NC0038822_Renewal (Application)_20080930

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit C00..3i g
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name
Facility Name
L.fnkafa C`O�f — A26-ne
Mailing Address
139 QW Lan k�,
city
mc,,
State /Zip Code
WC-4;Drlo3o
Telephone Number
39La-P-1 t5
Fax Number
(33tp) 3� O—a [ $ P R% != ♦V%t"' �\�1
e-mail Address
2. Location of facility producing discharge: SEP 3 0 2008
Check here if same address as above
Street Address or State Road DEN WATER
O IA I ITY
1
City POINT SOURCE H
State / Zip Code
County
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name P f(� Cad Ana 1 LA+i( A) LabO rcA-or i t S
Mailing Address AL. D . Q,eV 13 1©� 3100 f+
`r .
City 1 er rl���-- 5V i \ Imo.
State / Zip Code N G "21 a$t�
Telephone Number (33,P) Ci q Lo- a
Fax Number (2>3w) omp _o-3ap
1 of 3 Form-D 05/08

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater: >
Facility Generating Wastewater(check all that apply):
Industrial
❑
- Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
❑
Explain: �zr: dz,��s/ j1';.FF 33
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.): A ss + s � t \ L—; a , ,k y F4L 1 I + � `i
Population served: 3 J
S. of collection system
Ty
of sewer only) R❑ Combined (storm sewer and sanitary sewer)
•
6. OutfaS Iraforaiation: ' W- fei
Number of separate discharge points
Outfall Identification number(s)
Is t#,",p L#fpLiL-equipped, ►itl c i#f er? ❑Yes ❑ No
i t.� r F B '• i. F I
7. N1a&"f ieceiAvizig-• trinhn(s) 's (Pidvi4 jja map s]hounng the exact location of each outfall):
TL
i
S. Frequency of Discharge: ❑ Continuous I( Intermittent
If intermittent:
Days per week discharge occurs: Duration: F ` e+v A . J o r
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
000 9Q( T-� f3S• tctA �� , Sl-lJ� 7 e.C^� �Fi'� e1 ?��y � 9� � I 4 � /iL1
C 1\I 1. 0 A. c:J, Lk LA
2 of 3 Form-D 05108

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow e h C l MGD
Annual Average daily flow o VV v MGD (for the previous 3 years)
Maximum daily flow o 0 iC) MGD (for the previous 3 years)
11. Is this facility located on Ind}a'n country?
❑ Yes [ No
12. Effluent Data
Provide data for the parameters listed Fecal Colifonn, Temperature and pH shall be grab samples, for all other
parameters 24-hour composite sampling shall be used. If more than one analysis is reported, report daily maximum
and monthly average If only one analysis is reported, report as daily maximum
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
45
Fecal Coliform
jl C "
`, 0
o ,
Total Suspended Solids
e.j
3 0
Temperature (Summer)
Temperature (Winter)
pH
rr o
1
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
NESHAPS (CAA)
Ocean Dumping (MPRSA)
/WC (D G :2�- Dredge or fill (Section 404 or CWA)
Other
14. APPLICANT CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
T"'JA L-AA"' C' , AA,;,
Printed name of Person Signing Title
cn '
Signature of
I`19
Date
North Carolina General Statute 143-215 6 (b)(2) states 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 of a misdemeanor punishable by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both (18 U.S.0 Section 1001
provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both, for a similar offense )
3 of 3 Form-D 05/08

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
Racic Tnformation to determine notential for expedited hermit renewal
Reviewer/Date
on1
Permit Number
G $ 16 9, 1-
Facility Name
7 F, A Wc .
Basin Name/Sub-basin number
e a
Receiving Stream
i JT'VA4-T
Stream Classification in Permit
G
Does permit need NH3 limits?
4e, --7 OA-S -T.l*YvL,
Does permit need TRC limits?
Ao .-? AA-5 IF
Does permit have toxicity testing?
o
Does permit have Special Conditions?
Pro
Does permit have instream monitoring?
Is the stream impaired (on 303(d) list)?
/v0
Any obvious compliance concerns?
,4a 1,N -rus cAqr 7
Any permit mods since lastpermit?
rl&-A .orz
Existing expiration date
2 28 0
New expiration date
2
New permit effective,date-----
Miscellaneous Comments
!;om A Sr COnsa ts}nrc.E i 9uG y �� l0 F� t SSu 7
YES V This is a SIMPLE EXPEDITED permit renewal (administrative
renewal with no changes, or only minor changes such as TRC, NH3,
name/ownership changes). Include conventional WTPs in this group.
YES_ This is a MORE COMPLEX EXPEDITED permit renewal (includes
Special Conditions (such as EAA, Wastewater Management Plan), 303(d)
listed, toxicity testing, instream monitoring, compliance concerns, phased
limits). Basin Coordinator to make case -by -case decision.
YES_ This permit CANNOT BE EXPEDITED for one of the following reasons:
• Major Facility (municipal/industrial)
• Minor Municipals with pretreatment program
• Minor Industrials subject to Fed Effluent Guidelines (lb/day limits for BOD, TSS,
etc)
• Limits based on reasonable potential analysis (metals, GW remediation organics)
• Permitted flow > 0.5 MGD (requires full Fact Sheet)
• Permits determined by Basin Coordinator to be outside expedited process
a TB Version 8/18/2006 (NPDES Server/Current Versions/Expedited Fact Sheet)