NCG110133_COMPLETE FILE - HISTORICAL_20130111

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
Iv U& 1) 6133
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ d i 3 o I
YYYYM M D D

NCDENR
Non- Gr+ourvw Oo^u+ra or
ENVIRph M[MT arvo N-, w- RE9 RC,:
Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
PERMIT NAMEIOWNERSHIP CHANGE FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C 19 o I I I I N 10 101 1 1 I 1 0 I 3 3
]L Permit status prior to requested change.
a. Permit issued to (company name): City of Winston Salem — Muddy Creek WWTP
b. Person legally responsible for permit: Jan McHargue
First MI Last
Manaeer Solid Waste
"Title
PO Box 2511
Permit Holder Mailing Address
Winston-Salem NC 27107
City State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge): Muddy Creek WWTP
d. Facility address: 4561 Cooper Road
Address
Winston-Salem NC 27102
City State Zip
e. Facility contact person:
First 1 MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
X Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
c. Person responsible for permit:
. AIN 1
D NR - WATEH QUALITY
weN�nrlo c quu-. twstti% Branch
d. Facility name (discharge):
e. Facility address:
City of Winston-Salem — Muddy Creek WWTP
James F Crump
First MI Last
Superintendent of Wastewater
Title
2801 Griffith Road
Permit Molder Mailing Address
Winston-Salem NC 27103
City State Zip
[phone] frankcacityofws.org
Phone E-mail Address
Muddy Creek WWTP
4561 Cooper Road
Address �-
Winston-Salem NC 27102
City State Zip
f. Facility contact person: Ozie K Jones
First M1 Last
[phone] keitho cityofws.ore
Phone E-mail Address
1
Revised 2012Apr23

NPD1= --PERl1IT NAME/OWNERSHIP CHANGE FORM
Page 2of2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: Same
First Ml Last
Title
Mailing Address
City State Zip
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included; this application package will be
returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
1, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete,
101�1�r�
Signature Date
....................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 712008

WA
7
O `C
July 25, 2008
Mr. David K. Saunders
Muddy Creek Wastewater Treatment Plant
PO Box 2511
Winston Salem, NC 27102
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Colecn H. Sullins, Director
Division of Water Quality
Subject: General Permit No. NCGI 10000
Muddy Creek Wastewater Treatment Plant
COC NCG110133
Forsyth County
Dear Mr. Saunders:
In accordance with your application for a discharge permit received on July 03, 2008, we are
forwarding herewith the subject certificate of coverage to discharge under the subject state — NPDES
general permit. This permit is issued pursuant to the requirements of North Carolina General Statute 143-
215.1 and the Memorandum of Agreement between North Carolina and the US Environmental Protection
Agency dated October 15, 2007 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except after notice to the
Division of Water Quality. The Division of Water Quality may require modification or revocation and
reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be required
by the Division of Water Quality or permits required by the Division of Land Resources, Coastal Area
Management Act or any other federal or local governmental permit that may be required.
If you have any questions concerning this permit, please contact Brian Lowther at telephone
number [phone].
Sincerely,
for Coleen H. Sullins
cc: Winston Salem Regional Office, Rose Pruitt
Central Files
Stormwater Permitting Unit Files
eoil Carolina
AtllrQlty
North Carolina Division of Water Quality 1617 Mail Service Centei Raleigh, NC 27699-1617 Phone [phone] Customer Service
lnternet: www.newaterquali_. t ororg Location: 512 N. Salisbury St. Raleigh, NC 27604 Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 5046 Recycled110% Post Consumer Paper

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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCGI 10000
CERTIFICATE OF COVERAGE No. NCG110133
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
City of Winston-Salem
is hereby authorized to discharge stormwater from a facility located at
Muddy Creek Wastewater Treatment Plant
4561 Cooper Road
Winston Salem
Forsyth County
to receiving waters designated as Muddy Creek and Lower South Fork Muddy Creek, class C
waters in the Yadkin River Basin, in accordance with the effluent limitations, monitoring
requirements, and other conditions set forth in Parts I, I1, III, IV, V, and VI of General Permit
No. NCG 110000 as attached.
This certificate of coverage shall become effective July 25, 2008.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this 251h day of July, 2008.
for Coleen H. Sullins., Director
Division of Water Quality
By the Authority of the Environmental Management Commission

Cp
Muddy Creek Wastewater , J
Treatment Plant. '
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NCG110133
N
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Map Scale 1:24,000
Muddy Creek Wastewater
Treatment Plant
Latitude: 3511 59' 46" N
Longitude: 800 15' 59" W
County: Forsyth
Receiving Stream: Muddy Creek and
Lower South Fork Muddy Creek
Stream Class: C
Sub -basin: 03-07-04 (Yadkin River Basin)
Facility Location

Aonendix A: General Permit: Checklisfor Items to Review
Name of Project: I IvA) asJr w�.v (r .. (1., - f +
J
Revision Date: 0717110
Application review
a) The permit application has been signed and sufficiently completed.(Ye No
b) The SIC code accurately describes this facility's activities and is covered by this general
permit.
Notes: ias
c) Does the facility propose a new or expanding wastewater discharge to ORW waters (not
allowed), or waters upstream of ORW (special limits may apply)? Yes/(!!D
d) Does this facility have other permits?(Yes No, #s A;.. 0o37g/Z1
WHs 4 w� �-•, �Gooro 7 �Z
e) Hazardous Waste Activities? Y /No
f) DLR Mining Permit status requested: Yes/No
g) Regional Office input requested (RO Approval received: No objection received within 30
days,
a. Date request: D�'Z�bQi
b. Date received: ry7L24A
C. Contact Name: e,s, P,K:k1=
h) Is an ATC Required? Yes/1
i) DEH Approval Required (WS Water)? Yes
j) Erosion/ Sedimentarion Plan Appro,,ral for NCG14 or NCG02 ATC? Yes/
k) Application approved? Yes/No
1) Mecklenburg or Wake County? (If so, cc. final to county contact) Yes U
m) Special Notes: Notes
Phone logs
A-1

Re: Genera Permit NCG 11
Subject: Re: General Pen -nit NCG I 1
From: Rose Pruitt <[e-mail]>
Date: Thu, 24 Jul 2008 07:06:21 -0400
To: Brian Lowther <[e-mail]>
OK to issue this permit
Rose Pruitt
NCDENR-DWQ Winston-Sa.l.err Regional Office
Division of Water Quality, Sur. ace Water Protection
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
On 7/23/2008 2.29 PM, Brian Lowther wrote:
I-li Rose,
We've received an NOI from Muddy Creek Wastewater Treatment Plant
for their facility/site in Winston Salem (Forsyth County) for coverage
of their wastewater treatment plant under NCGI 1 (Treatment
Works SW/WW permit), The site discharges stornwater into Muddy Creek
and Lower South Fork Muddy Creek. They have a couple other pen -nits: Wastewater
nc0050342 and Land application wg0000094, wg0029804. The NOI is attached.
Does the Winston-Salem Regional Office have any concerns about issuing
this facility a COC for this general permit, and are there any
potential impacts to wetlands? If we don't receive any objections,
we'll issue the COC in 30 days.
Thanks.
Brian Lowther
1 of 1 7/24/2008 8: l4 AM