NC0069370_Fact Sheet_20210909

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
Fact Sheet
NPDES Permit No. NCOO6937O
Permit Writer/Email Contact Emily Phillips
Date: May 11, 2021
Division/Branch: NC Division of Water Resources/NPDES Complex Permitting
Fact Sheet Template: Version 09Jan2017
Permitting Action:
❑X Renewal
❑ Renewal with Expansion
❑ New Discharge
❑ Modification (Fact Sheet should be tailored to mod request)
Note: A complete application should include the following:
• For New Dischargers, EPA Form 2A or 2D requirements, Engineering Alternatives Analysis, Fee
• For Existing Dischargers (POTW), EPA Form 2A, 3 effluent pollutant scans, 4 2' species WET
tests.
• For Existing Dischargers (Non-POTW), EPA Form 2C with correct analytical requirements based
on industry category.
Complete applicable sections below. If not applicable, enter NA.
1. Basic Facility Information
Facility Information
Applicant/Facility Name:
Brookdale Hendersonville East
Applicant Address:
2601 Chimney Rock Road, Hendersonville NC 28792
Facility Address:
2601 Chimney Rock Road, Hendersonville NC 28792
Permitted Flow:
0.011 MGD [-102 people]
Facility Type/Waste:
Minor Municipal; 100% domestic
Facility Class:
Class II
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Treatment Units:
• Influent lift station
• Bar Screen
• Aeration basin
• Clarifier
• Tablet Chlorinator
• Tablet Dechlorination
• Chlorine contact chamber
• Sludge digester
• Effluent pump station
• Effluent Flow Recorder
• Activated sludge holding basin
Pretreatment Program (Y/N)
N
County:
Henderson
Region
Asheville
Briefly describe the proposed permitting action and facility background: Brookdale Hendersonville East
has applied for an NPDES permit renewal at 0.025 MGD. This facility serves a population of 102 people.
The facility has a single Outfall 001, until construction at a later time
2. Receiving Waterbodv Information:
Outfalls/Receiving Stream(s):
Outfall 001 — Clear Creek
Stream Segment:
6-88-4
Stream Classification:
C
303(d) listed/parameter:
N/A
Basin/Sub-basin:
French Broad/04-03-02
3. Effluent Data Summary
Table. Effluent Data Summary Outfall 001
See next page for table...
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EFFLUENT
CHARACTERISTICS
Parameter Code
EFFLUENT LIMITS
MONITORING REQUIREMENTS
Monthly
Average
Daily Maximum
Measurement
Frequency
Sample
Type
Sample
Location2
Flow3
50050
0.025 MGD
Continuous
Recorder
Influent or
Effluent
BOD, 5-Day (20 Deg. C)
C0310
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Solids
C0530
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Nitrogen, Ammonia Total (as N)
C0610
2 / month
Grab
Effluent
Fecal Coliform [geometric mean]
31616
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Chlorine, Total Residual (TRC)4
50060
28 pg/L
2 / week
Grab
Effluent
Temperature, °Centigrade - 00010
Weekly
Grab
Effluent
pH - 00400
> 6.0 and < 9.0 standard units
Weekly
Grab
Effluent
Fecal Coliform [geometric mean]
31616
Weekly
Grab
Upstream &
Downstream
4. Instream Data Summary
Instream monitoring may be required in certain situations, for example: 1) to verify model predictions
when model results for instream DO are within 1 mg/1 of instream standard at full permitted flow; 2) to
verify model predictions for outfall diffuser; 3) to provide data for future TMDL; 4) based on other
instream concerns. Instream monitoring may be conducted by the Permittee, and there are also
Monitoring Coalitions established in several basins that conduct instream sampling for the Permittee (in
which case instream monitoring is waived in the permit as long as coalition membership is maintained).
If applicable, summarize any instream data and what instream monitoring will be proposed for this
permit action: N/A
Is this facility a member of a Monitoring Coalition with waived instream monitoring (Y/N): NO
Name of Monitoring Coalition: N/A
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5. Compliance Summary
Summarize the compliance record with permit effluent limits (past 5 years): This facility has had one limit
violation in 2016 for BOD, which proceeded to NOV.
Summarize the compliance record with aquatic toxicity test limits and any second species test results
(past 5 years): N/A
Summarize the results from the most recent compliance inspection: Last inspection occurred August
2020, with numerous violations with the aerobic digester, both pump stations, and secondary clarifier.
6. Water Quality -Based Effluent Limitations (WQBELs)
Dilution and Mixing Zones
In accordance with 15A NCAC 2B.0206, the following stream flows are used for dilution considerations
for development of WQBELs: 1 Q 10 streamflow (acute Aquatic Life); 7Q10 streamflow (chronic Aquatic
Life; non -carcinogen HH); 30Q2 streamflow (aesthetics); annual average flow (carcinogen, HH).
If applicable, describe any other dilution factors considered (e.g., based on CORMIX model results): NA
If applicable, describe any mixing zones established in accordance with 15A NCAC 2B.0204(b): NA
Oxygen -Consuming Waste Limitations
Limitations for oxygen -consuming waste (e.g., BOD) are generally based on water quality modeling to
ensure protection of the instream dissolved oxygen (DO) water quality standard. Secondary TBEL limits
(e.g., BOD= 30 mg/1 for Municipals) may be appropriate if deemed more stringent based on dilution and
model results.
If permit limits are more stringent than TBELs, describe how limits were developed: NA
Ammonia and Total Residual Chlorine Limitations
Limitations for ammonia are based on protection of aquatic life utilizing an ammonia chronic criterion of
1.0 mg/1 (summer) and 1.8 mg/1 (winter). Acute ammonia limits are derived from chronic criteria,
utilizing a multiplication factor of 3 for Municipals and a multiplication factor of 5 for Non -Municipals.
Limitations for Total Residual Chlorine (TRC) are based on the NC water quality standard for protection
of aquatic life (17 ug/l) and capped at 28 ug/1 (acute impacts). Due to analytical issues, all TRC values
reported below 50 ug/1 are considered compliant with their permit limit.
Describe any proposed changes to ammonia and/or TRC limits for this permit renewal: There are no
proposed changes.
Reasonable Potential Analysis (RPA) for Toxicants NA
If applicable, conduct RPA analysis and complete information below.
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The need for toxicant limits is based upon a demonstration of reasonable potential to exceed water quality
standards, a statistical evaluation that is conducted during every permit renewal utilizing the most recent
effluent data for each outfall. The RPA is conducted in accordance with 40 CFR 122.44 (d) (i). The NC
RPA procedure utilizes the following: 1) 95% Confidence Level/95% Probability; 2) assumption of zero
background; 3) use of'V2 detection limit for "less than" values; and 4) stream flows used for dilution
consideration based on 15A NCAC 2B.0206. Effective April 6, 2016, NC began implementation of
dissolved metals criteria in the RPA process in accordance with guidance titled NPDES Implementation of
Instream Dissolved Metals Standards, dated June 10, 2016.
A reasonable potential analysis was conducted on effluent toxicant data collected between NA. Pollutants
of concern included toxicants with positive detections and associated water quality standards/criteria.
Based on this analysis, the following permitting actions are proposed for this permit:
• Effluent Limit with Monitoring. The following parameters will receive a water quality -based
effluent limit (WQBEL) since they demonstrated a reasonable potential to exceed applicable
water quality standards/criteria: NA
• Monitoring Only. The following parameters will receive a monitor -only requirement since they
did not demonstrate reasonable potential to exceed applicable water quality standards/criteria,
but the maximum predicted concentration was >50% of the allowable concentration: NA
• No Limit or Monitoring: The following parameters will not receive a limit or monitoring, since
they did not demonstrate reasonable potential to exceed applicable water quality
standards/criteria and the maximum predicted concentration was <50% of the allowable
concentration: NA
• POTW Effluent Pollutant Scan Review: Three effluent pollutant scans were evaluated for
additional pollutants of concern.
o The following parameter(s) will receive a water quality -based effluent limit (WQBEL)
with monitoring, since as part of a limited data set, two samples exceeded the allowable
discharge concentration: NA
o The following parameter(s) will receive a monitor -only requirement, since as part of a
limited data set, one sample exceeded the allowable discharge concentration: NA
If applicable, attach a spreadsheet of the RPA results as well as a copy of the Dissolved Metals
Implementation Fact Sheet for freshwater/saltwater to this Fact Sheet. Include a printout of the RPA
Dissolved to Total Metal Calculator sheet if this is a Municipality with a Pretreatment Program.
Toxicity Testing Limitations
Permit limits and monitoring requirements for Whole Effluent Toxicity (WET) have been established in
accordance with Division guidance (per WET Memo, 8/2/1999). Per WET guidance, all NPDES permits
issued to Major facilities or any facility discharging "complex" wastewater (contains anything other than
domestic waste) will contain appropriate WET limits and monitoring requirements, with several
exceptions. The State has received prior EPA approval to use an Alternative WET Test Procedure in
NPDES permits, using single concentration screening tests, with multiple dilution follow-up upon a test
failure.
Describe proposed toxicity test requirement: NA
Mercury Statewide TMDL Evaluation
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There is a statewide TMDL for mercury approved by EPA in 2012. The TMDL target was to comply
with EPA's mercury fish tissue criteria (0.3 mg/kg) for human health protection. The TMDL established a
wasteload allocation for point sources of 37 kg/year (81 lb/year), and is applicable to municipals and
industrial facilities with known mercury discharges. Given the small contribution of mercury from point
sources (-2% of total load), the TMDL emphasizes mercury minimization plans (MMPs) for point source
control. Municipal facilities > 2 MGD and discharging quantifiable levels of mercury (>1 ng/l) will
receive an MMP requirement. Industrials are evaluated on a case -by -case basis, depending if mercury is a
pollutant of concern. Effluent limits may also be added if annual average effluent concentrations exceed
the WQBEL value (based on the NC WQS of 12 ng/1) and/or if any individual value exceeds a TBEL
value of 47 ng/1
NA Table. Mercury Effluent Data Summary
# of Samples
Annual Average Conc. ng/L
Maximum Conc., ng/L
TBEL, ng/L
WQBEL, ng/L
Describe proposed permit actions based on mercury evaluation: NA
Other TMDL/Nutrient Management Strategy Considerations
If applicable, describe any other TMDLs/Nutrient Management Strategies and their implementation
within this permit: NA
Other WQBEL Considerations
If applicable, describe any other parameters of concern evaluated for WQBELs: NA
If applicable, describe any special actions (HQW or ORW) this receiving stream and classification shall
comply with in order to protect the designated waterbody: NA
If applicable, describe any compliance schedules proposed for this permit renewal in accordance with
15A NCAC 2H 0107(c) (2) (B), 40CFR 122.47, and EPA May 2007 Memo: NA
If applicable, describe any water quality standards variances proposed in accordance with NCGS 143-
215.3(e) and 15A NCAC 2B.0226for this permit renewal: NA
7. Technology -Based Effluent Limitations (TBELs)
Municipals (if not applicable, delete and skip to Industrials)
Are concentration limits in the permit at least as stringent as secondary treatment requirements (30 mg/l
BOD5/TSS for Monthly Average, and 45 mg/l for BOD5/TSS for Weekly Average). NA
If NO, provide a justification for alternative limitations (e.g., waste stabilization pond). NA
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Are 85% removal requirements for BOD5/TSS included in the permit? NA
If NO, provide a justification (e.g., waste stabilization pond). NA
Industrials (if not applicable, delete and skip to next Section) NA
Describe what this facility produces:
List the federal effluent limitations guideline (ELG) for this facility:
If the ELG is based on production or flow, document how the average production/flow value was
calculated:
For ELG limits, document the calculations used to develop TBEL limits:
Table. TBEL Development per NA
Pollutant
Daily Maximum
BPT/BAT
(lb/1000 lb)
Daily Maximum
Monthly Average
BPT/BAT
(lb/1000 lb)
Monthly Average
Limit
(lb/d)
Limit
(lb /d)
If any limits are based on best professional judgement (BPJ), describe development: NA
Document any TBELs that are more stringent than WQBELs: NA
Document any TBELs that are less stringent than previous permit: NA
8. Antidegradation Review (New/Expanding Discharge):
The objective of an anti -degradation review is to ensure that a new or increased pollutant loading will not
degrade water quality. Permitting actions for new or expanding discharges require an anti -degradation
review in accordance with 15A NCAC 2B.0201. Each applicant for a new/expanding NPDES permit
must document an effort to consider non -discharge alternatives per 15A NCAC 2H.0105 (c)(2). In all
cases, existing instream water uses and the level of water quality necessary to protect the existing use is
maintained and protected.
If applicable, describe the results of the antidegradation review, including the Engineering Alternatives
Analysis (EAA) and any water quality modeling results: NA
9. Antibacksliding Review:
Sections 402(o)(2) and 303(d)(4) of the CWA and federal regulations at 40 CFR 122.44(1) prohibit
backsliding of effluent limitations in NPDES permits. These provisions require effluent limitations in a
reissued permit to be as stringent as those in the previous permit, with some exceptions where limitations
may be relaxed (e.g., based on new information, increases in production may warrant less stringent TBEL
limits, or WQBELs may be less stringent based on updated RPA or dilution).
Are any effluent limitations less stringent than previous permit (YES/NO): NO
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If YES, confirm that antibacksliding provisions are not violated: NA
10. Monitoring Requirements
Monitoring frequencies for NPDES permitting are established in accordance with the following
regulations and guidance: 1) State Regulation for Surface Water Monitoring, 15A NCAC 2B.0500; 2)
NPDES Guidance, Monitoring Frequency for Toxic Substances (7/15/2010 Memo); 3) NPDES Guidance,
Reduced Monitoring Frequencies for Facilities with Superior Compliance (10/22/2012 Memo); 4) Best
Professional Judgement (BPJ). Per US EPA (Interim Guidance, 1996), monitoring requirements are not
considered effluent limitations under Section 402(o) of the Clean Water Act, and therefore anti -
backsliding prohibitions would not be triggered by reductions in monitoring frequencies.
For instream monitoring, refer to Section 4.
11. Electronic Reporting Requirements
The US EPA NPDES Electronic Reporting Rule was finalized on December 21, 2015. Effective
December 21, 2016, NPDES regulated facilities are required to submit Discharge Monitoring Reports
(DMRs) electronically. Effective December 21, 2020, NPDES regulated facilities will be required to
submit additional NPDES reports electronically. This permit contains the requirements for electronic
reporting, consistent with Federal requirements.
12.Summary of Proposed Permitting Actions:
A. Table. Current Permit Conditions and Proposed Changes NA
Parameter
Current Permit
Proposed Change
Basis for Condition/Change
NA
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MGD — Million gallons per day, MA - Monthly Average, WA — Weekly Average, DM — Daily Max
13. Public Notice Schedule:
Permit to Public Notice: 05/11/2021
Per 15A NCAC 2H .0109 & .0111, The Division will receive comments for a period of 30 days following
the publication date of the public notice. Any request for a public hearing shall be submitted to the
Director within the 30 days comment period indicating the interest of the party filing such request and the
reasons why a hearing is warranted.
14. Fact Sheet Addendum (if applicable):
Were there any changes made since the Draft Permit was public noticed (Yes/No): NO
If Yes, list changes and their basis below: NA
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LOCALiQ
StarNews I The Dispatch f Times -News
Sun Journal I The Daily News I The Star
The Free Press 1 Gaston Gazette
PROOF OF PUBLICATION
Ncdenr-Div. Of Water Resources
1617 MAIL SERVICE CENTER
RALEIGH NC 27699
STATE OF NORTH CAROLINA, COUNTY OF GASTON
The Gaston Gazette, a newspaper printed and published in the city
of Gastonia, and of general circulation in the County of Gaston,
State of North Carolina, and personal knowledge of the facts
herein state and that the notice hereto annexed was Published in
said newspapers in the issue:
05/14/2021
and that the fees charged are legal.
Sworn to and subscribed before on 05/14/2021
Legal Clerk
Notary, State of Wf, County of BroX9
My commision expires
Publication Cost: $151.80
Order No: 5857872
Customer No: 489035
PO #:
TFf[S IS NOT AN INVOICE!
Please do not use this form for payment r'enuUance.
# of Copies:
-1
VICKY FELTY
Notary Public
State of Wisconsin
PO Box 631245 Cincinnati, OH 45263-1245
Public Notice
North Carolina
Environmental
Management
Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a
NPDES Wastewater Permit
NC0074268 Crowders Creek
WWTP The North Carolina
Environmental Management
Commission proposes 1a
issue a NPDES wastewater
discharge permit to the
person(s) listed below. Writ-
ten comments regarding the
Proposed permit will be
accepted until 30 days after
the publish date of this
notice. The Director of the
NC Division of Water
Resources (DWR) may hold
a public hearing should there
be a significant degree of
public interest. Please mail
comments and/or informa-
tion requests to DWR at the
above address. interested
persons may visit the DWR
at 512 N. Salisbury Street,
Raleigh, NC 27604 to review
information on file. Addi-
tional information on NPDES
permits and this notice may
be found on our website:
hltp:/ldeq.nc.govlabout/d ivisi
ons/water- resources/water-
resources-per m its/wa ste-
water-bran c h/n Ades-wa ste-
water/public-notices,or by
calling [phone], The
City of Gastonia 15642 South
York Highway, Gastonia, NC
28052] has requested renewal
of NPDES permit NC0074268
for its Crowders Creek
Wastewater Treatment
Plant, located in Gaston
County. This permitted facil-
ity discharges treated munic-
ipal and industrial waste-
water to Crowders Creek, a
class C water in the Catawba
River Basin. Currently,
BOD, ammonia, fecal
coliform, dissolved oxygen,
pH, total residual chlorine,
total cyanide, total phospho-
rous loading, and total nitro-
gen loading are water qual-
ity limited. This discharge
may affect future allocutions
in this segment of the Crow-
ders Creek.
May 14, 2021 #5857872
Page 1 of 1

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
September 23, 2020
Brookdale Senior Living DBA Brookdale Hendersonville East
Attn: Andria Dale, Executive Director
2601 Chimney Rock Rd
Hendersonvlle, NC 28792
Subject: Permit Renewal
Application No. NC0069370
Brookdale Hendersonville East
Henderson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the September 16, 2020 receipt of your permit renewal application
and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq. nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
cc: Central Files w/application
ec: WQPS Laserfiche File w/application
Sincerely,
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
North ,:.a ro ra Department of Envrronmentai Quality I Division of Water ResaL roes
Ashev e Regara Of oe 12090 U.S. 70 Highway I Swannanoa, North C4 ro ra 28776
828 33E-45DO

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit NCOO `f 3 7
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
Facility Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
?ro o f le_ SP,rti v is k i V i,- v\ •
l3roo kola.le- Re. d EA-V--
2601 Chi nane� '.oc r ?w
I-ki ilt.-- s vn ✓. Ile_. 1U C� '374 7.
92.i) 6 R 2- iq II
( ) 616- 31J3
2. Location of facility producing discharge:
Check here if same address as above
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.
to the Operator in Responsible Charge or ORC)
Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
1 of 3
Lt
A 12 e S
sc.nF Ci-
(Note that this is not referring
ic-F "12
( ) 'z 7 '> - L 7 ( C
( )
#11 t 4 L., p) c, c-� C) rr'C'-* \ 4 e. ()iV%
Form-D 11/12

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
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 3 3
Residential ❑ Number of Homes
School 0 Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served: 1 02_
5. Type of collection system
Ej Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) L;l:. 1-
Is the outfall equipped with a diffuser? ❑ Yes p No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
6,1 eck'
8. Frequency of Discharge: 1!� Continuous ❑ Intermittent
If intermittent: 1
Days per week discharge occurs: 7 Duration: 7 `1 /-7 • i> • l�
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.
r
iT r Sc- ry
Aa(C•l %G�i
hcLS� h.
COI t , r, k u
h lL tve,
2oi3
I LA e_
c,:.A, tC.�t (1,1A.C.Nw‘h ir-
cii5e:"
i r‘ k
4 % v' a.1 d 511,.E 1, ,1 A 1 ,5 bc•:
Form-D 11/12

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
NPDES APPLICATION — FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow : < - MGD
Annual Average daily flow i v C ( MGD (for the previous 3 years)
Maximum daily flow C . 'L 3 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes 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 morimum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average
over the past 36 months for parameters currently in our permit. Mark other parameters "N/A".
Parameter
Daily
Maxunum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
S C.' 7
7, Z `I S 15
M j l
Fecal Coliform
, j
i • 5 z 3
# / , vc % s +, l
Total Suspended Solids
t 5.
. 31 t
►vt j t
Temperature (Summer)
21 , 3
15,L
C.
Temperature (Winter)
) -i
t 5—. c
C.
pH
S'`+
7. 3c''
5�..
13. List all permits, construction approvals and/or applications:
Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
Permit Number
14. APPLICANT CERTIFICATION
Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
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.
Printed name of Person Signing Title
cuk e Oirrc,7Jr-
frlot u a 5/ )E i)c
Signature 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 11/12

DocuSign Envelope ID: DBB2E3F5-597D-411D-9C78-17377D024808
Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow : < 2 3 MGD
Annual Average daily flow r O 4> MGD (for the previous 3 years)
Maximum daily flow C . 'i- 3 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® 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
over the past 36 months for parameters currentlu in our permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
5 C, • r7
7, Z'1
ri
in J '1
Fecal Coliform
5-
i • S z 3
- ii t ,..'t,
0., (
Total Suspended Solids
15.3
,� ; 3 I 1
rvt7 I
Temperature (Summer)
21 ..3
I S , c
C
Temperature (Winter)
) -j
(5. c: `1
C,
pH
S,`I
7. 3cf
51-
13. List all permits, construction approvals and/or applications:
Permit Number Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
14. APPLICANT CERTIFICATION
Permit Number
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 ac urate.
AVLA 1r CL OCk C-LA e
Printed name of Person Signing Title
•
5 / 3? Ei;/)c,
Signature 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 11/12