NC0029190_Permit (Issuance)_20140307

MPDES DOCUMENT SCAMMIMC COVER SHEET
NPDES Permit: NC0029190
WWTP
1T-�7 AW Af
Document Type: Permit Issuance
Wasteload Allocation
Authorization to Construct (AtC)
Permit Modification
Staff Report
201 Facilities Plan
Instream Assessment (67B)
Environmental Assessment (EA)
Permit
History
Document Date: March 7, 2014
This document is printed o x reuse paper-ignore any
coateat oa the resrerse side

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Thomas A. Reeder John E. Skvarla III
Governor Director Secretary
March 7, 2014
Mr. Jason Joyce
N.C. DOT
P.O. Box 250
North Wilkesboro, N.C. 28659-0250
Subject: Issuance of NPDES Permit NC0029190
I-77 Rest Area WWTF
Surry County
Class WW-2
Dear Mr. Joyce:
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 includes no major changes from the draft permit sent to you on January
15, 2014.
➢ NOTE: Proposed Federal regulations require electronic submittal of all discharge monitoring
reports (DMRs). The proposed regulations specify that if a state does not establish a system to
receive such submittals permittees must submit DMRs electronically to the Environmental
Protection Agency (EPA). Accordingly, NC DENR has established an electronic data-submission
system. Permittees must begin using the system no later than 270 days following the effective
date of permit renewals. In your case, that deadline is January 1, 2015.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty (30)
days following receipt of this letter. This 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 transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal
requirements to obtain any other Federal, State, or Local governmental permit that may be required. If you
have any questions concerning this permit, please contact Charles Weaver at telephone number (919) 807-
6391.
i
Since
/�rely,
Thomas A. Reeder -
cc: Central Files Winston-Salem Regional Office NPDES Unit
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 512 North Salisbury Street,Raleigh,North Carolina 27604
Phone: [phone]/FAX [phone]/http://poaal.ncdenr.org/web/wq
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Permit NCO029190
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
PERMIT
TO 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,
The North Carolina Department of Transportation
is hereby authorized to discharge wastewater from a facility located at the
DOT I-77 Rest Area
I-77, southeast of Lambsburg
Surry County
to receiving waters designated as Naked Run 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 April 1, 2014:
This permit and authorization to discharge shall expire at midnight on February 28, 2019.
Signed this day March 7, 201
j vJZ. �i
Tho ��s A. Reeder, Director
Dillon of Water Resources
By Authority of the Environmental Management Commission
Iof7

Permit NCO029190
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
number 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.
The North Carolina Department of Transportation is hereby authorized to:
1. Continue to operate an existing 0.030 MGD wastewater treatment facility consisting of
the following components:
♦ Comminutor
♦ Parallel extended aeration basins
♦ Parallel clarifiers
♦ Dosing Tank
♦ Two surface sandfilters
♦ Chlorine metering pump
♦ Chlorine contact chamber
♦ Tablet dechlorination
♦ Step aeration
This facility is located at the DOT I-77 Rest Area, off I-77 southeast of Lambsburg in
Surry County.
2. Discharge treated wastewater (via Outfall 001) from said facility at the location
specified on the attached map into Naked Run, currently classified WS-IV Trout
waters in the Yadkin-Pee Dee River Basin.
2of7

Permit NCO029190
Part I
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 monitored' by the Permittee as specified below:
{PARAMETER _ LIMITS __ MONITORIN_G REQUIREMENTS
Monthly Daily Measurement
[P.CS Code] Sample Type Sample Locationz I
_ Average . Maximum Frequency_ _ ,
Flow 0.030 MGD Continuous Recording Influent or Effluent
50050
BOD, 5-day, 201 C 30.0 mg/L 45.0 mg/L Weekly Composite Effluent
00310
Total Suspended Solids 30.0 mg/L 45.0 mg/L Weekly Composite Effluent
[00530]
NH3 as N Weekly Composite Effluent
00610
Total Residual Chlorine(TRC)3
50060 28 µg/L 2/Week Grab Effluent
Fecal Coliform(geometric mean) 2001100 ml 400/100 ml Weekly Grab Effluent
31616
Temperature(°C)[000101 Daily Grab Effluent
Temperature("C) Weekly Grab U& D
00010
pH >6.0 and<9.0 standard units 2/Month Grab Effluent
00400 — —
0 Oxygen[ 0300] Daily average>2.0 mg/L Weekly Grab Effluent
0030
Dissolved Oxygen Weekly Grab U & D
[003001
Chronic Toxicity^TGP3B Quarterly Composite Effluent
Total Nitrogen (NO2+NO3+TKN)[006001 Quarterly Composite Effluent
Total Phosphorus[006651 1 1
Quarterly Composite Effluent
Footnotes:
1. No later than January 1. 2015, the permittee shall begin submitting discharge monitoring reports
electronically using the Division's eDMR application system [see A. (4)].
2. U: upstream at least 50 feet from the outfall. D: downstream at least 100 feet from the outfall, before
the Virginia DOT rest area discharge.
3. The Division shall consider all effluent TRC values reported< 50 µg/L to be in compliance with the
permit. However, the Permittee shall continue to record and submit all values reported by a North
Carolina certified laboratory (including field certified), even if these values fall below 50 µg/L.
4. Chronic Toxicity (Ceriodaphnia) P/F at 13% with testing in February, May, August, and November [see
A. (2)].
There shall be no discharge of floating solids or visible foam in other than trace amounts
3of7

Permit NCO029190
A. (2) CHRONIC TOXICITY PERMIT LIMIT (QUARTERLY)
The effluent discharge shall at no time exhibit observable inhibition of reproduction or significant
mortality to Ceriodaphnia dubia at an effluent concentration of 13 %.
The permit holder shall perform at a minimum, quarterly monitoring using test procedures
outlined in the "North Carolina Ceriodaphnia Chronic Effluent Bioassay Procedure," Revised
February 1998, or subsequent versions or "North Carolina Phase II Chronic Whole Effluent
Toxicity Test Procedure" (Revised-February 1998) or subsequent versions. The tests will be
performed during the months of February, May, August and November. Effluent sampling
for this testing 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-February 1998) or subsequent versions.
The chronic value for multiple concentration tests will be determined using the geometric mean of
the highest concentration having no detectable impairment of reproduction or survival and the
lowest concentration that does have a detectable impairment of reproduction or survival. The
definition of"detectable impairment," collection methods, exposure regimes, and further statistical
methods are specified in the "North Carolina Phase II Chronic Whole Effluent Toxicity Test
Procedure" (Revised-February 1998) 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. If reporting
pass/fail results using the parameter code TGP3B, DWQ Form AT-1 (original) is sent to the
below address. If reporting Chronic Value results using the parameter code THP3B, DWQ Form
AT-3 (original) is to be sent to the following address:
Attention: NC DENR/ DWR/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.
Test data shall be complete, accurate, include all supporting cheinical/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 measured 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 permittee 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. The
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.
4of7

Permit NCO029190
Should any test data from this monitoring requirement or tests performed by the North Carolina
Division of Water Quality 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 then 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 Forms 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.
A. (3) NUTRIENT REOPENER FOR HIGH ROCK LAKE
This permit may be reopened and modified to implement nutrient requirements in accordance
with any future TMDL and / or nutrient management strategy for High Rock Lake.
A. (4) 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 is beginning implementation in
late 2013.
NOTE: This special condition supplements or supersedes the following sections within
Part II of this permit (Standard Conditions for NPDES Permits):
• Section B. (11.) Signatory Requirements
• Section D. (2.) Reporting
• Section D. (s.) Records Retention
• Section E. (5.) Monitoring Reports
1. Reporting [Supersedes Section D. (2J and Section E. (5 ) (a)1
Beginning no later than January 1, 2015, 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
5of7

Permit NCO029190
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/ Division of Water Resources / Information Processing Unit
ATTENTION: Central Files / eDMR
1617 Mail Service Center
Raleigh, NC 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 electronically to the Division unless the permittee re-applies for and is
granted a new temporary waiver by the Division.
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/admin/bog/ipidednn•
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.
11. d
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. (11.)(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/bog/ipLi/ediiir
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
CERTIFICATION WILL BE ACCEPTED:
6of7

Permit NCO029190
"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 ant 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 D. (6.)]
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. This period may be extended by request of the Director at any time [40
CFR 122.411.
7of7

47
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Discharge Point
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NC DOT 1-77 Surry County Rest Area - NC0029190 Facility '
USGS Quad:B17NW Location
Receiving Stream: Toms Creek Latitude: 36'23'57"
Stream Class: C Longitude: 80'29'18"
Subbasin: 03-07-03 �(� Map not to scale

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`• + , Public Notice + nl'arnifrogenfecaticoliform'.•'�
Nortd,car6uria. and totafresidualefilorine are .
Y ,Environmental.Management j wafebquality limited_."NC DOT:
m M '
}Comissi6nPDES'Unn requested renewal of NPDES"
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* CAROLINA 1617�Mail.Service'Center permit NC0029190/f TSurry
Raleigh;NC 27699-1617 County Rest Area:Facility drag.
Y COUNTY Y Notice of Intent to Issue a cfiarges to Naked'.RmNadkin-
` NPDES,Wastew`ater Permit Pee;Dee RiBer'Basin+Cm-, '
. The North'Carolrna+Environ- rentlo dissolved oxygen fee' ',I
AFFIDAVIT OF PUBLICATION memo.Mosegemesue.a mis coliform and total'residuah
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DES,wastewatec discfiarge •ited.,-
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permiQo`the person(s)liste 'I
the undersigned, a Notary Public of said County and State, duly below.Written comments re- ._ Publish January 18,2014
garding the proposed,perm.t'. —
ssioned, qualified and authorized by law to administer oaths, wilube accepted until 30.days —
all appeared Ferris W. Simpson who being first duly antic .a e Diretbr of hers
Y PP P g Y notice.The Directorof the NO
deposes and says: that he(she) is Business Manager t, Division of Water Resources
;her or other officer or employee authorized to make affidavit) of (DWR)may hold a'pub.ic'fear-
ing should.there be a signific-
AS MEDIA, LLC, engaged in the publication of a newspaper known ant degree of public interest.
PPlease mail.comments and/or
IUNT AIRY NEWS, published, issued, and entered as periodicals 1 information requests to DWR
at the above address Inter-
mil in the city of Mount Airy in said County and State; that he (she) ested persons may visit the
orized to make this affidavit and sworn statement; that the notice or DWR at 512N Salisbury..
,Street Raleigh NC toreview
egal advertisement, a true copy of which is attached hereto, was information on file Additional
I
ted in MOUNT AIRY NEWS on the following dates: information.on,NPDES per.mits and,this notice may be-
found,omour website:
6tto7/portal ncdenr org/iveb/wq,
—�+ y[l Y , •/swo/os/npdes/calendar.or by
[phone].,Virgin,
j ia!_DOT requested renewal:of
NPDES permit NC0039420/1-
7,7 Rest Area W WTP dis-
! cfiarge/Surry County. F.aciliry
discharges.to:Naked'Run•
Cr`eek/Yadkin'PeeRiver Basin.,
at the said newspaper in which such notice, paper, document or _i Currently A,mm`oriia nitrogen,?
dvertisement was published was, at the time of each and every fecal co..form; a d total'res.d , r
ual'chlorine are water quality'
publication, a newspaper meeting all of the requirements and r limited..NO DENR/Div:of
rations of Section 1-597 of the General Statutes of North Carolina Parks a ReoreaW it
- quested renewal:pf permit
is a qualified newspaper within the meaning of Section 1-597 of f NC0031166/Pi.otMountain L
ieral Statutes of North Carolina. state'Paik wWTF/sorry
County.•,Fadility discnargesip;
G iassy.0 Fee
k/Yadkin,Pee Dde/`,
River Basin`.Currently'amrrio.,'1;Y
�_day of 2014 =
i
+
Signature of person making affidavit -
to and subscribed before me, this_c day of
12014 .
N ary Public
mmission expires: January 15, 2018
DRIDGET HENDEFiSOfV
NOTARY PUBLIC
Yadkin County
North Carolina
My Commission Expires January 15,2018

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory, Governor Thomas A. Reeder, Director John E. Skvarla III, Secretary
January 13, 2014
MEMORANDUM
To: Lisa Edwards
NC DENR / DWR / Regional Engineer
Winston-Salem Regional Office
From: Charles H. Weaver, Jr.
NPDES Unit
Subject: Review of Draft NPDES Permit NCO029190
N.C. DOT / I-77 Rest Area WWTP
Sorry County
Please indicate below your agency's position or viewpoint on the draft permit and return this
form by February 13, 2014. If you have any questions on the draft permit, please contact
me at the telephone number or e-mail address listed at the bottom of this page.
§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§
RESPONSE: (Check one)
XConcur with the issuance of this permit provided the facility is operated and maintained
properly, the stated effluent. limits are met prior to discharge, and the discharge does not
contravene the designated water quality standards.
Concurs with issuance of the above permit, provided the following conditions are met:
❑ Opposes the issuance of the above permit, based on reasons stated below, or attached:
i
Signed Date: f 1 Zev
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 919 8076391 (fax)919 807-6489
VISIT US ON THE INTERNEET @ HTTP;//PORru.Y,COENR.ORGMEahNc chades.weaver@ ncdenr.gov
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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,toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date Charles H. Weaver 1/13/2014
Permit Number NCO029190
Facility Name N.C. DOT/I-77 Rest Area WWTP
Basin Name/Sub-basin number 03-07-03
Receiving Stream Naked Run Creek
Stream Classification in Permit WS-IV Trout
Does permit need Daily Max NH3 limits? N /A
Does permit need TRC limits/lan a e? No—already resent
Does permit have toxicity testing? Yes. All tests passed since May 2010.
Does permit have Special Conditions? No
Does permit have instream monitoring? Dissolved Oxygen, Temperature
Is the stream impaired(on 303(d) list)? No
For whatparameter?
Any obvious compliance concerns? None. No enforcements since 2005. Two
violations in 2013, one in 2012.
Any permit modifications since lastpermit? None. .
New expiration date 2/28/2019
Comments on Draft Permit ➢ Added parameter codes.
➢ Added High Rock reopener condition.
➢ Added eDMR requirements.
Most Commonly Used Expedited Language:
• 303(d) laneuaee for Draft/Final Cover Letters: "Please note that the receiving stream
is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List.
Addressing impaired waters is a high priority with the Division, and instream data will
continue to be evaluated. If there is noncompliance with permitted effluent limits and
stream impairment can be attributed to your facility, then mitigative measures may be
required".
TRC lanauase for Comoliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values < 50 µg/L will be treated as zero for
compliance purposes."
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Impact. Disregard any content on the back of this page.

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 Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit COO aq I q
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 Ja U C
Facility Name T- i (L/ 11(i f/o. c 1`/% ;-iPP. .5K51
r
Mailing Address P 0. �Ox " E�0
City /, V�I Ik�S i7hYD
State / Zip Code ,/ C, ;q
Telephone Number (3�4) q 0 3- c) 20"�G
Fax Number ( 3 3&) q D 2- 0 2; 3
e-mail Address f T e �� ncdo7 . a a l
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road _ 17 r J(2L_ M P4 10 5
city )c
(i'I ✓1PQ51' 0r l,.-rt mS k!IrQ --
State / Zip Code N Cj
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)
Name �Ci '< if, p -
VI ra a':; V n i ra. i 0
Mailing Address F t OX n 50
city ;J• ` y:LKe V;Dr0
State / Zip Code
Telephone Number ( '✓j'a) l t`1�- Q ;r�� ``i
Fax Number (j ✓) G) G) !)
e-mail Address
,`y
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t of 3 o6H �"U" 4117
P��F4 V

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% 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 E2/ Explain: Res+ Rr-eo,
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.): y� 1
,r ll'`iZr S�Ct�e. Re.S+
Number of persons served: _
5. Typ f collection system
Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) 00 I
Is the outfall equipped with a diffuser? ❑ Yes U No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
AIai,PL( ,Li i1
S. Frequency of Discharge: Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
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.
�UYYiRIi-Ar�,r i cat'
Pao (ie i
� x-'rer,�er' Qnfa�i!1Y'� �jClainS
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2 of 3 �: LffC' 7- �•' �!` U r i Form-0 11112

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow ,030 MGD
Annual Average daily flow 0,0'0 5 MGD (for the previous 3 years)
Maximum daily flow 0,01S MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes R No
12. Effluent Data
NEW APPLICANTS:Provide data for the parameters listed.Fecal Coliform, Temperature and pH shall be grab
samples,for all otherparameters 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 dailymaximum.
RENEWAL APPLICANTS: Provide the highest single reading(Daily Maximum)and Monthly Average over
the past 36 months for parameters curre luintiourpermit. Mark other parameters 'NIA".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5) yy o j
Fecal Coliform a 0 D I a e G eon
Total Suspended Solids 1 3, 4 M
Temperature (Summer) [10-
Temperature (Winter) NIP
pH N1rT
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 No L)0.q cl) 61 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.
S,s�h yauc� ire4�1 �'G1pe5�
Printed name of Person Signing Title
/f 8 -26-r3
Si ture'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 11112