NC0057151_Renewal (Application)_20200513

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ROY COOPER r, ' ' 9:
Governor
MICHAEL S.REGAN `. ,- ,
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Secretary Q"�'",,per'
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
May 13, 2020
Town of Mars Hill
Attn: Jason Riddle, ORC
PO Box 368
Mars Hill, NC 28754-0368
Subject: Permit Renewal
Application No. NC0057151
Mars Hill WWTP
Madison County
Dear Applicant:
The Water Quality Permitting Section acknowledges the May 13, 2020 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. 150E-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://deq.nc.gov/permits-regulations/permit-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
. .5C-
Wren Thedfor
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
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NPDES Permit NC0057151
Town of Mars Hill
RECEIVED
Madison County MAY 18 2020
N00057151 NCDEQ/DWR/NPDES
The Town of Mars Hill would like to request the renewal of its wastewater treatment
plant permit(NPDES Permit NC0057151). There has been no additions to treatment
process or plant design from the last permit. Our facility has an excellent record of
compliance and is still below it designed flow capacity. If you have any questions feel
free to call me at(828) 689-2301 or my work Cell #[phone] and my email is
[e-mail]
Town of Mars Hill
WWTP- ORC
J on Rid e 5 7/2020

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill VVVVTP, NC0057151 Renewal French Broad
FORM
2A h ' i S FO ' M 2A AP LICATION OVERVIEW
NPDES •
APPLICATION OVERVIEW
Form 2A has been developed in a modular format and consists of a "Basic Application Information" packet
and a "Supplemental Application Information" packet. The Basic Application Information packet is divided
into two parts. All applicants must complete Parts A and C. Applicants with a design flow greater than or
equal to 0.1 MGD must also complete Part B. Some applicants must also complete the Supplemental
Application Information packet. The following items explain which parts of Form 2A you must complete.
BASIC APPLICATION INFORMATION:
A. Basic Application Information for all Applicants. All applicants must complete questions Al through A.8. A treatment works
that discharges effluent to surface waters of the United States must also answer questions A.9 through A.12.
B. Additional Application Information for Applicants with a Design Flow>_0.1 MGD. All treatment works that have design flows
greater than or equal to 0.1 million gallons per day must complete questions 8.1 through B.6.
C. Certification. All applicants must complete Part C(Certification).
SUPPLEMENTAL APPLICATION INFORMATION:
D. Expanded Effluent Testing Data. A treatment works that discharges effluent to surface waters of the United States and meets
one or more of the following criteria must complete Part D(Expanded Effluent Testing Data):
1. Has a design flow rate greater than or equal to 1 MGD,
2. Is required to have a pretreatment program(or has one in place), or
3. Is otherwise required by the permitting authority to provide the information.
E. Toxicity Testing Data. A treatment works that meets one or more of the following criteria must complete Part E(Toxicity Testing
Data):
1. Has a design flow rate greater than or equal to 1 MGD,
2. Is required to have a pretreatment program(or has one in place), or
3. Is otherwise required by the permitting authority to submit results of toxicity testing.
F. Industrial User Discharges and RCRA/CERCLA Wastes. A treatment works that accepts process wastewater from any
significant industrial users(Sills)or receives RCRA or CERCLA wastes must complete Part F(Industrial User Discharges
and RCRA/CERCLA Wastes). SlUs are defined as:
1. All industrial users subject to Categorical Pretreatment Standards under 40 Code of Federal Regulations(CFR)403.6 and
40 CFR Chapter I, Subchapter N(see instructions); and
2. Any other industrial user that:
a. Discharges an average of 25,000 gallons per day or more of process wastewater to the treatment works(with certain
exclusions);or
b. Contributes a process wastestream that makes up 5 percent or more of the average dry weather hydraulic or organic
capacity of the treatment plant;or
c. Is designated as an SIU by the control authority.
G. Combined Sewer Systems. A treatment works that has a combined sewer system must complete Part G(Combined Sewer
Systems).
ALL APPLICANTS MUST COMPLETE PART C (CERTIFICATION)
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 1 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill WVVfP, NC0057151 Renewal French Broad
BASIC APPLICATION INFORMATION
PART A. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS:
All treatment works must complete questions A.1 through A.8 of this Basic Application Information Packet.
A.1. Facility Information.
Facility Name Town of Mars Hill WWTP
Mailing Address P.O.Bow 368
Mars Hill,NC,28754
Contact Person Jason Riddle
Title WWTP ORC
Telephone Number [phone]
Facility Address 504 Cascade Street
(not P.O.Box) Mars Hill NC 28754
A.2. Applicant Information. If the applicant is different from the above,provide the following:
Applicant Name
Mailing Address
Contact Person
Title
Telephone Number ( )
Is the applicant the owner or operator(or both)of the treatment works?
® owner IS operator
Indicate whether correspondence regarding this permit should be directed to the facility or the applicant.
❑ facility ® applicant
A.3. Existing Environmental Permits. Provide the permit number of any existing environmental permits that have been issued to the treatment works
(include state-issued permits).
NPDES PSD
UIC Other
RCRA Other
A.4. Collection System Information. Provide information on municipalities and areas served by the facility. Provide the name and population of each
entity and,if known,provide information on the type of collection system(combined vs.separate)and its ownership(municipal,private,etc.).
Name Population Served Type of Collection System Ownership
Town of Mars Hill CS 3150 Municipal Jason Riddle WWTP ORC
Total population served
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 2 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill WVVfP, NC0057151 Renewal French Broad
A.5. Indian Country.
a. Is the treatment works located in Indian Country?
❑ Yes ® No
b. Does the treatment works discharge to a receiving water that is either in Indian Country or that is upstream from(and eventually flows
through)Indian Country?
El yes ® No
A.6. Flow. Indicate the design flow rate of the treatment plant(i.e.,the wastewater flow rate that the plant was built to handle). Also provide the
average daily flow rate and maximum daily flow rate for each of the last three years. Each year's data must be based on a 12-month time period
with the 12th month of`this year"occurring no more than three months prior to this application submittal.
a. Design flow rate 0.425 MGD
Two Years Apo Last Year This Year
b. Annual average daily flow rate 0.167 mqd 0.173 mqd 0.176 mgd
c. Maximum daily flow rate 0.273 mqd 0.288 mgd 0.372 mqd
A.7. Collection System. Indicate the type(s)of collection system(s)used by the treatment plant. Check all that apply. Also estimate the percent
contribution(by miles)of each.
® Separate sanitary sewer 100
❑ Combined storm and sanitary sewer
A.8. Discharges and Other Disposal Methods.
a. Does the treatment works discharge effluent to waters of the U.S.? ® Yes 0 No
If yes,list how many of each of the following types of discharge points the treatment works uses:
i. Discharges of treated effluent
ii. Discharges of untreated or partially treated effluent
iii. Combined sewer overflow points
iv. Constructed emergency overflows(prior to the headworks)
v. Other
b. Does the treatment works discharge effluent to basins,ponds,or other surface impoundments
that do not have outlets for discharge to waters of the U.S.? 0 Yes ® No
If yes,provide the following for each surface impoundment:
Location:
Annual average daily volume discharge to surface impoundment(s) MGD
Is discharge ❑ continuous or ❑ intermittent?
c. Does the treatment works land-apply treated wastewater? ❑ Yes ® No
If yes,provide the following for each land application site:
Location:
Number of acres:
Annual average daily volume applied to site: MGD
Is land application ❑ continuous or ❑ intermittent?
d. Does the treatment works discharge or transport treated or untreated wastewater to another
treatment works? 0 Yes ® No
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 3 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill VWVfP, NC0057151 Renewal French Broad
If yes,describe the mean(s)by which the wastewater from the treatment works is discharged or transported to the other treatment works
(e.g.,tank truck,pipe).
If transport is by a party other than the applicant,provide:
Transporter Name
Mailing Address
Contact Person
Title
Telephone Number (
For each treatment works that receives this discharge,provide the following:
Name
Mailing Address
Contact Person
Title
Telephone Number (
If known,provide the NPDES permit number of the treatment works that receives this discharge
Provide the average daily flow rate from the treatment works into the receiving facility. MGD
e. Does the treatment works discharge or dispose of its wastewater in a manner not included
in A.8.through A.8.d above(e.g.,underground percolation,well injection): 0 Yes ® No
If yes,provide the following for each disposal method:
Description of method(including location and size of site(s)if applicable):
Annual daily volume disposed by this method:
Is disposal through this method ❑ continuous or ❑ intermittent?
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 4 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill VVVVTP, NC0057151 Renewal French Broad
WASTEWATER DISCHARGES:
If you answered"Yes"to question A.8.a,complete questions A.9 through A.12 once for each outfall(including bypass points)through
which effluent is discharged. Do not include information on combined sewer overflows in this section. If you answered"No"to question
A.8.a,go to Part B,"Additional Application Information for Applicants with a Design Flow Greater than or Equal to 0.1 MGD."
A.9. Description of Duffel!.
a. Outfall number 001
b. Location Town of Mars Hill WVVfP,504 Cascade Street,Mars Hill,NC 28754
(City or town,if applicable) (Zip Code)
Madison NC
(County) (State)
(Latitude) (Longitude)
c. Distance from shore(if applicable) ft.
d. Depth below surface(if applicable) ft.
e. Average daily flow rate MGD
f. Does this outfall have either an intermittent or a periodic discharge? 0 Yes ® No (go to A.9.g.)
If yes,provide the following information:
Number f times per year discharge occurs:
Average duration of each discharge:
Average flow per discharge: MGD
Months in which discharge occurs:
g. Is outfall equipped with a diffuser? ❑ Yes ® No
A.10. Description of Receiving Waters.
a. Name of receiving water Gabriel Creek
b. Name of watershed(if known) Ivy River—French Broad River Basin
United States Soil Conservation Service 14-digit watershed code(if known):
c. Name of State Management/River Basin(if known):French Broad
United States Geological Survey 8-digit hydrologic cataloging unit code(if known):
d. Critical low flow of receiving stream(if applicable)
acute cfs chronic cfs
e. Total hardness of receiving stream at critical low flow(if applicable): mg/I of CaCO3
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 5 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill VWVTP, NC0057151 Renewal French Broad
A.11. Description of Treatment
a. What level of treatment are provided? Check all that apply.
® Primary ® Secondary
❑ Advanced 0 Other. Describe:
b. Indicate the following removal rates(as applicable):
Design BOD5 removal or Design CBOD5 removal
Design SS removal 9/0
Design P removal
Design N removal
Other
c. What type of disinfection is used for the effluent from this outfall? If disinfection varies by season,please describe:
Chlorine liquid
If disinfection is by chlorination is dechlorination used for this outfall? El Yes ❑ No
Does the treatment plant have post aeration? ® Yes ❑ No
A.12. Effluent Testing Information. All Applicants that discharge to waters of the US must provide effluent testing data for the following
parameters. Provide the indicated effluent testing required by the permitting authority for each outfall through which effluent is
discharged. Do not include information on combined sewer overflows in this section. All information reported must be based on data
collected througn analysis conducted using 40 CFR Part 136 methods. In addition,this data must comply with QA/QC requirements of
40 CFR Part 136 and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136. At a
minimum,effluent testing data must be based on at least three samples and must be no more than four and one-half years apart.
Outfall number: 001
MAXIMUM DAILY VALUE AVERAGE DAILY VALUE
PARAMETER
Value Units Value Units Number of Samples
pH(Minimum) 6.5 s.u.
pH(Maximum) 7.1 s.u.
Flow Rate 0.436 mgd 0.175 mgd 356
Temperature(Winter) 17.9 C 15.1 c 21
Temperature(Summer) 26.1 C 25.1 c 31
For pH please report a minimum and a maximum daily value
MAXIMUM DAILY AVERAGE DAILY DISCHARGE
POLLUTANT DISCHARGE ANALYTICAL ML/MDL
Number of METHOD
Conc. Units Conc. Units Samples
CONVENTIONAL AND NON CONVENTIONAL COMPOUNDS
BIOCHEMICAL OXYGEN BOD5 16.2 Mg/I 10.8 Mg/I 52 SM5210B 2.0
DEMAND(Report one) CBOD5
FECAL COLIFORM 46 #100 ML 9.56 100ML 52 SM9222D 1
TOTAL SUSPENDED SOLIDS(TSS) 23.2 Mg/I 7.5 Mg/I 52 SM2540D 1.0
END OF PART A.
REFER TO THE APPLICATION OVERVIEW (PAGE 1) TO DETERMINE WHICH OTHER PARTS
OF FORM 2A YOU MUST COMPLETE
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 6 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill WVVfP, NC0057151 Renewal French Broad
BASIC APPLICATION INFORMATION
PART B. ADDITIONAL APPLICATION INFORMATION FOR APPLICANTS WITH A DESIGN FLOW GREATER THAN OR
EQUAL TO 0.1 MGD(100,000 gallons per day).
All applicants with a design flow rate>_0.1 MGD must answer questions B.1 through B.6. All others go to Part C(Certification).
B.1. Inflow and Infiltration. Estimate the average number of gallons per day that flow into the treatment works from inflow and/or infiltration.
18,000 gpd
Briefly explain any steps underway or planned to minimize inflow and infiltration.
Currently repairing manholes that have broken concrete around covers also drafting planes to rework two pump stations
That have ground water infiltration around top of wall seams and lids.
B.2. Topographic Map. Attach to this application a topographic map of the area extending at least one mile beyond facility property boundaries. This
map must show the outline of the facility and the following information. (You may submit more than one map if one map does not show the entire
area.)
a. The area surrounding the treatment plant,including all unit processes.
b. The major pipes or other structures through which wastewater enters the treatment works and the pipes or other structures through which
treated wastewater is discharged from the treatment plant. Include outfalls from bypass piping,if applicable.
c. Each well where wastewater from the treatment plant is injected underground.
d. Wells,springs,other surface water bodies,and drinking water wells that are: 1)within'/4 mile of the property boundaries of the treatment
works,and 2)listed in public record or otherwise known to the applicant.
e. Any areas where the sewage sludge produced by the treatment works is stored,treated,or disposed.
f. If the treatment works receives waste that is classified as hazardous under the Resource Conservation and Recovery Act(RCRA)by truck,rail,
or special pipe,show on the map where the hazardous waste enters the treatment works and where it is treated,stored,and/or disposed.
B.3. Process Flow Diagram or Schematic. Provide a diagram showing the processes of the treatment plant,including all bypass piping and all
backup power sources or redunancy in the system. Also provide a water balance showing all treatment units,including disinfection(e.g.,
chlorination and dechlorination). The water balance must show daily average flow rates at influent and discharge points and approximate daily flow
rates between treatment units. Include a brief narrative description of the diagram.
B.4. Operation/Maintenance Performed by Contractor(s).
Are any operational or maintenance aspects(related to wastewater treatment and effluent quality)of the treatment works the responsibility of a
contractor? ❑ Yes ® No
If yes,list the name,address,telephone number,and status of each contractor and describe the contractor's responsibilities(attach additional
pages if necessary).
Name:
Mailing Address:
Telephone Number: ( )
Responsibilities of Contractor:
B.5. Scheduled improvements and Schedules of Implementation. Provide information on any uncompleted implementation schedule or
uncompleted plans for improvements that will affect the wastewater treatment,effluent quality,or design capacity of the treatment works. If the
treatment works has several different implementation schedules or is planning several improvements,submit separate responses to question B.5
for each. (If none,go to question B.6.)
a. List the outfall number(assigned in question A.9)for each outfall that is covered by this implementation schedule.
b. Indicate whether the planned improvements or implementation schedule are required by local,State,or Federal agencies.
❑ Yes ❑ No
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 7 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill WWTP, NC0057151 Renewal French Broad
c. If the answer to B.5.b is"Yes,"briefly describe,including new maximum daily inflow rate(if applicable).
d. Provide dates imposed by any compliance schedule or any actual dates of completion for the implementation steps listed below,as
applicable. For improvements planned independently of local,State,or Federal agencies,indicate planned or actual completion dates,as
applicable. Indicate dates as accurately as possible.
Schedule Actual Completion
Implementation Stage MM/DD/YYYY MM/DD/YYYY
-Begin Construction
-End Construction / / / /
-Begin Discharge / / / /
-Attain Operational Level / / / /
e. Have appropriate permits/clearances concerning other Federal/State requirements been obtained? ❑ Yes 0 No
Describe briefly:
B.6. EFFLUENT TESTING DATA(GREATER THAN 0.1 MGD ONLY).
Applicants that discharge to waters of the US must provide effluent testing data for the following parameters. Provide the indicated
effluent testing required by the permitting authority for each outfall through which effluent is discharged. Do not include information
on combine sewer overflows in this section. All information reported must be based on data collected through analysis conducted
using 40 CFR Part 136 methods. In addition,this data must comply with QA/QC requirements of 40 CFR Part 136 and other appropriate
QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136. At a minimum effluent testing data must be
based on at least three pollutant scans and must be no more than four and on-half years old.
Outfaii Number: U01
MAXIMUM DAILY AVERAGE DAILY DISCHARGE
DISCHARGE ANALYTICAL
POLLUTANT METHOD ML/MDL
Conc. Units Conc. Units Number of
Samples
CONVENTIONAL AND NON CONVENTIONAL COMPOUNDS
AMMONIA(as N) 0.8 Mg/I 0.4 Mg/I 52 SM4500NH3F 0.1
CHLORINE(TOTAL <17 Ug/I <17 Ug/I 104 SM4500CLG 17
RESIDUAL,TRC)
DISSOLVED OXYGEN 8.61 Mg/I 6.36 Mg/I 52 SM4500-0 G 0.1
TOTAL KJELDAHL 5.44 Mg/I 2.1 Mg/I 2 EPA351.2 0.50
NITROGEN(TKN)
NITRATE PLUS NITRITE
NITROGEN
OIL and GREASE
PHOSPHORUS(Total) 1.7 Mg/I 0.96 Mg/I 2 SM4500PF 0.050
TOTAL DISSOLVED SOLIDS
(TDS)
OTHER
END OF PART B.
REFER TO THE APPLICATION OVERVIEW (PAGE 1) TO DETERMINE WHICH OTHER PARTS
OF FORM 2A YOU MUST COMPLETE
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 8 of 22

FACILITY NAME AND PERMIT NUMBER: PERMIT ACTION REQUESTED: RIVER BASIN:
Town of Mars Hill VWVfP, NC0057151 Renewal French Broad
BASIC APPLICATION INFORMATION
PART C. CERTIFICATION
All applicants must complete the Certification Section. Refer to instructions to determine who is an officer for the purposes of this
certification. All applicants must complete all applicable sections of Form 2A,as explained in the Application Overview. Indicate below which
parts of Form 2A you have completed and are submitting. By signing this certification statement,applicants confirm that they have reviewed
Form 2A and have completed all sections that apply to the facility for which this application is submitted.
Indicate which parts of Form 2A you have completed and are submitting:
El Basic Application Information packet Supplemental Application Information packet:
❑ Part D(Expanded Effluent Testing Data)
❑ Part E(Toxicity Testing: Biomonitoring Data)
❑ Part F(Industrial User Discharges and RCRA/CERCLA Wastes)
❑ Part G(Combined Sewer Systems)
ALL APPLICANTS MUST COMPLETE THE FOLLOWING CERTIFICATION.
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 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 and official title Jason Riddle—W VTP ORC
Signature . 11Ane""�
Telephone number 828)206-6479
Date signed 5/7/2020
Upon request of the permitting authority,you must submit any other information necessary to assure wastewater treatment practices at the treatment
works or identify appropriate permitting requirements.
SEND COMPLETED FORMS TO:
NCDENR/ DWQ
Attn: NPDES Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
EPA Form 3510-2A(Rev.1-99). Replaces EPA forms 7550-6&7550-22. Page 9 of 22

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Latitude: 35°49'38" N State Grid/Ouad: D 8 SE/Mars Hill,NC not to scale
Longitude: 82e 33'28" W Permitted Flow: 0.425 MGD -0-
Receiving Stream: Gabriel Creek Drainage Basin: French Broad River NPDES Permit No. NC0057151
Stream Class: C Sub-Basin: 04-03-04 North
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Town of Mars Hill
Sludge Management Plan
Our sludge management consists of two 44,000 gallon aerobic digesters and a 3/4 meter
phoenix belt press. We have a covered sludge storage area in the belt press building to
hold sludge till the time of disposal . All residuals will be stabilized by aerobic digestion
to significantly reduce pathogens (as described in 40 CFR Part 257,Appendix 2)The
sludge is hauled by a contractor to Lakeway Recycling & Sanitation in Lowland TN
Jason Rid,.e
ifee.._
ORC-WWTP
5/7/2020

:..., ; TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION
i_;f
DIVISION OF SOLID WASTE MANAGEMENT
r WASTE EVALUATION FEE WORKSHEET
1. DATE Central Office Use Only
March 28, 2011 SPC 10#
1-GENERATOR
(A) Name: Town of Mars Hill NC
Address: P.0. Box 368
Mars Hill, NC
Zip Code: 28754
Phone: s 828 ) 689-2301
(B) Contact Person: Robert Sams
Title: Public Works Director
828 206-2386
Phone: ( )
3.Amount Enclosed: $ 250.00 4. X New Application
Renewal
5. Name and Address of Waste Processing or Disposal Facility
Name: Lakeway Recycling & Sanitation
Address: 5155 Enka Hwy.
Lowland
Zip Code: 37778
6. Frequency of Disposal: X Monthly I Annually Other
(specify)
Central Office Use Only
CD Number Date Received Amount Receipt# Comments
Send original with payment directly to the Central Office