NC0043257_More Information (Received)_20210601

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Form
NPDES
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions may result in denial of the application.
Facility Information
N 1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1
Facility name
Nature Trail MHC WWTP
Mailing address (street or P.O. box)
524 Meadow Ave. Loop
City or town
Banner Elk
State
NC
ZIP code
28604
Contact name (first and last)
Matthew Raynor
Title
Environmental Director
Phone number
[phone]
Email address
[e-mail]
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
326 Nature Trail
City or town
Chapel Hill
State
NC
ZIP code
27517
1.2
Is this application for a facility that has yet to commence
❑ Yes 4 See instructions on data submission
requirements for new dischargers.
discharge?
✓ No
Applicant Information
1.3
Is applicant different from entity listed under Item
❑ Yes
1.1 above?
Item 1.4.
v No -3 SKIP to
Applicant name
Applicant address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
1.4
Is the applicant
the facility's owner, operator, or both? (Check only one response.)
❑ Operator ❑ Both
✓ Owner
1.5
To which entity
should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Applicant ❑ Facility and applicant
(they are one and the same)
✓ Facility
Existing Environmental Permits
1.6
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.)
Existing Environmental Permits
v NPDES
(discharges to surface
RCRA (hazardous waste)
❑ UIC (underground injection
control)
water)
❑ PSD (air emissions)
❑ Nonattainment program (CM)
•
NESHAPs (CAA)
dumping (MPRSA)
❑ Dredge or fill (CWA Section
404)
❑ Other (specify)
• Ocean
Page 1

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Collection System and Population Served
1.7
Provide the collection system information requested below for the treatment works.
Municipality
Served
Population
Served
Collection System Type
(indicate percentage)
Ownership Status
800
no% separate sanitary sewer
ID Own ❑ Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
❑ Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
Total
Population
Served
800
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
100 %
0
Indian Country
1.8
Is the treatment works located in Indian
❑ Yes
Country?
v
No
1.9
Does the facility discharge to a receiving
❑ Yes
water that flows through
v
Indian Country?
No
Design and Actual
Flow Rates
1.10
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
0.04o mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.031 mgd
0.031 mgd
0.031 mgd
Maximum Daily Flow Rates, (Actual)
Two Years Ago
Last Year
This Year
0.077 mgd
0.075 mgd
0.065 mgd
Discharge Points
by Type
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Discharge Points by Type
Treated Effluent
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
1
0
0
0
0
Page 2

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods
Outfalls Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes v No -4 SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Location
Average Daily Volume
Discharged to Surface
Impoundment
Continuous or Intermittent
(check one)
gpd
❑ Continuous
❑ Intermittent
gpd
❑ Continuous
❑ Intermittent
gpd
❑ Continuous
El Intermittent
1.14
Is wastewater applied to land?
❑ Yes v
No 4 SKIP to Item 1.16.
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Location
Size
Average Daily Volume
Applied
Continuous or
Intermittent
(check one)
acres
d
gip'
❑ Continuous
❑ Intermittent
acres
gp d
❑ Continuous
❑ Intermittent
acres
gl d
0 Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment
❑ Yes V
prior to discharge?
No -4 SKIP to Item 1.21.
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods Continued
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
NPDES number of receiving facility (if any) 0 None
Average daily flow rate mgd
1.21
Is the wastewater disposed of in a manner other than
not have outlets to waters of the State of North Carolina
❑ Yes v
those a
(e.g.,
No
ready mentioned in Items 1.14 through 1.21 that do
underground percolation, underground injection)?
+ SKIP to Item 1.23.
1.22
Provide information in the table below on these other disposal methods.
Information on Other D sposal Methods
Disposal
Method
Description
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acresgpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acresgpd
❑ Continuous
0 Intermittent
Variance
Requests
1.23
Do
Consult
❑
12
you intend to request or renew one or more of the
with your NPDES permitting authority to determine
Discharges into marine waters (CWA •
Section 301(h))
Not applicable
variances authorized at 40 CFR 122.21(n)? (Check all that apply.
what information needs to be submitted and when.)
Water quality related effluent limitation (CWA Section
302(b)(2))
Contractor Information
1.24
Are any operational or maintenance aspects (related to
the responsibility of a contractor?
❑ Yes 12
wastewater treatment and effluent quality) of the treatment works
No +SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Mailing address
(street or P.O. box)
City, state, and ZIP
code
Contact name (first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
SECTION 2. ADDITIONAL INFORMATION
(40 CFR 122.21(j)(1) and
(2))
o
Outfalls to Waters of the State of North Carolina
a
rn
o
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes r No 4 SKIP to Section 3.
Inflow and Infiltration
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Topographic
Map
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
❑ Yes ❑ No
Flow
Diagram
2.4
Have
(See
•
you attached a process flow diagram or schematic to this application that contains all the required information?
instructions for specific requirements.)
Yes ❑ No
Scheduled Improvements and Schedules of Implementation
2.5
Are
■
improvements to the facility scheduled?
Yes
■ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list outfall
numbers
Begin
Construction
(MM/DD/YYYY)
End
Construction
(MM/DD/YYYY)
Begin
Discharge
(MM/DD/YYYY)
Attainment of
Operational
Level
(MM/DD/YYYY)
1.
2.
3.
4.
2.7
Have appropriate permits/clearances
response.
❑ Yes
concerning other federal/state requirements been obtained? Briefly explain your
• No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Description of Outfalls
N 3. INFORMATION ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number o01
Outfall Number
Outfall Number
State
North Carolina
County
Chatham
City or town
Chapel Hill
Distance from shore
1 ft.
ft.
ft.
Depth below surface
0 ft.
ft.
ft.
Average daily flow rate
0.031 mgd
mgd
mgd
Latitude
° „
Longitude
"
Seasonal or Periodic Discharge Data
3.2
Do any of the outfalls described
❑ Yes
under Item 3.1 have seasonal or
periodic
MI
discharges?
No 4 SKIP to Item 3.4.
3.3
If so, provide the following information
for each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
mgd
mgd
mgd
Months in which discharge
occurs
Diffuser Type
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes
Cil
No a SKIP to Item 3.6.
3.5
Briefly describe the diffuser type
at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Waters of
the U.S.
3.6
Does
one
the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
or more discharge points?
Yes ❑ No -*SKIP to Section 6.
Page 6

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Receiving Water Description
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall Number ���
Outfall Number
Outfall Number
Receiving water name
Cub Creek
Name of watershed, river,
or stream system
Neuse River
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
mg/L of
CaCO3
mg/L of
CaCO3
mg/L of
CaCO3
Treatment Description
3.8
Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number Outfall Number
Outfall Number
Highest Level of
Treatment (check all that
apply per outfall)
❑ Primary
0 Equivalent to
secondary
0 Secondary
❑ Advanced
❑ Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BOD5 or CBOD5
80
TSS
80 %
%
%
Phosphorus
0 Not applicable
%
0 Not applicable
ok
0 Not applicable
o
/o
Nitrogen
0 Not applicable
80 %
❑ Not applicable
%
0 Not applicable
0
/o
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Treatment Description Continued
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
Sodium Hypochlorite 12.5 % liquid feed
Sodium Bi-sulfite Dechlorination
Outfall Number
o01
Outfall Number
Outfall Number
Disinfection type
Sodium Hypochlorite
Seasons used
all
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Yes
■ Not applicable
❑ Yes
❑ No
v
Yes
❑ No
• No
Effluent Testing Data
3.10
Have you completed
monitoring for all Table A parameters and
attached the results
to the application package?
Yes
• No
3.11
Have you conducted any WET tests during the 4.5 years prior to
discharges or on any receiving water near the discharge points?
❑ Yes
the date of the
application on any of the facility's
SKIP to Item 3.13.
✓ No —>
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
Number of tests of receiving
water
3.14
Does the POTW
reasonable potential
use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
to discharge chlorine in its effluent?
Complete Table B, including chlorine. ❑ No -3 Complete Table B, omitting chlorine.
19 Yes -,
3.15
Have you completed
package?
monitoring for all applicable Table B pollutants and attached the results to this application
❑ No
✓ Yes
3.18
Have you completed monitoring for all applicable Table D pollutants
attached the results to this application package?
❑ Yes
required by
No
your NPDES permitting authority and
sampling required by NPDES
authority.
additional
permitting
Page 8

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Continued
3.19
Has the POTW conducted either (1) minimum of four
or (2) at least four annual WET tests in the past 4.5
❑ Yes
quarterly WET tests for one year
years?
No 4 Complete
preceding this permit application
tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above
❑ Yes
tests to your NPDES permitting
No 4 Provide
authority?
results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
(MM1DDNYYY)
Summary of Results
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment
works conducted a toxicity reduction
evaluation?
Item 3.26.
■ Yes
• No -3 SKIP to
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls
❑ Yes
and attached the results to the application
Not
package?
because previously submitted
NPDES •ermittin. author i .
applicable
information to the
Page 9

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Modified Application Form 2A
Modified March 2021
SECTION 6. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
submitting with your application. For
permitting authority. Note that not
Checklist and Certification Statement
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are
each section, specify in Column 2 any attachments that you are enclosing to alert the
all applicants are required to provide attachments.
Column 1
Column 2
Section
1: Basic Application
for All Applicants
❑ w/ variance request(s) ❑ wl additional attachments
✓
Information
Section
2: Additional
❑ w/ topographic map ❑ wl process flow diagram
❑ wl additional attachments
0
Information
Section
3: Information on
Discharges
✓ w/ Table
A ❑ w/ Table D
B ❑ wl additional attachments
C
✓ w/ Table
❑ w/ Table
Effluent
Section 4: Not Applicable
Section 5: Not Applicable
Section
6: Checklist and
Statement
❑ w/attachments
Certification
6.2
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)
Matthew E. Raynor
Official title
Environmental Director
Signatur
Mr/ W-,111
. I,
ld /
Date signe
yip 2(
Page 10

NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
0utfall Number
001
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS FOR ALL POTWS
Pollutant
Biochemical oxygen demand
o BODS or ❑ CBOD5
(report one)
Fecal coliform
Design flow rate
pH (minimum)
pH (maximum)
Temperature (winter)
Temperature (summer)
Total suspended solids (TSS)
Maximum Daily Discharge
Value
32
2419
0.77
6.8
7.6
12
26.7
82
Units
mg/1
MPN/100m1
MGD
UNITS
UNITS
C
C
mg/I
Average Daily Discharge
Value
5.1
3.5
0.031
14
21
6.9
Units
mg/I
MPN/100m1
MGD
C
C
mg/I
104
104
730
Daily
Daily
104
Number of
Samples
Analytical
Method1
SM 5210 B-2011
Colilert 18
SM 2540D-2011
ML or MDL
(include units)
1 ML
O MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

EPA Identification Number
NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Outfall Number
Modified Application Form 2A
Modified March 2021
TABLE B. EFFLUENT PARAMETERS
Pollutant
FOR ALL POTWS WITH A FLOW EQUAL TO OR GREATER THAN 0.1 MGD
Maximum Daily Discharge Average Daily Discharge
Analytical
Method'
ML or MDL
(include units)
Value
Units
Value
Units
Number
plesf
Ammonia (as N)
❑ ML
0 MDL
Chlorine
(total residual, TRC)2
0
mg/I
0
mg/I
g
daii Y
sm 4500 ClG
❑ ML
0 MDL
Dissolved oxygen
❑ ML
❑ MDL
Nitrate/nitrite
❑ ML
0 MDL
Kjeldahl nitrogen
0 ML
0 MDL
Oil and grease
❑ ML
❑ MDL
Phosphorus
0 ML
❑ MDL
Total dissolved solids
0 ML
❑ MDL
' Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A (Revised 3-19)
Page 12

EPA Identification Number
NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Form Approved 03/05/19
OMB No.2040-0004
Form
1
NPDES
.—.EPA
U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater
GENERAL INFORMATION
SECTION
1. ACTIVITIES REQUIRING AN NPDES PERMIT (40 CFR 122.21(f) and
(f)(1))
cn
Name, Mailing Address, and Location Activities Requiring an NPDES Permit
0
1.1
Applicants Not Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly
treatment works?
If yes, STOP. Do NOT complete
Form 1. Complete Form 2A.
owned
1.1.2
Is the facility a new or existing treatment works
treating domestic sewage?
If yes, STOP. Do NOT No
complete Form 1. Complete
Form 2S.
v No
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal
operation or a concentrated aquatic
production facility?
Yes 4 Complete Form 1
and Form 2B.
feeding
animal
1.2.2
Is the facility an existing
commercial, mining,
currently discharging
❑ Yes 4 Complete
1 and
manufacturing,
or silvicultural facility that is
process wastewater?
,. No
Form r No
Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
mining, or silvicultural facility that has
commenced to discharge?
Yes -3 Complete Form 1
and Form 2D.
not yet
1.2.4
Is the facility a new
commercial, mining,
discharges only nonprocess
❑ Yes 4 Complete
1 and
or existing manufacturing,
or silvicultural facility that
wastewater?
v No
Form v No
Form 2E.
1.2.5
Is the facility a new or existing facility
discharge is composed entirely of stormwater
associated with industrial activity
discharge is composed of both stormwater
non-stormwater?
Yes 4 Complete Form 1
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
(b) 15).
whose
or whose
and
19 No
2. NAME,
2.1
MAILING ADDRESS, AND LOCATION (40 CFR 122.21(f)(2))
Facility Name
Nature Trail MHC WWTP
2.2
EPA Identification Number
2.3
Facility Contact
Name (first and last)
Matthew Raynor
Title
Environmental Director
Phone number
[phone]
Email address
[e-mail]
2.4
Facility Mailing Address
Street or P.O. box
52 Meadow Ave. Loop
City or town
Banner Elk
State
NC
ZIP code
28604
EPA Form 3510-1 (revised 3-19)
Page 1

EPA Identification Number
NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Form Approved 03/05/19
OMB No. 2040-0004
Name, Mailing Add,
and Location Continued
2.5
Facility Location
Street, route number, or other specific identifier
326 Nature Trail
County name
Chatham
County code (if known)
City or town
Chapel Hill
State
NC
ZIP code
27517
3. SIC
AND NAICS CODES (40 CFR 122.21(f)(3))
co
Operator Information SIC and NAICS Codes
0
3.1
SIC Code(s)
Description (optional)
3.2
NAICS Code(s)
Description (optional)
4. OPERATOR
INFORMATION (40 CFR
122.21(f)(4))
4.1
Name of Operator
Pete Salisbury
4.2
Is the name
❑ Yes
you listed in Item 4.1 also the owner?
v No
4.3
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
Private ❑ Other (specify)
Phone Number of Operator
4.4
[phone]
Operator Information
Continued.
4.5
Operator Address
Street or P.O. Box
34 Southpointe
City or town
Pittsboro
State
NC
ZIP code
27312
Email address of operator
[e-mail]
N 5. INDIAN
LAND (40 CFR 122.21(f)(5))
0
c_r
5.1
Is the
■Yes
facility
located
151No
on Indian Land?
EPA Form 3510-1 (revised 3-19)
Page 2

EPA Identification Number
NPDES Permit Number Facility Name
NC0043257 Nature Trail MHC WWTP
Form Approved 03/05/19
OMB No. 2040-0004
SECTION
6. EXISTING ENVIRONMENTAL PERMITS (40 CFR 122.21(f)(6))
In Map Existing Environmental
Permits
6.1
Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
✓
.. •
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
fluids)
■ '
• Nonattainment program (CAA)
❑ NESHAPs (CAA)
■ Ocean dumping
❑ Dredge or fill (CWA Section 404)
❑
Other (specify)
7. MAP
(40 CFR 122.21(f)(7))
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
0 Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
8. NATURE
OF BUSINESS (40 CFR 122.21(f)(8))
Nature of Business
8.1
Describe the nature of your business.
Mobile Home Park
SECTION
9. COOLING
WATER INTAKE STRUCTURES (40 CFR 122.21(f)(9))
Cooling Water
Intake Structures
9.1
Does your facility use cooling water?
❑ Yes 0 No -9• SKIP to Item 10.1.
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
N 10. VARIANCE
REQUESTS (40 CFR 122.21(f)(10))
Variance Requests
10.1
Do you intend to request or renew one or more of the variances authorized at 40
CFR 122.21(m)? (Check all that
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
• Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
p Not applicable
EPA Form 3510.1 (revised 3-19)
Page 3

EPA Identification Number
NPDES Permit Number
NC0043257
Facility Name
Nature Trail MHC WWTP
Form Approved 03/05/19
OMB No.2040-0004
SECTION 11. CHECKLIST
AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
Checklist and Certification Statement
11.1
In Column 1 below, mark the sections of Form 1 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
Column 2
v Section 1: Activities Requiring an NPDES Permit
❑ w/ attachments
Section 2: Name, Mailing Address, and Location
•
w/ attachments
❑
Section 3: SIC Codes
❑
wl attachments
❑
Section 4: Operator Information
❑
w/ attachments
❑
Section 5: Indian Land
❑
w/ attachments
❑
Section 6: Existing Environmental Permits
•
w/ attachments
❑
Section 7: Map
•
wl topographicmap ❑ w/ additional attachments
■
Section 8: Nature of Business
❑ wl attachments
■
Section 9: Cooling Water Intake Structures
❑ w/ attachments
12
Section 10: Variance Requests
❑ w/ attachments
Section 11: Checklist and Certification Statement
❑ w/ attachments
11.2
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)
Matthew E. Raynor
Official title
Environmental Director
Signature
iTh
Date signed
EPA Form 3510-1 (revised 3-19)
Page 4