (1976).
PRIMARY INDUSTRY CATEGORY means any industry category listed in the NRDC settlement agreement (Natural Resources Defense
Council et al. v. Train, 8 E.R.C. 2120 (D.D.C. 1976), modified 12 E.R.C. 1833 (D.D.C. 1979)); also listed in appendix A of part 122.
PRIVATELY OWNED TREATMENT WORKS means any device or system which is (1) used to treat wastes from any facility whose
operator is not the operator of the treatment works and (2) not a "POTW."
PROCESS WASTEWATER means any water which, during manufacturing or processing, comes into direct contact with or results from the
production or use of any raw material, intermediate product, finished product, byproduct, or waste product.
PROPOSED PERMIT means a state NPDES "permit" prepared after the close of the public comment period (and, when applicable, any
public hearing and administrative appeals) which is sent to EPA for review before final issuance by the State. A "proposed permit" is not a
"draft permit."
PUBLICLY OWNED TREATMENT WORKS or POTW (defined at § 403.3) means a treatment works as defined by CWA Section 212,
which is owned by a state or municipality (as defined by CWA Section 502(4)). This definition includes any devices or systems used in the
storage, treatment, recycling, and reclamation) of municipal sewage or industrial wastes of a liquid nature. This definition also includes
sewers, pipes, and other conveyances only if they convey wastewater to a POTW. The term also means the municipality as defined in
CWA Section 502(4), which has jurisdiction over the indirect discharges to and the discharges from such a treatment works.
REGIONAL ADMINISTRATOR means the Regional Administrator of the appropriate Regional Office of the Environmental Protection
Agency or the authorized representative of the Regional Administrator.
ROCK CRUSHING AND GRAVEL WASHING FACILITIES (defined at § 122.27) means facilities which process crushed and broken
stone, gravel, and riprap (See 40 CFR 436, subpart B, including the effluent limitations guidelines).
SCHEDULE OF COMPLIANCE means a schedule of remedial measures included in a "permit', including an enforceable sequence of
interim requirements (for example, actions, operations, or milestone events) leading to compliance with the CWA and regulations.
SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.
SEWAGE FROM VESSELS means human body wastes and the wastes from toilets and other receptacles intended to receive or retain
body wastes that are discharged from vessels and regulated under section 312 of the CWA, except that with respect to commercial
vessels on the Great Lakes this term includes graywater. For the purposes of this definition, "graywater" means galley, bath, and shower
water.
SEWAGE SLUDGE means any solid, semi -solid, or liquid residue removed during the treatment of municipal waste water or domestic
sewage. Sewage sludge includes, but is not limited to, solids removed during primary, secondary, or advanced waste water treatment,
scum, septage, portable toilet pumpings, type III marine sanitation device pumpings (33 CFR 159), and sewage sludge products. Sewage
sludge does not include grit or screenings, or ash generated during the incineration of sewage sludge.
1-14

FORM 1—GLOSSARY CONTINUED
SILVICULTURAL POINT SOURCE (defined at § 122.27) means any discernible, confined, and discrete conveyance related to rock
crushing, gravel washing, log sorting, or log storage facilities which are operated in connection with silvicultural activities and from which
pollutants are discharged into waters of the United States. This term does not include non -point source silvicultural activities such as
nursery operations, site preparation, reforestation and subsequent cultural treatment, thinning, prescribed burning, pest and fire control,
harvesting operations, surface drainage, or road construction and maintenance from which there is natural runoff. However, some of these
activities (such as stream crossing for roads) may involve point source discharges of dredged or fill material which may require a CWA
Section 404 permit (see 33 CFR 209.120 and part 233).
SITE means the land or water area where any "facility or activity" is physically located or conducted, including adjacent land used in
connection with the facility or activity.
SLUDGE -ONLY FACILITY means any "treatment works treating domestic sewage" whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d) of the CWA
which govern minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.
STATE means any of the 50 States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Commonwealth of the Northern Mariana Islands, the Trust Territory of the Pacific Islands, or an Indian Tribe as defined in
these regulations which meets the requirements of § 123.31 of this chapter.
STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an "approved program," or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, "State Director"
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.
STORMWATER (or STORM WATER) (defined at § 122.26(b)(13)) means stormwater runoff, snow melt runoff, and surface runoff and
drainage.
STORMWATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY (defined at § 122.26(b)(14)) means the discharge from any
conveyance that is used for collecting and conveying stormwater and that is directly related to manufacturing, processing or raw materials
storage areas at an industrial plant. The term does not include discharges from facilities or activities excluded from the NPDES program
under this part 122. For the categories of industries identified in this section, the term includes, but is not limited to, stormwater discharges
from industrial plant yards; immediate access roads and rail lines used or traveled by carriers of raw materials, manufactured products,
waste material, or by-products used or created by the facility; material handling sites; refuse sites; sites used for the application or disposal
of process waste waters (as defined at 40 CFR 401); sites used for the storage and maintenance of material handling equipment; sites
used for residual treatment, storage, or disposal; shipping and receiving areas; manufacturing buildings; storage areas (including tank
farms) for raw materials, and intermediate and final products; and areas where industrial activity has taken place in the past and significant
materials remain and are exposed to stormwater. For the purposes of this paragraph, material handling activities include storage, loading
and unloading, transportation, or conveyance of any raw material, intermediate product, final product, by-product or waste product. The
term excludes areas located on plant lands separate from the plant's industrial activities, such as office buildings and accompanying
parking lots as long as the drainage from the excluded areas is not mixed with stormwater drained from the above described areas.
Industrial facilities (including industrial facilities that are federally, State, or municipally owned or operated that meet the description of the
facilities listed in paragraphs 1 through 14 below) include those facilities designated under the provisions of 40 CFR 122.26(a)(1)(v). The
following categories of facilities are considered to be engaging in "industrial activity" for purposes of 40 CFR 122.26(b)(14):
1. Facilities subject to stormwater effluent limitations guidelines, new source performance standards, or toxic pollutant effluent standards
under 40 CFR Subchapter N (except facilities with toxic pollutant effluent standards which are exempted under paragraph 11 below);
2. Facilities classified as Standard Industrial Classification 24, Industry Group 241 that are rock crushing, gravel washing, log sorting, or
log storage facilities operated in connection with silvicultural activities defined in 40 CFR 122.27(b)(2)—(3) and Industry Groups 242
through 249; 26 (except 265 and 267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441, 373; (not included are all other types of
silvicultural facilities);
3. Facilities classified as Standard Industrial Classifications 10 through 14 (mineral industry) including active or inactive mining
operations (except for areas of coal mining operations no longer meeting the definition of a reclamation area under 40 CFR 434.11(1)
because the performance bond issued to the facility by the appropriate SMCRA authority has been released, or except for areas of
non —coal mining operations which have been released from applicable State or Federal reclamation requirements after
December 17, 1990) and oil and gas exploration, production, processing, or treatment operations, or transmission facilities that
discharge stormwater contaminated by contact with or that has come into contact with, any overburden, raw material, intermediate
products, finished products, byproducts or waste products located on the site of such operations; (inactive mining operations are
mining sites that are not being actively mined, but which have an identifiable owner/operator; inactive mining sites do not include sites
1-15

FORM 1-GLOSSARY CONTINUED
where mining claims are being maintained prior to disturbances associated with the extraction, beneficiation, or processing of mined
materials, nor sites where minimal activities are undertaken for the sole purpose of maintaining a mining claim);
4. Hazardous waste treatment, storage, or disposal facilities, including those that are operating under interim status or a permit under
subtitle C of RCRA;
5. Landfills, land application sites, and open dumps that receive or have received any industrial wastes (waste that is received from any
of the facilities described under this subsection) including those that are subject to regulation under subtitle D of RCRA;
6. Facilities involved in the recycling of materials, including metal scrapyards, battery reclaimers, salvage yards, and automobile
junkyards, including but limited to those classified as Standard Industrial Classification 5015 and 5093;
7. Steam electric power generating facilities, including coal handling sites;
8. Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221-25), 43, 44, 45, and 5171 which have
vehicle maintenance shops, equipment cleaning operations, or airport deicing operations. Only those portions of the facility that are
either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication),
equipment cleaning operations, airport deicing operations, or which are otherwise identified under paragraphs 1-7 or 9-11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system, used in the
storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved
pretreatment program under 40 CFR 403. Not included are farm lands, domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility, or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing, grading and excavation, except operations that result in the disturbance of less than five acres
of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34
(except 3441), 35, 36, 37 (except 373), 38, 39, and 4221-25.
TOXIC POLLUTANT means any pollutant listed as toxic under section 307(a)(1) or, in the case of "sludge use or disposal practices," any
pollutant identified in regulations implementing section 405(d) of the CWA.
TREATMENT WORKS TREATING DOMESTIC SEWAGE (TWTDS) means a POTW or any other sewage sludge or waste water
treatment devices or systems, regardless of ownership (including federal facilities), used in the storage, treatment, recycling, and
reclamation of municipal or domestic sewage, including land dedicated for the disposal of sewage sludge. This definition does not include
septic tanks or similar devices. For purposes of this definition, "domestic sewage" includes waste and waste water from humans or
household operations that are discharged to or otherwise enter a treatment works. In States where there is no approved State sludge
management program under section 405(f) of the CWA, the Regional Administrator may designate any person subject to the standards for
sewage sludge use and disposal in 40 CFR 503 as a "treatment works treating domestic sewage," where he or she finds that there is a
potential for adverse effects on public health and the environment from poor sludge quality or poor sludge handling, use or disposal
practices, or where he or she finds that such designation is necessary to ensure that such person is in compliance with 40 CFR 503.
UPSET (defined at § 122.41(n)) means an exceptional incident in which there is unintentional and temporary noncompliance with
technology based permit effluent limitations because of factors beyond the reasonable control of the permittee. An upset does not include
noncompliance to the extent caused by operational error, improperly designed treatment facilities, inadequate treatment facilities, lack of
preventive maintenance, or careless or improper operation.
VARIANCE means any mechanism or provision under section 301 or 316 of the CWA or under 40 CFR 125, or in the applicable "effluent
limitations guidelines" which allows modification to or waiver of the generally applicable effluent limitation requirements or time deadlines of
the CWA. This includes provisions which allow the establishment of alternative limitations based on fundamentally different factors or on
sections 301(c), 301(g), 301(h), 301(i), or 316(a) of the CWA.
WATERS OF THE UNITED STATES as defined at § 122.2.
WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test.
1-16

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110012909843
NCO088331
Kershaw WTP
OMB No. 2040-0004
U.S. Environmental Protection Agency
Form
1
VolEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
Applicants Not Required to Submit Form 1
1.1
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 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
n-
production facility?
currently discharging process wastewater?
o
❑ Yes 4 Complete Form 1 No
❑ Yes 4 Complete Form 0 No
a
and Form 213.
1 and Form 2C.
0
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
C
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
d
❑ Yes 4 Complete Form 1 0 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-
• • i
Facility Name
2.1
Kershaw WTP
0
2.2
EPA Identification Number
.o
J
110012909843
'a
2.3
Facility Contact
d
Name (first and last)
Title
Phone number
-o
Timothy Buck
County Manager
[phone]
Q
c
Email address
[e-mail]
d
2.4
Facility Mailing Address
ZStreet
or P.O. box
PO Box 158
City or town
State
ZIP code
Bayboro
NC
28515
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110012909843
NCO088331
Kershaw WTP
OMB No. 2040-0004
CPT
2.5
Facility Location
d c
Street, route number, or other specific identifier
Q o
U
4116 Kershaw Road
0
County name
County code (if known)
_r
cc is
M U
Pamlico
E -a
City or town
State ZIP code
z cc
Arapahoe
INC 28510
SECTION•D
1
SIC Code(s)
Description (optional)
3.1
4941
Water Treatment
ai
m
a
0
U
N
U
Z
3.2
NAICS Code(s)
Description (optional)
`O
2213
Water Treatment
U
N
Name of Operator
4.1
Pamlico County Water System
0
4.2
Is the name you listed in Item 4.1 also the owner?
E
❑✓ Yes ElNo
0
L
4.3
Operator Status
❑ Public —federal ❑ Public —state ❑✓ Other public (specify) Municipal
o
❑ Private ❑ Other (specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
w
Street or P.O. Box
C5
E
PO Box 158
City or town
State
ZIP code
0
Bayboro
NC
28515
is �o
a
Email address of operator
0
[e-mail]
SECTION1
Is the facility located on Indian Land?
R
5.1
0
❑ Yes 0 No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP OMB No. 2040-0004
tECTION 6. EXISTING ENVIRONMENTAL1
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
m NPDES (discharges to surface ❑ RCRA (hazardous wastes) ❑ UIC (underground injection of
water) fluids)
•Y NCO088331
w` a ❑ PSD (air emissions) ❑ Nonattainment program (CAA) ❑ NESHAPs (CAA)
rn
c
w ElOcean dumping (MPRSA) ElDredge or fill (CWA Section 404) ElOther (specify)
7.1 I 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 2B.)
8.1 Describe the nature of your business.
Groundwater treatment from 2 wells in the Castle Hayne Aquifer. Backwash water from 2 sand filters and 2 ion
exchange water softeners. Backwash water is dechlorinated before discharge with S02.
in
m
c
.y
3
m
0
O
N
7
f6
Z
9.1 Does your facility use cooling water?
❑ Yes ❑✓ No '* SKIP to Item 10.1.
9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
75 W
O Y
U C
10.1 I Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
Cn apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
d
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
R Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name
Form Approved 03/05/19
110012909843 NCO088331 Kershaw WTP
OMB No. 2040-0004
SECTIONI
CERTIFICATION STATEMENT (40
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
d
❑✓ Section 7: Map
w/ topographic
❑v ❑ w/ additional attachments
5
ma
U)
o
❑✓ Section 8: Nature of Business
❑ w/ attachments
❑ Section 9: Cooling Water Intake Structures
❑ w/ attachments
U
❑ Section 10: Variance Requests
❑ w/ attachments
v
c
❑� Section 11: Checklist and Certification Statement
❑ w/ attachments
d
11.2
Certification Statement
s
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
Timothy Buck
County Manager
Signa a
Date signed
EPA Form 3510-1 (revised 3-19) Page 4