NC0069370_renewal application_20200916

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 OCOO& C 3 7,.)
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
Mailing Address 601 C% i n.�.n �/� nC _ � /2')10d
City n S 12n ✓ � f _ Ad � D��i 7,
State / Zip Code
Telephone Number Rli) 6 t4 ! I
Fax Number (32) 6 11, - 3? 13
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
city
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)
IQFT[il
Mailing Address
city
State / Zip Code
41 i pkegs'-'n1 CA -
Telephone Number 7 -7 3- G 7 6 0
Fax Number ( )
e-mail Address
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Form-D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 1000/6 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:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served: 1y2
5. Type of collection system
N Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points �-
Outfall Identification number(s) . U G j-
Is the outfall equipped with a diffuser? ❑ Yes �] No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfallr
8. Frequency of Discharge: La� Continuous
If intermittent: 7
Days per week discharge occurs:
❑ Intermittent
Duration: 2 q )-i • 1> . l�>
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.
{:,
ter, I r\'C %'v 1\i
2 of 3 i Form-D 11112
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NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 1000/6 domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow U Z MGD
Annual Average daily flow # 0 MGD (for the previous 3 years)
Maximum daily flow C & 2-:3 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
NEW APPLICANTS: Provide data for the parameters listed. Fecal Coliform, 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.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average
over the past 36 months for narameters currentlu in uour hermit. Mark other parameters "N/A'.
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD;)
(1
7,
Fecal Coliform
1• S Z 3
�t e 7�� �
Total Suspended Solids
l
3 t
ryl - j
Temperature (Summer)
2-7. 3
t 5, e
G
Temperature (Winter)
t �{
` ; . c %
c;
pH
`� `"�
7. 3A
5u
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
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.
CA -
Printed name of Person Signing Title
Signature of Applicant
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.C, 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 11/12