NC0082821_PERMIT ISSUANCE_20140402

NPDES DOCYNENT SCANNIM& COVER SHEET
NPDES Permit:
NC0082821
Statesville Fertilizer Plant
Document Type.
Permit Issuance
Wasteload Allocation
Authorization to Construct (AtC)
Permit Modification
Complete File - Historical
Renewal Application
Speculative Limits
Instream Assessment (67b)
Environmental Assessment (EA)
Permit
History
Document Date:
Aril 2, 2014
ThiB dooumeat iB printed oa reuBe paper - ignore any
coateat oa the resrerBe Bide

14710A'
NC®ENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
April 2, 2014
Ms Lauren Faulkner
Southern States Cooperative, Inc
P O Box 26234
Richmond, VA 23260
Subject Issuance ofNPDES Permit NCO082821
Southern States - Statesville Fertilizer Plant W WTP
Iredell County
Dear Ms Faulkner
John E Skvarla, III
Secretary
Division personnel have reviewed and approved your application for renewal of the subject permit
Accordingly, we are forwarding the attached NPDES discharge 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 U S Environmental Protection Agency dated October 15, 2007 (or as
subsequently amended)
This final permit contains no significant changes to its terms from those found in the draft permit sent to
you on January 24, 2014 However, you are reminded of the new condition requiring electronic
reporting of discharge monitoring report (DMR) data using the Division's cDMR internet application
This new requirement will become effective on February 1, 2015
If any parts, measurement frequencies or sampling requirements contained in this permit arc
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty
(30) days following receipt of this letter 1 his request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings (6714 Mail Service Center, Raleigh, North Carolina 27699-6714) Unless
such demand is made, this decision shall be final and binding
Please note that this permit is not tiansferable except aftei notice to the Division I he Division may
require modification or revocation and reissuance of the permit 1 his permit does not affect the legal
requirements to obtain other permits which may be iequired by the Division of Water RCSOL[lces or
permits required by the Division of Land Resources, the Coastal Area Management Act or any other
Federal or Local governmental permit that may be required
1617 Mall service Center Raleigh North Carolina 27699 1617
Phone 919A07 6300 Vntemet w ncwaterqualdy org
An Equal Opportunity 1 AKrrualive Action Employer - Made in part by recycled paper

Ms Lauren Faulkner
NC0082821 Permit Renewal 2014
p2
If you have any questions concerning this permit, please contact Bob Sledge at telephone number (919)
807-6399, or via e-mail at bob sledge@ncdenr gov
Smcer ly,
Thomas A Reeder �—
cc Central Files
Mooresville Regional Office/Water Quality
NPDES File
ec Aquatic Toxicology Unit

[Lim li[�areffiIFi►i.'i► l
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
PERMIT
170 DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Southern States Cooperative, Inc.
is hereby authorized to discharge wastewater from a facility located at the
Statesville Fertilizer Plant
2582 Salsbury Highway
Six Miles East of Statesville
Iredell County
to receiving waters designated as Fourth Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in Parts
I, II, III and IV hereof
This permit shall become effective May 1, 2014
This permit and authorization to discharge shall expire at midnight on March 31, 2019
Signed this day April 2, 2014
A Reeder, Director
of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 8

Permit NC0082821
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked As of this permit issuance, any previously issued permit bearing this mmnbei is no longer
effective Therefore, the exclusive authority to operate and discharge from this facility arises under the
permit conditions, requirements, terms, and provisions included herein
Southern States Cooperative, Inc
is hereby authorized to
Continue to operate an existing 0 144 MGD groundwater remediation system with the following
components
♦ Three recovery wells
♦ Lift station with wet well
♦ Caustic solution tank with pH measuring device
The facility is located six miles east of Statesville at the Statesville Fertilizer Plant, off U S Highway
70, in Iredell County
2 Discharge from said treatment works at the location specified on the attached map into Fourth Creek,
classified C waters in subbasin 03-07-06 of the Yadkin -Pee Dee River Basin
Page 2 of 8

C1GWi'if[i1[K1I1Y.W. iI
PART
A (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of this permit and lasting until expiration, the
Permittee is authorized to discharge from outfall 001 Such discharges shall be limited and monitoredt
by the Perm3ttee as specified below
- -- - -
EFFLUENT CHARACTERISTIM'
'r Parameter Code,_,
-^M7µ tPv �_-..r- ^r-m
LIMITS 4
gym,-_ c.� --spa..
MONITORIN&REQOIREMENTS
- x« -1-+
i
Monthly
Average ^_j
/Daily
Maximum
Measurement
--Freque`ncy „
Sample
.!Type
Sample
Location ^
FIow2 50050
Monitor & Report
Continuous
Recording
Effluent
Total Suspended Solids C0530
30 0 mg/L
45 0 mglL
2/Month
Grab
Effluent
NH3 as N (April 1 — October 31) C0610
7 8 mglL
35 0 mgll
2/Month
Grab
Effluent
NH3 as N (November 1 — March 31) C0610
Monitor & Report
2/Month
Grab
Effluent
pH 00400
> 6 0 and < 9 0 standard units
2/Month
Grab
Effluent
Copper 01042
Monitor & Report
Monthly
Grab
Effluent
Chlorides 00940
Monitor & Report
Monthly
Grab
Effluent
Total Nitrates (NO3—N) 00620
Monitor & Report
Monthly
Grab
Effluent
Total Nitrogen (NO2+NO3+TKN) C0600
Monitor & Report
Monthly
Grab
Effluent
Total Phosphorus C0665
Monitor & Report
Monthly
Grab
Effluent
Chronic Toxiaty3 TGP3B
Quarterly
Grab
Effluent
Footnotes
1 No later than February 1, 2015 (270 days from the effective date of this permit), begin submitting
discharge monitoring reports electronically using NC DWR's eDMR application system See
Condition A (3 )
2 All volumes of wastewater leaving the facility shall be monitored If continuous flow monitoring is not
feasible, then the discharger shall record the approximate time that discharge began and ended, along with the
instantaneous flow at the time of the effluent sampling
3 Chronic Toxicity (Ccreodaphnra dubia) 7-day pass/tad test at 3% in 1 ebruary, May, August and November
See condition A (2 )
Ther a shall be no discharge of floating solids or visible foam in other than trace amounts
Page 3 of 8

Permit NC0082821
A (2) CHRONIC TOXICITY PERMIT LIMIT (QUARTERLY)
The effluent discharge shall at no time exhibit observable inhibition of reproduction or significant
mortality to Ceriodapbnia dubia at an effluent concentration of 3 %
The petmit holder shall petfoim at a minimum, gum lei monitoring using test pioccduies outlined in
the "North Carolina Ceriodaphnia Chronic Effluent Bioassay Procedure," Revised December 2010, or
subsequent versions or "North Carolina Phase II Chronic Whole Effluent Toxicity Test Procedure"
(Revised- December 2010) or subsequent versions The tests will be performed during the months of
February, May, August and November These months signify the first month of each three month
toxicity testing quarter assigned to the facility Effluent sampling for this testing must be obtained
during representative effluent discharge and shall be performed at the NPDES permitted final effluent
discharge below all treatment processes
If the test procedure performed as the first test of any single quarter results in a failure or ChV
below the permit limit, then multiple -concentration testing shall be performed at a minimum, in
each of the two following months as described in "North Carolina Phase II Chronic Whole
Effluent Toxicity Test Procedure" (Revised -December 2010) or subsequent versions
All toxicity testing results required as part of this permit condition will be entered on the Effluent
Discharge Monitoring Form (MR-1) for the months in which tests were performed, using the parameter
code TGP313 for the pass/fail results and THP3B for the Chronic Value Additionally, DWR Form A f-
3 (original) is to be sent to the following address
Attention North Carolina Division of Water Resouices
Environmental Sciences Section
1621 Mail Service Center
Raleigh, North Carolina 27699-1621
Completed Aquatic Toxicity Test Forms shall be filed with the Environmental Sciences Section no later
than 30 days after the end of the reporting period for which the report is made
Tt,st data shall be complete, accurate, include all supporting chemical/physical measurements and all
concentration/response data, and be certified by laboratory supervisor and ORC or approved designate
signature Total residual chlorine of the effluent toxicity sample must be measuied and reported if
chlorine is employed for disinfection of the waste stream
Should there be no discharge of flow from the facility during a month in which toxicity monitoring is
required, the permrttee will complete the information located at the top of the aquatic toxicity (AT) test
form indicating the facility name, permit number, pipe number, county, and the month/year of the report
with the notation of "No Flow" in the comment area of the form 1 he report shall be submitted to the
Environmental Sciences Section at the address cited above
Should the permittee fail to monitor during a month in which toxicity monitoring is required, monitoring
will be required during the following month Assessment of toxicity compliance is based on the toxicity
testing quartet, which is the three month time interval that begins on the first day of the month in which
toxicity testing is required by this permit and continues until the final day of the third month
Page 4 of 8

Permit NC0082821
A (2) CHRONIC TOXICITY PERMIT LIMIT (QUARTERLY), continued
Should any test data from this monitoring requirement or tests performed by the North Carolina Division
of Water Resources indicate potential impacts to the receiving stream, this permit may be re -opened and
modified to include alternate monitoring requirements or limits
If the Permittee monitors any pollutant more frequently than required by this permit, the results of such
monitoring shall be included in the calculation & reporting of the data submitted on the DMR & all AT
Form submitted
NOTE Failure to achieve test conditions as specified in the cited document, such as minimum control
organism survival, minimum control organism reproduction, and appropriate environmental controls,
shall constitute an invalid test and will require immediate follow-up testing to be completed no later
than the last day of the month following the month of the initial monitoring
Page 5 of 8

Permit NCO082821
A (3) ELECTRONIC REPORTING OF DISCHARGE MONITORING REPORTS
Proposed federal regulations require electronic submittal of all discharge monitoring reports (DMRs)
and specify that, if a state does not establish a system to receive such submittals, then permittees must
submit DMRs electronically to the Environmental Protection Agency (EPA) The Division anticipates
that these regulations will be adopted and ns beginning iuiplenioutation iu late 2013
NO fE This special condition supplements or supersedes the following sections within Part 11 of this
permit (Standard Conditions for NPDES Permits)
• Section B
(I I )
• Section D
(2 )
• Section D
(6 )
• Section E
(5 )
Signatory Requirements
Reporting
Records Retention
Monitoring Reports
1 Reporting ]Supersedes Section D (2 ) and Section E (5 ) (a)1
Beginning no later than 270 days from the effective date of this permit, the permittee shall begin
reporting discharge monitoring data electronically using the NC DWR's Electronic Discharge
Monitoring Report (eDMR) internet application
Monitoring results obtained during the previous month(s) shall be summarized for each month and
submitted electronically using eDMR The eDMR system allows permitted facilities to enter
monitoring data and submit DMRs electronically using the internet Until such time that the state's
eDMR application is compliant with EPA's Cross -Media Electronic Reporting Regulation
(CROMERR), permittees will be required to submit all discharge monitoring data to the state
electronically using eDMR and will be required to complete the eDMR submission by printing,
signing, and submitting one signed original and a copy of the computer printed eDMR to the
following address
NC DENR / DWR / Information Processing Unit
ATTENTION Ccntral Files / eDMR
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
If a permittee is unable to use the eDMR system due to a demonstrated hardship or due to the facility
being physically located in an area where less than 10 percent of the households have broadband
access, then a temporary waiver from the NPDES electronic reporting requirements may be granted
and discharge monitoring data may be submitted on paper DMR forms (MR 1, 1 1, 2, 3) or
alternative forms approved by the Director Duplicate signed copies shall be submitted to the
mailing address above
Requests for temporary waivers from the NPDES electronic reporting requirements must be
submitted in writing to the Division for written approval at least sixty (60) days prior to the date the
facility would be required under this permit to begin using eDMR temporary waivers shall be valid
for twelve (12) months and shall thereupon expire At such time, DMRs shall be submitted
clectionically to the Division unless the permittee re -applies for and is granted a new temporary
waiver by the Division
Page 6 of 8

Permit NC0082821
A (3) ELECTRONIC REPORTING OF DISCHARGE MONITORING REPORTS, continued
Information on eDMR and application for a temporary waiver from the NPDES electronic reporting
requirements is found on the following web page
http //portal ncdenr org/web/wq/admm/bog/ipu/edmr
Regardless of the submission method, the first DMR is due on the last day of the month following
the issuance of the permit or in the case of a new facility, on the last day of the month following the
commencement of discharge
2 Signatory Requirements [Supplements Section B (11 ) (b) and supersedes Section B (I I ) (d)l
All eDMRs submitted to the permit issuing authority shall be signed by a person described in Part II,
Section B (11 )(a) or by a duly authorized representative of that person as described in Part II,
Section B (I I )(b) A person, and not a position, must be delegated signatory authority for eDMR
reporting purposes
For eDMR submissions, the person signing and submitting the DMR must obtain an eDMR user
account and login credentials to access the eDMR system For more information on North
Carolina's eDMR system, registering for eDMR and obtaining an eDMR user account, please visit
the following web page
http //portal ncdenr org/web/wq/admin/bouhpu/edmr
Certification Any person submitting an electronic DMR using the state's eDMR system shall make
the following certification [40 CFR 122 22] NO OTHER STATEMENTS OF CERI IFICATION
WILL BE ACCEPTED
"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 pei sonnel
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 submitted 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 fines and imprisonment for knowing violations "
3 Records Retention [Supplements Section 1) (6 )1
The permittee shall retain records of all Discharge Monitoring Reports, including eDMR
submissions These records or copies shall be maintained for a period of at least 3 years from the
date of the report "I his period may be extended by request of the Director at any time [40 CFR
122 411
A (4) NUTRIENI REOPENER FOR HIGH ROCK LAKE
This permit may be reopened and modified to implement nutrient requirements in accordance with any
future 1 MDL and/or nutrient management strategy foi High Rock Lake
Page 7 of 8

Permit NCO082821
,
�I
of
Southern States Cooperative, Inc
Facility
Latitude 3604626 Sub Basin 0307-06
Longitude 80°4640 Quad Name Statesville East
Stream Class C Receiving Stream Fourth Creek
North
Location
�NPDES PermitNCO082821
Iredell County
Page 8 of 8

The Charlotte Observer Publishing Co
Charlotte, NC
North Carolina } ss Affidavit of Publication
Mecklenburg County }
Charlotte Observer
REFERENCE 145583 NCDENR/DWO/POINT SOURCE
0000891774 Public Notice North Carolina Environmental
Management Commission/NPDES Unit 1617
Mail Service Center Raleigh, NC 27699-1617
Before the undersigned, a Notary Public of said County and
State, duly authorized to administer oaths affirmations etc
personally appeared, being duly sworn or affirmed according
to law, doth depose and say that he/she is a representative of
The Charlotte Observer Publishing Company, a corporation
organized and doing business under the laws of the State of
Delaware and publishing a newspaper known as The
Charlotte Observer in the city of Charlotte, County of
Mecklenburg, and State of North Carolina and that as such
he/she is familiar with the books, records, files and business
of said Corporation and by reference to the files of said
publication, the attached advertisement was inserted The
following is correctly copied from the books and files of the
aforesaid Corporation and Publication
PUBLISHED ON 02/05/2014
AD SPACE 43 LINES
FILED ON 02/05/2014
NAME
In
Nc
TITLE
DATE
the day and year aforesaid
My commission Expires
FEB 0 6 2014

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets Expedited permits are generally simple 100% domestics (e g , schools, mobile
home parks, etc) that can be administratively renewed with minor changes, but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, tonicity testing,
instream monitoring, compliance concerns)
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Bob Sledge 1/27/2014
Permit Number
NC0082821
Faci lity Name
Statesville Fertilizer Plant(GW Remediation
Basin Name/Sub-basin number
Yadkin — Pee Dee 03-07-06
Receiving Stream
Fourth Creek
Stream Classification in Permit
C
Does pernut need Daily Max NH3 Imuts)
No ahcadv included
Does permit need TRC Inuits/lam�ua-ge?
No ahcadv included
Does permit have toxicity testing?
Yes
Does permit have Special Conditions?
I oxicrty existing, added High Rock Lake,
ieo ever and eDMR condition
Does pernut have instream monitoring?
No
Is the stream impaired on 303 d list
No
Any obvious compliance concerns?
No
Any peimit mods since lastpermit?
No
Current expiration date
March 31, 2014
New expiration date
March 31, 2019
Comments received on Draft
Yes No If Yes, discuss response with
Supervisor

w U
Southern States Cooperative, Inc
6606 West Broad Street
Richmond, Va 23230 1717
Mail Address P O Box 26234
Richmond, Va 23260-6234
Telephone [phone]
September 19th, 2013
SOUTHERN
STATES
North Carolina Department of Environment and Natural Resources
Division of Water Quality-NPDES Unit
Attention Mr Charles Weaver
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RE NPDES Permit Renewal Application for the Southern States Statesville
Fertilizer Plant (Permit #NC0082821)
Dear Mr Weaver,
The Southern States Cooperative, Inc (SSC) is submitting the completed Permit
Renewal Application for the Statesville Fertilizer Plant is currently covered under
NDPES Permit #NC0082821 to the North Carolina Department of Environment
and Natural Resources- Division of Water Quality This permit expires on March
31", 2014 and at this time there have been no changes to the groundwater treatment
system since the last permit was issued
If you need any additional information, please contact me at [phone]
Sincerely,
Lauren B raulkner
Environmental Project Manager
Cc Bruce Gran Statesville fertilizer Plant,t/anager
Tom Wheeler Operations Slanager for the SSC Fertilizer Division

Southern States Cooperative Inc
6606 West Broad Street
Richmond, Va 23230 1717
Mail Address P O Box 26234
Richmond, Va 23260 6234
Telephone [phone]
September 19`h, 2013
SOUTHERN
STATES
North Carolina Department of Environment and Natural Resources
Division of Water Quahty-NPDES Unit
Attention Mr Charles Weaver
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RE NPDES Permit Renewal Application for the Southern States Statesville
Fertilizer Plant (Permit #NC008282I )- Sludge Management Narrative
Dear Mr Weaver,
The Southern States Cooperative, Inc (SSC) is submitting this brief explanation
regarding a sludge management plan on behalf of the Statesville Fertilizer Plant
that is currently covered under NDPES Permit 4NCO082821 to the North Carolina
Department of Environment and Natural Resources- Division of Water Quality
this permit is for the discharge that is generated as a result of the groundwater
remediation system There are no solids or sludge generated as a result of this
process and so this facility does not have a sludge management plan
If you need any additional information, please contact me at [phone]
Sincerely,
Lauren B Faulkner
Environmental Project Manager
Cc Bruce Gray -Statesville Fertdecer Plant Alanager
Tom Wheeler Operations Afanager for the SSC 1 emlccr Drvtreon

NPDES PERMIT APPLICATION - SHORT FORM C - Minor Industrial
Minor industrial, manufacturing and commercial facilities
Mail the complete application to
N C DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
1 Contact Information
Owner Name
Facility Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
NPDES Permit Number NC0082821
Please print or type
Southern States Cooperative, Inc
Statesville Fertilizer Plant
PO Box 26234
Richmond
Virginia 23260
804-281-1 189
804-281-1396
Lauren faulkner@sscoop com
2 Location of facility producing discharge
Check here if same as above ❑
Street Address or State Road 2582 Salisbury Highway
City
Statesville
State / Zip Code
North Carolina 28677
County
Iredell
3 Operator Information
Name of the firm, consultant
or other entity that operates the facility (Note that this is not referring to the
Operator in Responsible Charge or ORC)
Name
Southern States Cooperative, Inc
Mailing Address
PO Box 26234
City
Richmond
State / Zip Code
Virginia 23260
Telephone Number
804-281-1189
Fax Number
804-281-1396
4 Ownership Status
Federal ❑ State ❑ Private ® Public ❑
Page 1 of 5 C MI 10/08

NPDES PERMIT APPLICATION - SHORT FORM C - Minor Industrial
Minor industrial, manufacturing and commercial facilities
5 Standard Industrial Classification (SIC) code(s) 2875
6 Number of employees 28
7 Describe the treatment system List all installed waste treatment components with capacities,
describe the processes that generate wastewaters If the space prootded is not sufficient attach a
separate sheet of paper with the system description
There is a ground water pump and treat system that has 3 recovery wells that pump
groundwater into a treatment system where the pH is adjusted using a caustic solution
before it is discharged into Fourth Creek
8 Is facility covered under federal effluent limitation guidehnesl� No ® Yes ❑
If yes, specify the category?
9 Principal product(s) produced nitrogen -based fertilizers
Principal raw material(s) consumed ammonium sulfate, anhydrous ammonia, granular lime,
urea, potash, urea ammonium nitrate solution 32%
Briefly describe the manufacturing process(es)
This is a fertilizer manufacturing plant that produces bulk and bagged nitrogen -based fertilizers
through an ammoniation process that uses anhydrous ammonia, sulfuric acid and urea ammonium
nitrate to solution to create different blends of fertilizers These fertilizers typically contain different
concentrations of nitrogen, phosphorus and potash
Page 2 of 5 C MI 10108

NPDES PERMIT APPLICATION - SHORT FORM C - Minor Industrial
Minor industrial, manufacturing and commercial facilities
10 Amount of principal product produced or raw material consumed
Listspecific amounts consumed and/or units of roduction over the last three ears
Product Produced or Raw Material
Consumed
AVERAGE
Product Produced or Raw Material
Consumed
PEAK
per Day
N/A -groundwater remediation system
N/A -groundwater remediation system
per Month
per Year
11 Frequency of discharge Continuous ❑ Intermittent
If intermittent * The system only operates from November through April
Days per week discharge occurs Variable Duration
12 Types of wastewater discharged to surface waters only
Discharge
Flow
GALLONS PER DAY
Sanitary - monthly average
Utility water, etc - monthly average
Process water- monthly average
Stormwater - monthly average
Other - monthly average
Explain Groundwater remediation
system
0 144 MGD
Monthly Average
total discharge (all types)
13 Number of separate discharge points 1 Outfall Identification number(s) 001
14 Name of receiving stream(s) (Promde a map showing the exact location of each outfall, including
latitude and longitude]
Fourth Creek classified C waters in subbasin 03-07-06 of the Yadkin -Pee Dee River Basin
Latitude 35° 46'25" Longitude 80°46'40"
Page 3 of 5 C MI 10/08

NPDES PERMIT APPLICATION - SHORT FORM C - Minor Industrial
Minor industrial, manufacturing and commercial facilities
15 Effluent Data [for new or proposed discharges]
Provide data for the parameters listed 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
NOTE Permittees requesting renewal should complete the table ONLY for the parameters
currently monitored Summarize the past 3 years of effluent data
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
N/A
N/A
N/A
Chemical Oxygen Demand (COD)
N/A
N/A
N/A
Total Organic Carbon
N/A
N/A
N/A
Total Suspended Solids
169
70
mg/L
Ammonia as N
236
54
mg/L
Temperature (Summer)
N/A
N/A
N/A
Temperature (Winter)
N/A
N/A
N/A
pH
838
684
SU
Fecal Coliform (If sanitary waste is
present)
N/A
N/A
N/A
Total Residual Chlorine (if chlorine is
used)
N/A
N/A
N/A
16 List all permits, construction approvals and/or applications (check all that apply and provide permit
numbers or check none tf not applicable)
Type Permit Number Type Permit Number
Hazardous Waste (RCRA)
U[C (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
NESHAPS (CAA)
Ocean Dumping (MPRSA)
NCO082821 Dredge or fill (Section 404 or CWA)
Other
17 List any chemicals that may be discharged (Please list and explain source and potential
amounts)
nitrates
Page 4 of 5 C MI 10/08

NPDES PERMIT APPLICATION - SHORT FORM C - Minor Industrial
Minor industrial, manufacturing and commercial facilities
18 Is this facility located on Indian country? (check one)
Yes ❑ No
19 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
Signature of Applicant
Date
North Carolina General Statute 143-215 6 (b)(2) provides that 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 sox 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 )
Page 5 of 5 C MI 10108