NC0002828_Standards Form 1990_20100524

SOXeli CAROLIr1A DEPT. OF NATURAL RESOURCES XiD COMMU►VITY DEVELOPMENT
ENVIRONMENTAL MANAGEMENT COMMISSION FOR AGENCY USE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTkM
APPLICATION FOR PERMIT TO DISCHARGE WASTEWATER::
STANDARD FORM A — MUNICIPAL
sje2N'O-6
SECTION L APPLICANT AND FACILITY DESCRIPTION _ Unless otherwise specified on this form all items are to be completed. It an Item Is not applicable Indicate *NA.' �6
ADDITIONAL INSTRUCTIONS FOR SELECTED ITEMS APPEAR IN SEPARATE INSTRUCTION 130OKLET AS INDICATED. REFER TO
BOOKLET BEFORE FILLING OUT THESE ITEMS.
t. Legal Name of Applicant -
(see Instructions)
2. Malting Address of Applicant
(see Instructions)
Number 3 Street
Ctty
State
Zip Code
3. Applicant's Authorized Agent
(see instructions)
Name and Title
Number 6 Street
City
State
Zip Code
Telephone
4. Previous Application
If a previous application for a per-
mit under the National Pollutant
Discharge Elimination System has
been made. give the date of
application.
101
102s
103b
1020
102d
1039
103b
103C
103d
103e
103f
104
Please Print or Type
Zarn, Inc.
Northeast Market Street Ext. 1001
Reidsville
NC
27320
Hydro Management Services , Inc.
2419 Lewisville-Clemmons Road
Clemmons
NC
27012 X s.
t:a,r. .-. A has. � � • � j
919 766-0270�� ,
Area Number
Code
IN
i
YR MO DAY
b
ti
1
I certify that I am familiar with the Information contained In this application and that to the best of my knowledge and belief such Information
is true, complete, and accurate.
wI • n
Printed Name of Person Slim Title
:I ggo- 12- 05
102t YR MO DAY
Signature of Applicant or ALWhiirlzed Agent Date Application Signed
North Carolina General Statute 143-215.6(b)(2).provides that: Any person who knowingly makes
any false statement representation, or certification in any application, record, report, plan,
or other document files or required to be maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, or who falsifies,, -tampers with,
or knowingly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under Article 21 or regulations of the Environmental Management
Commission implementing that Article, shall be guilty or a misdemeanor punishable by a fine
not to exceed $10,000, or by imprisonment not to exceed six months, or by both. (18'U.S.C-
Section 1001 provides a punishment by a fine or not more than $10,000 or imprisonment not
more than 5 years, or both, for a similar offense.)

• 6
' FOR AGENCY UiE
5. Facility (see Instructions)
Give the name. ownership. and physi-
cal location of the plant or other -
operating facility where discharge(s)
presently occur(s) or will occur.?.
Zarn, Inc.
Names
x"
e4• .<Y.
Northeast Market Street Ext. 1001 '
Reidsville, NC 27320
Ownership (Public, Private or
Both Public and Private).
Orb_:
❑ PUB XZPRV ❑ 8PP
Check block If a Federal facility
af0
❑ FED
and give GSA Inventory Control
,
Number
Location:
Number i Street
w!
--
same as above
City
;
R::
-
County
State
6. Discharge to Another Municipal
P.
Facility (see Instructions)
a. Indicate If part of your discharge
`ii}fi;,`
❑ Yes XM No
Is into a municipal waste trans-
7.:.'.:
Port system under another re.
sponsible organization. If yes,
complete the rest of this Item
-
and continue with Item 7. It no.
<• ; <
go directly to Item 7.
0. Responsible Organization
Receiving Discharge
'1Qib
N/A
Name
Number a Street
10iC
City
g0�
State
1pM
Zip Code
IOU
C. Facility Which Receives Discharge IQ"-.
Give the name of the facility
(waste treatment plant' which re-
ceives and Is ultimately respon-
sible for treatment of the discharge
from your facility.
d. Average Daily Flow to Facility
(mod) Give your average dally
flow Into the receiving facility.
7. Facility Discharges. Number and
Discharge Volume (see Instructions)
Specify the number of discharges
described In this application and the
volume of water discharged or lost
to each of the categories below.
Estimate average volume per day In
million gallons per day. Do not In.
dude Intermittent or noncontlnuous.
overflows, bypasses or seasonal dls•
charges from lagoons, holding
Ponds, etc.
N/A
N/A mod

To: Surface Water
Surface Impoundment with
no Effluent
Underground Percolation
well (Injection)
Other
Total Item 7
If 'other' Is specified, describe
If any of the discharges from this
facility are Intermittent. such as from
overflow or bypass points, or are
seasonal or periodic from lagoons,
holding ponds,'etc., complete Item 8.
8. Intermittent Discharges
a. Facility bypass points
Indicate the number of bypass
points for the facility that are
discharge points.(see Instructions)
b. Facility Overflow Points
Indicate the number of overflow
points to a surface water for the
facility (see Instructions).
c. Seasonal or Periodic Discharge
Points Indicate the number of
points where seasonal discharges
occur from holding ponds.
lagoons, etc.
9. Collection System Type
Indicate the type and length (In
miles) of the collection system used
by this facility. (see instructions)
Separate Storm
Separate Sanitary
Combined Sanitary and Storm
Both Separate Sanitary and
Combined Sewer Systems
Both Separate Storm aw:
Combined Sewer Systems
Length
10. Municipalities or Areas Served
(see Instructions)
Total Population Served
FOR AGENCY USE
u `Q
Number of Total Volume Discharged,
Discharge Points Million Gallons Per Day
107a1
.07r�;
y_
�x
a
w.•
t pTt i .
i0#tx'
1 QT1s1:
1t?fa
❑ SST
❑ SAN
❑ CSS
❑ 8SC
1�b'
:@jSC
< 1 miles
Actual Population '
Name
Served
•
:mac, �,;,�
R$k(.
tit3s;
.i�Qp:..
1 lei
I-3

FOR AGENCY USE
.002 (002)
11. Average Daily Industrial Flow 0053 (04W
Total estimated average daily waste
flow from all Industrial sources.1W
Note: All major industries (as defined In Section IV)
discharging to the municipal system must be
listed In Section IV.
12. Permits, Licenses and Applications
List all existing, pending or denied permits, licenses and applications related to discharges from this facility.(s" Instructions)
2.
3.
For
Type of Permit
Date
Date
Date
Expiration
Issuing Agency
Agency Use
or Ucense
10 Number
Filed
Issued
Denied
Oats
YR/MO/DA'
Y R/M I A
YR/MQ/DA
Yk/M0/DA
31,
NCDNRCD
gp� g"X AIX
IR',
A
NC0002828
7-31-91
R
4�M
13- Maps and Drawings
Attach all required maps and drawings to the back of this application. (s" Instructions)
14. Additional Information

r
STANDARD FORM A —MUNICIPAL FORAGE CY USE
SECTION U. BASIC DISCHARGE DESCRIPTION
,
Complete this section for each present or proposed dischargeIndicated in Section 1. Items 7 and i, that Is to surface waters. This Includes
discharges to other municipal sewerage systems In which the waste water does not go through a treatment works prior to being dischargeei to
surface waters. Discharges to wells must be described where there are also dlsCharglls to surface waters from this facility. Separate
descriptions of each discharge are required even If several discharges originate In the same facility. All values for an existing discharge should
be representative of the twelve previous months of operation. If this Is a proposed discharge, values should reflect best engineering estimates.
ADDITIONAL INSTRUCTIONS FOR SELECTED ITEMS APPEAR IN SEPARATE INSTRUCTION BOOKLET AS INDICATED. REFER TO
BOOKLET BEFORE FILLING OUT THESE ITEMS.
1. Discharge Serial No. and Name 001
a. Discharge Serial No. s01�.; 002
(see Instructions) ,
b. Discharge Nam. :oib' Zarn, Inc.
Give name of discharge. If any
(see Instructions) 88 7
c. Previous Discharge Serial No 2014.
If a previous NPOES permit
application was made for this dis-
charge (Item 4. Section 1) provide
Previous discharge serial number.
2. Discharge Operating Dates N/A
a. Discharge to Begin Date 20,.
If the discharge has never YR MO
occurred but Is planned for some
future date, give the date the
discharge will begin.
b. Discharge to End Date If the dis• t 202b N/A
charge Is scheduled to be dlscon- YR MO
tinued within the next 5 years.
give the date (within best estimate)
the discharge will end. Give rea-
son for discontinuing this discharge
In Item 17.
3. Discharge Location Name the
Political boundaries within which Agency
the point of discharge Is located:
North Carolina
State-------
:V
Rockingham
:?f•
County 36
(if applicable) City or Town 1030 Reidsville
4. Discharge Point Description
(see Instructions)
Discharge Is Into (check one)
Stream (Includes ditches. arroyos.
and other watercourses)
Estuary
Lake
Ocean
Well (Injection)
Other
If 'other* is checked, specify type
S. Discharge Point — Lat/Long..
State the precise location of the
Point of discharge to the nearest
second. (see Instructions)
Latitude
Longitude
2041a 1 Y4STR
Q EST
o •'
❑ LKE
❑ OCE
O WEL
❑ OTH
;Oat
Soil
36 b DEG. 45 MIN. 10 SEC
7900EG. 30 . MIN. 15 SEC
11-1 1This section contains 8 pages.

DISCHARGE SERIAL NUMBER
FOR AGENCY USE
S. Discharge Receiving water Name Unnamed tributary to Lick Fork Creek. Roanoke
Name the waterway at the point of .00 .•. .
dlschar".(see instructions) River Basin
If the discharge Is through an Out- ZBED
fall that extends beyond the shoreline
Or Is below the mean low water line,
complete Item 7.
7. Offshore Discharge
For Agency Usi
1�or
4
For Agency Use
303e
x
a. Discharge Distance from+ Shore
EaTi ''
N/A feet
b. Discharge Depth Below Water
N/A
Surface
j@Tj1
feet
If discharge is from a bypass or an overflow
point or Is
a seasonal discharge from a lagoon, holding pond, etc., complete Items •, 9 or 10,
a$ applicable, and continue with Item 11.
a• Bypass Discharge (see Instructions)
a. Bypass Occurrence
Check when bypass Occurs
,
Wet weather
so:at
❑ Yes NXNo
Dry weather
a8til.;
❑ Yes' by -No
b. Bypass Frequency Give the
actual or approximate number
Of bypass Incidents per year.
•- Wet Weather
.=0arp
0 timer per year
:.
Dry weather)'
0 times per year
C. Bypass Duration Give the
average bypass duration In hours.
y`
Wet weather
r�'M`a�.:
0 hours
Dry Weather
,.
hours
d. Bypass Volume Give the
average volume per bypass Incident,
In thousand gallons.
Wet weather
=awl..
0 thousand gallons per Incident
Dry weather
?�
thousand gallons per incident
e. Bypass Reasons Give reasons
N/A
why bypass occur."
,
Proceed to Item 11.
9. Overflow Discharge (see Instructions)
a. Overflow Occurrence Check
when Overflow occurs.
Wet weather
Dry weather
b. Overflow Frequency Give the
actual Or approximate Incidents
per year.
Wet weather
Dry weather
❑ Yes V&o
❑ Yes XM No
—_.times per year
0 times per year
II.2

DISCHARGE SERIAL NUMBER
FOR AO<NCY Ulm
c. Overflow Duration Give the
average overflow duration In
hours.
Wet weather
=p>qj
hours
Dry weather:
Hours
d. Overflow -Volume Give the
average volume per overflow
Incident In thousand gallons.
Wet weather
Qs
0
thousand gallons per Incident
0
Dry weather
thousand gallons per Incident
Proceed to Item 11.1'.r
..�
10. Sessonal/Periodic Discharges
<rstiy
a. Seasonal/Perlodic Discharge
Frequency It discharge Is Inter-
`r ,
`; 441 :.i
N/A times per year
mittent from a holding pond,
'V"
lagoon, etc., give the actual or
xl:s
approximate number of times
this discharge occurs per year,
b. Seasonal/Periodic Discharge
N�A
Volume Give the average
:.?
thousand gallons per discharge occurrence
volume per discharge occurrence
In thousand gallons.
c. Seasonal/Periodic Discharge
N/A
Duration Give the average dura-
'';p;:
days
tlon of each discharge occurrence
y{K:
In days.
d. Seasonal/Periodic Discharge
Occurrence —Months Check the
+'
❑JAN
FE8 MAR
❑ ❑
months during the year when
fx?�`A>
the discharge normally occurs.
y�s,�
❑AP•R
❑ MAY ❑JUN
A.4 .
-;"
❑ OCT
❑ NOV ❑ DEC
11. Discharge Treatment � �x
a. Discharge Treatment Description >
Describe waste abatement prac-
tices used on this discharge with
a brief narrative. (See Instruc-
tions) Flow enters plant through a splitter box. Part
of the flow enters an aerated surge basin, while
the remainder is screened by a manual bar rack
and enters the activated sludge basin. The flow
then goes through a rectangular clarifier with
return sludge capabilities. The flow is then
1.
measured and disinfected in a.chlorine contact
chamber.
U-3

DISCHARGE SERIAL NUMBER
b. Discharge Treatment Code:
<.
JS, S, AS,• N, P(PH)
Using the Codes listed In Table 1
111:¢
of the Initructlon Booklet.
describe the waste abatement
"
processes applied to this dis-
charge in the Order in which
they occur, If possible.
Separate all codes with Commas
except where slashes are used
»'
to designate parallel operations.
If this discharge Is from a municipal waste
, ,9
treatment plant (not an overflow or
bypass), Complete Items 12 and 13
12. Plant Design and Operation Manuals
41--
Check which of the following are
Currently available
a. Engineering Design Report
::;j:::
❑
b. Operation and Maintenance
Manual
ai13
13. Plant Design Data (see instructions)
•'
'K..ti
• a. Plant Design Flow ( mod.)
:� .: �F
.005 mgd
b Plant Design 800 Removal (%)
85 %
c. Plant Design N Removal (%)
N/A %
d. Plant Design P Removal (%)
213
N/A %
e. Plant Design SS Removal
i011 •
N/A %
f. Plant Began Operation (year)
_.in
-N/A
g. Plant Last Major Revision (year)
N A
FOR AGENCY USE

DISCHARGE SERIAL NUMBER
001
14. Description of Influent and Effluent (see instructions)
kn
R AGENCY US:.
Influent
Effluent
Parameter and Code
o
c -4
o
0
<>
<>
z<
$•
E
E
S<
rar<
z�
y
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Flow
Million gallons per day
365 days
50050 .
.0043
.002
.008
per year
-
I i
pH
!
Units
00400
Temperature (winter)
l
* F
270 days
74028
12.3
12.1
10.4
16.0
per year
-
G I
Temperature (summer)
a
74027
21.2
22.3
16.1
26.1
" "
-
G
Fecal Streptococci Bacteria
Number/100 ml
74054
xx
•. (Provide if available)
Fecal Coliform Bacteria
Number/100 ml
74055xxx
(Provide if available)
26
(2)month
24
G
Total Coliform Bacteria
Number/100 nd
74056
xxx
(Provide if available)
BOD 5-day
mg/1
00310
3.41
1 •
7
(2)month
24
C
Chemical Oxygen Demand (COD)
mg/1
00340
(Provide if available)
OR
Total Organic Carbon (TOC)
'
mg/ 1
00680
(Provide if available)
(Either analysis is acceptable)
Chlorine —Total Residual
mg/)
50060
II-5

DISCHARGE SERIAL NUMBER
001
14. Description of Influent and Effluent (spa Instructions) (Continued)
FOR AGENCY USED
'.i
Influent
Effluent
7
o
xx
Parameter and Code
'3
a
�
=
�<
w<
z<
ti
(l)
(2)
(3)
(4)
(S)
(6)
(7)
Total Solids
mg/l
00500
Total Dissolved Solids
mg/l
70300
Total Suspended Solids
mg/l
00530
10.4
3
24
(2)month
24
-C
Settleable Matter (Residue)
ml/1
.
00545
Ammonia (as N)
mg/l
00610
(Provide if available)
21
1
4
(2)month
24
C
Kjeldahl Nitrogen
mg/l
00625
(Provide if available)
4.9
2
18.5
(2) month
24
C
Nitrate (as N)
mg/l
00620
(rrovido if available)
Nitrite (as N)
mg/l
00615
"
(Provide if available)
Phosphorus Total (as P)
mg/l
00665
(Provide if available)
Dissolved Oxygen (DO)
mg/l
00300
-five
da
6.4 �
.6.2.
6.6
Per week]
270
G
11-6

01 SCHARGi SERIAL NUMBER /OR AGENCY USE
001
16. Additional Wastewater Characteristics
Check the box next to each parameter If It Is present In the effluent. (see Instructions)
Parameter
Parameter
C
Parameter
WE
(215)
(215)
b.
(215)
V
_
a
a
a.
Bromide
Cobalt
Thallium
71870
01037
01059
Chloride
Chromium
Titanium
00940
01034
01152
Cyanide
Copper
Tin
00720
01042
01102
Fluoride
Iron
Zinc
00951
01045
01092
Sulfide
Lead
Algicides•
00745
01051
74051
Aluminum
Manganese
Chlorinated organic compounds*
01105
01055
74052
Antimony
Mercury
Oil•and grease
01097
71900
00550
Arsenic
Molybdenum
Pesticides*
01002
01062
74053
Beryllium
Nickel
Phenols
01012
01067
32730
Barium
Selenium
Surfactants
01007
01147
38260
Boron
Silver
Radioactivity*
i 01022
01077
-74050
Cadmium
'
i 01027
• Provide specific compound and/or element in item 17, if known.
Pesticides (Insecticides, fungicides, and rodenticides) must be reported in terms olt the acceptable common names specified in Acceptable Com-
mon Names and aem Led Names for the Insredient Statement on Pesticide Labels, 2nd Edition, Environmental Protection Agency, Washington,
D.C. 20250, June 1972. as required by Subsection 162.7(b) of the Regulations for the Enforcement of the Federal Insecticide. Fungicide. and
Rodenticide Act.
II-7

DISCHARGE SERIAL NUMBER
002
14. Description of Influent and Effluent (s" instructions)
FOR AGENCY USE
Influent
Influent
Effluent
Parameter and Code
o
c >
c
o
a2
X
M
l
C
e
<>
1'aP
<>
s<
_<
g �c
�.<
Z<
E
N
(1)
(2)
(3)
(4)
(S)
(6)
(7)
Flow
Million gallons per day
365 day
50050
.002
.001
.009
per yea
-
- i
1
pH
I
Units
270 days
00400
6.5
7.0
per year
-
G '
Temperature (winter)
,F
270 day
l
74028
11.25
6
20
per yea
-
G I
Temperature (summer)
OF
270 day
74027
19.2
16
24
per year
-
G
Fecal Streptococci Bacteria
Number/100 ml
I
740S4
(Provide if available)
Fecal Coliform Bacteria
Number/100 ml
,
74055
X.XX
(Provide if available)
Total Coliform Bacteria
Number/100 ml
74056
XXX
(Provide if available)
BOD 5-day
mg/1
00310
Chemical Oxygen Demand (COD)
mg/1
00340
(Provide if available)
OR
Total Organic Carbon (TOC)
'
mg/1
00680
(Provide if available)
,
(Either analysis is acceptable)
Chlorine —Total Residual
mg/I
50060
11-5

DISCHARGE SERIAL NUMBER
• 002
14. Description of Influent and Effluent (see Instructions) (Continued)
FOR AGENCY USE
Influent
Effluent
Parameter
and Code
V
>
c V
c
<
<
>
V M
Z!
(I)
(2)
(3)
(4)
(5)
(6)
(7)
Total Solids
mg/l
00500
Total Dissolved Solids
mg/l
70300
Total Suspended Solids
mg/l
00530
-
Settleable Matter (Residue)
Mill
00545
Ammonia (as N)
mg/l
00610
(Provide if available)
i(ieldahl Nitrogen
mg/l
00625
(Provide if available)
Nitrate (as N)
mg/l
00620
(Provide if available)
Nitrite (as N)
mg/1
'
00615
"
(Provide if available)
'
Phosphorus Total (as P)
mg/l
00665
(Provide if available)
Dissolved Oxygen (DO)
mg/1
00300
,
11-6

DISCHARGE SERIAL NUMBER
002
FOR AGENCY USE
a`
r3
w
16. Additional Wastewater Characteristics
Check the box next to each parameter It It is present In the affluent. (see Instructions)
Parameter
Parameter
Parameter
(215) _
(215)
(215)
u
Bromide
Cobalt
Thallium
71870
01037
01059
Chloride
Chromium
Titanium
00940
01034
01152
Cyanide
Copper
Tin
00720
01042
01102
Fluoride
Iron
Zinc
00951
01045
01092
Sulfide
Lead
Algicides'
.00745
01051
74051
Aluminum
Manganese
Chlorinated organic compounds'
01105
01055
74052
Antimony
Mercury
Oil and grease
01097
71900
00550
Arsenic
Molybdenum
Pesticides*
01002
01062
74053
Beryllium
Nickel
Phenols
01012
01067
32730
Barium
Selenium
Surfactants
01007
01147
38260
Boron
Silver
Radioactivity'
01022
01077
-74050
Cadmium
01027
• Provide specific compound and/or element in Item 17, if known:
Pesticides (Insecticides, fungicides, and rodenticides) must be reported in terms of the acceptable common names specifled In Acceptable Cons-
rnon Names and Chemical Names for the Ingredient Statement on Pesticide Label; 2nd Edition, Environmental Protection Agency, Washington,
D.C. 20250, June 1972, as required by Subsection 162.7(b) of the Regulations for the Enforcement of the Federal Insecticide, Fungicide, and
Rodenticide Act.
II.7

DIACHARdE SERIAL NUMBER
19. Plant Controls Check If the follow-
Ing Plant controls are available
for this discharge
Alternate power source for major
pumping facility Including those
for Collection system lift stations
t
[3 APS
Alarm for power or equlpnwnt
failure
0 ALM
17. Additional Information
jc•' Item
ME Number
Information
FOR AGENCV 4.05
A H-.,
-.J
.9u. LGOVERNMENT PAINTING Or'ricr. *73n-sos.47a

• IrOR AGENCY US[
STANDARD FORM A —MUNICIPAL
SECTION IM SCHEDULED IMPROVEMENTS AND SCHEDULES OF IMPLEMENTATION
This section requires Information on any uncompleted Implementation schedule which has been Imposed for construction of waste treatment
facilities. Requirement schedules may have been established by local, Stste.or Federal agencies or by court action. IF YOU ARE SUBJECT TO
SEVERAL DIFFERENT IMPLEMENTATION SCHEDULES. EITHER BECAUSE OF DIFFERENT LEVELS OF AUTHORITY IMPOSING
DIFFERENT SCHEDULES (ITEM 1b) AND/OR STAGED CONSTRUCTION OF SEPARATE OPERATIONAL UNITS (ITEM 1c), SUBMIT A
SEPARATE SECTION III FOR EACH ONE.
S
I. Improvements Required FOR AGENCY USE
a. Discharge Serial Numbest xa` "WSJ. a r?nl��� r: ,�r...eut: x . .a,.. •.
Affected List the discharge
serial numbers, assigned In Sec-
tion 11. that are covered by this
implementation schedule '>
' 0. Authority Imposing .Requirement
Check the appropriate Item Indl-
cating the authority for the Im- Ks '
'' 4
plementatlon schedule. If the
?:Z
Identical Implementation ached. . ;�-
ule has been ordered by more z
than one authority, check the ^a`
appropriate Items. (see in. ti'p
structions)'^
saav; O LOC
Locally developed plan
....,q . ❑ ARE
Arsawlds Plan0 BAS
Basin Plan <'
State approved ImpNmentatlon ❑ SQS
schedule
Federal approved water quality ~' K
, .... ' O was
standards Implementation plan
Federal enforcement procedure ENF
or action
A«'^<•:c<>`:
Y.;.
0 CRT
State court order FED
�..:.
Federal court order
. e. Improvement Description Specify the 3-character code for the
General Action De'scrlptlon In Table 11 that best describes the
Improvements required by the Implementation schedule. It more
than one schedule applies to the faclllty because of a staged con-
struction schedule, state the Stigs of constructlon.being described
here with the appropriate general action code. subrnk a separate
Section II I for each stage of construction planned. Also, list all
the 3-character (Specific Action) codes which desCflbe In -more
detail the pollution abatement practices that the Implementation
schedule requires.
3-Character general action •�='.
descriptionQ'
3-character specific action
descriptions
2. Implementation Schedule and 3. Actual Completion Dates
Provide dates imposed by schedule and any actual dates of completion for Implementation stsps .
listed below. Indicate dates as accurately as possibli. (see Instructions) '
Implemsntatlon Steps 2. Schedule (Yr /Mo /Day) 3. Actual Completion (Yr /Mo /Day)
a. Preliminary plan complete 3D;t
b. Final plan complete 392b
c. Financing complete i contract
awarded =<:
w y .
d. Site acquiredOZd.
s. Begin constructions
f. End construction 3C / / /-/
i?1
g. Begin Discharge
h. Operational level attained
This section contains 1 page.
III-1
G•o a65.707

FOR AGENCY USE1
STANDARD FORM A -MUNICIPAL
~
SECTION Iff INDUSTRIAL WASTE CONTRIBUTION TO MUNICIPAL SYSTEM
Submit a description of each major industrial facility discharging to the municipal system, using a separate Section IV for each facility descrip•
tion. indicate the 4 digit Standard Industrial Classification (SIC) Code for the Industry, the major product or raw material.
the flow (in thtxc-
sand gallons per day). and the characteristics of the wastewater discharged from the Industrial facility Into the municipal system. Consult :able
I I I for standard measures of products or raw materials. (see Instructions)
1• Major Contributing Facility
(see Instructions)
Name 401 a
Numbers. Street 401b
City 4014
County 401 d
State 401 •
Zip Code 401 f
2. Primary Standard Industrial 402
Classification Code (see
Instructions)
Units (See
3. Principal Product or Raw Quantity
Table 11!
Material (see Instructions)
Product 402a yam'_:.
#034
'w
}: • s
.. Raw Material 403b
��:...
4. Flow Indicate the volume of water
discharged Into the municipal sys- 404a thousand gallons per day
tam in thousand gallons per day
and whether this discharge Is Inter- 404b ❑ intermittent (Int) ❑Contlnwous(con)
mittent or continuous.
S. Pretreatment Provided Indicate If 40S ❑Yes ONO
pretreatment is provided prior to '
entering the municipal system
'
6. Characteristics of Wastewater
(see instructions)
Parameter
Name
40Ga
Parameter
Number
,
409b
Value
IV-1 This section contsins ! page.
GPO 665•706

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