WQ0013808_Permit Renewal_20180104

State of North Carolina
Department of Environmental Quality
Division of Water Resources
• DW R WATER QUALITY REGIONAL OPERATIONS SECTION
Division of Water Resources NON-DISCHARGE APPLICATION REVIEW REQUEST FORM
January 2,2018
To: WSRO-WQROS: Sherri Knight/George Smith
From: Ashley Kabat, Water Quality Permitting Section-Non-Discharge Permitting Unit
Permit Number: WQ0013808 Permit Type: Wastewater Irrigation
Applicant: Kotis Properties,Inc. Project Type: Renewal
Owner Type: Organization Owner in BIMS?Yes
Facility Name: Summerfield Shopping Center WWTF Facility in BIMS?Yes
Signature Authority: William Kotis Title: President
Address: PO Box 9296,Greensboro,NC 27429-9296 County: Guilford
Fee Category: Non-Discharge Minor Fee Amount: $0
Comments/Other Information:
Attached, you will find all information submitted in support of the above-referenced application for your review,
comment,and/or action. Within 45 calendar days,please take the following actions:
® Return this form completed. ® Return a completed staff report.
❑ Attach an Attachment B for Certification. ❑ Issue an Attachment B Certification.
When you receive this request form,please write your name and dates in the spaces below,make a copy of this sheet,and
return it to the appropriate Central Office Water Quality Permitting Section contact person listed above.
RO-WQROS Reviewer: PcVr , C,k ' ' I Date:
NC D`partmc nt of
Environmental Quality
Received
JAN 04 2 ;8
Winston-Salem
Regional Office
FORM: WQROSNDARR 09-15 Page 1 of 1

ROY COOPER
Governor
f;o
MICHAEL S. REGAN
Secretary
Water Resources LINDA CULPEPPER
ENVIRONMENTAL QUALITY Interim Director
January 2, 2018
WILLIAM KOTIS—PRESIDENT
KOTIS PROPERTIES,INC.
PO Box 9296
GREENSBORO,NORTH CAROLINA 27429-9296
Subject: Acknowledgement of
Application No. WQ0013808
Summerfield Shopping Center
WWTF
Wastewater Irrigation System
Guilford County
Dear Mr.Kotis:
The Water Quality Permitting Section acknowledges receipt of your permit application and
supporting documentation received on January 2, 2018. Your application package has been assigned the
number listed above,and the primary reviewer is Ashley Kabat.
Central and Regional Office staff will perform a detailed review of the provided application, and
may contact you with a request for additional information. To ensure maximum efficiency in processing
permit applications, the Division of Water Resources requests your assistance in providing a timely and
complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
Ashley Kabat at(919) 807-6348 or [e-mail].
Sincerely,
Nathaniel D.Thornburg, Supervisor
Division of Water Resources
cc: Winston-Salem Regional Office,Water Quality Regional Operations Section
Permit File WQ0013808
------"Nothing Compares-,
State of North Carolina I Environmental Quality I Water Resources I Water Quality Permitting I Non-Discharge Permitting
1617 Mail Service Center I Raleigh,North Carolina 27699-1617
919-807-6332

• RECEIVED/NCDEQ/DWR
,AA 0 y 291 State of North Carolina
Department of Environmental Quality
' Dw R
Non-Disoharge Division of Water Resources
Permitting Unit NON-DISCHARGE SYSTEM RENEWAL
Division of Water Resources INSTRUCTIONS FOR FORM: NDSR 06-16&SUPPORTING DOCUMENTATION
This form is for renewal without modification for all non-discharge system permits,except Residuals Management permits.
For more information, visit the Water Quality Permitting Section's Non-Discharge Permitting Unit.
A. Non-Discharge System Renewal(FORM: NDSR 06-16)Application(All Application Packages):
Submit one original and one copy of the completed and appropriately executed Non-Discharge System Renewal (FORM:
NDSR 06-16)application.
❑ The Applicant's Certification shall be signed in accordance with 15A NCAC 02T.0106(b). Per 15A NCAC 02T.0106(c),an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the
criteria in 15A NCAC 02T.0106(b).
B. Existing Permit(All Application Packages):
® Submit two copies of the most recently issued permit.
C. Certificate of Public Convenience and Necessity(All Application Packages for Privately-Owned Public Utilities):
® Per 15A NCAC 02T .0115(a)(I),provide two copies of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non-discharge system.
D. Operation and Maintenance Agreement(All Application Packages for Single-Family Residences):
❑ Submit one original and one copy of the signed Operation and Maintenance Agreement(FORM: SFRWWIS O&M).
E. Operational Agreements(All Application Packages for Home/Property Owners'Associations and Developers of lots to be sold):
> Home/Property Owners'Associations
❑ Per 15A NCAC 02T.0115(c),submit an original and one copy of the properly executed Operational Agreement(FORM:
HOA).
❑ Per 15A NCAC 02T .0115(c), submit an original and one copy of the proposed or approved Articles of Incorporation,
Declarations and By-laws.
> Developers of lots to be sold
❑ Per 15A NCAC 02T.0115(b),submit an original and one copy of the properly executed Operational Agreement(FORM:
DEV).
F. Site Map(All Application Packages for permits originally issued or modified after September 1,2006):
❑ Submit two copies of an updated site map in accordance with 15A NCAC 02T.0105(d).
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON-DISCHARGE PERMITTING UNIT
By U.S.Postal Service: By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N.SALISBURY ST.
RALEIGH,NORTH CAROLINA 27699-1617 RALEIGH,NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone] FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM:NDSR 06-16&SUPPORTING DOCUMENTATION Page 1 of 1

RECEIVED/NCDEA/DWR State of North Carolina •
DWR Department of Environmental Quality
JA.N 0 1010 Division of Water Resources •
DivisionNon-Discharge
of Water Resources NON-DISCHARGE SYSTEM RENEWAL
Permitting Unit FORM: NDSR 06-16
I. PERMITTEE INFORMATION:
1. Permittee's name:Kotis Properties,Inc.
2. Signature authority's name: Bill Kotis per 15A NCAC 02T.0106(b) Title: President
3. Permittee's mailing address:Post Office Box 9296
City: Greensboro State: NC Zip:27429-9296
4. Permittee's contact information: Phone number: [phone] Email Address:[e-mail]
II. FACILITY INFORMATION:
1. Facility name: Summerfield Shopping Center
2. Facility's physical address:4548 US Highway 220 North
City: Summerfield State:NC Zip:27358- County:Guilford
III. PERMIT INFORMATION:
1, Existing permit number: WQ0013808 and most recent issuance date: September 12,2008
2. Existing permit type: Wastewater Irrigation
3. Has the facility been constructed? ®Yes or No
Applicant's Certification per 15A NCAC 02T.0106(b):
1, , attest that this application for
(Signature
Siignat re Authority's name&title from Application Item 1.2.)
OLUY�NPRfiEla QPiNti \ C7utc2
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that any discharge of wastewater
from this non-discharge system to surface waters or the land will result in an immediate enforcement action that may include civil
penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. I also understand that if all required parts of this application package are not completed and that
if all required supporting information and attachments are not included,this application package will be returned to me as incomplete.
I further certify that the Applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater
facility without proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are
compliant with any active compliance schedule,and do not have any overdue annual fees per 15A NCAC 02T.0105(e).
NOTE— In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed$10,000 as wel as civil penalties up to$25,000 per violation.
Signature: Date: ai ...iv /7
FORM:NDSR 06-16 Page 1 of 1