HomeMy WebLinkAboutNC0089559_Renewal (Application)_20210416ist and Certification Statement
NPDES Permit Number
NC089559
Facility Name
RIDGE HAVEN WWTP
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6.1
6.2
Modified Application Form 2A
Modified March 2021
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In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Section 1: Basic Application
Information for All Applicants
Section 2: Additional
Information
✓
Section 3 Information on
Effluent Discharges
w/ variance request(s)
Column 2
w/ additional attachments
Section 4: Not Applicable
w/ topographic map
w/ additional attachments
w/ process flow diagram
w/TableA
w/ Table B
w/ Table C
w/ Table D
w/ additional attachments
Section 5: Not Applicable
Section 6: Checklist and
Certification Statement
w/ attachments
Certification Statement
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 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 fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Paul Johnson
Signature
Official title
WWTP ORC
Date signed
4/9/2021
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