NC0080659_Renewal Application_20201027

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MOD
Mail the complete application to:
N. C. DENR / Division of Water Resources / NPDES Program
1617 Mail Service Center, Raleigh, NC 27699.1617
NPDES Permit C00
If you are completng this form in computer use the TAB key or the up - down arrows to moue 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
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above E
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.
referring to the Operator in Responsible Charge or ORC)
Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address i, ;
(Note that this is not
1 of 3 Fom}D 912013

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generatin¢
Wastewater(check
all that apply):
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes _
School
Number of Students/Staff
T�
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centersy
restaurants, etc.): �. re `e
� «CY:scvi rti�:�4�f,� S�l�C�:� �13ru� t /
Number of persons served: LAI
5. Type of collection system
0 Separate (sanitary sewer only)
6. Out fall Information:
❑ Combined (storm sewer and sanitary sewer)
Number of separate discharge points _C4d_9E_
Outfall Identification number(s) _ .V
Is the outfall equipped with a diffuser? Yes ❑ No
7. Name of receiving stream(s) (NEW a lfcant : Provide a map showing the exact location of each
outfall): L,(f?1e'C .'RV_USLt C, r1a`) oY1
S. Frequency of Discharge: Continuous ❑ Intermittent
If intermittent: Duration:
Days per week discharge occurs:
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.
lV� G 6' G
Form-D 91200

NPDES APPLICATION - FORM D
'For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow : ,CC ` MGD
Annual Average daily flow C , CC(; MGD (for the previous 3 years)
Maximum daily flow (?,CC ` MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes P4 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
fAe �f sr manfhc fnr nnrampters nvrrenthi in rmur nermit. Mark other Darameters "N/A".
Daily
Monthly
Units of
Parameter
Maximum
Averse
Measurement
Biochemical Oxygen Demand (BODS)
Fecal Coliform
r
v ey c, al
Total Suspended Solids
/ S
✓Yvr %
Temperature (Summer)
-3
cy(
O C
Temperature (Winter)
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES 1{/ r-r- . r r `i Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non -attainment program (CAA)
14. 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.
name
Title
Date
o�aa Oa�a
North Carolina General Sla(ut4 143.215.6 (b)(2) stales. Any person who knowingly makes any false statement representation, or cerlificalion in any
application, record, report, plan, or other document files or required to be maintained under Arlicle 21 or regulations of the Environmental Management
Commission implementing [hat Article, or who falsities, tampers with, or knowingly renders Inaccufale 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 9/2013