NCG560034_COC_20120411

Beverly Eaves Perdue
Governor
Mr. Jell\Treusdenhil
City of Clinton
P.O. Box 199
Clinton, NC 28329
Dear Permittee:
TPFA
NCENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P.E. Dee Freeman
Director Secretary
April 11, 2012
RECEIVED
APR 1 7 2012
DENR-FAYETTEVILLE REGIONAL OFFICE
Subject: Issuance of Certificate of Coverage NCG560034
Clinton Mosquito Control
Sampson County
The Division has received and approved your for coverage under General Permit
NCG560000. The Division hereby issues Certificate of Coverage (CoC) NCG560034 pursuant to the
requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between North Carolina and the US Environmental Protection agency dated October 15, 2007 [or
as subsequently amended].
If any parts, measurement frequencies or sampling requirements contained in this General
Permit are unacceptable to you, you have the right to request an individual permit by submitting
an individual permit application. Unless such demand is made, the CoC shall be final and
binding.
If you have any questions concerning the requirements of the General Permit, please
contact Jeff Poupart [919 807-6309 or [e-mail]].
ely,
Charles Wakild, P.E.
cc: fFayetteville_R-egional Office e�
NPDES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604
An Equal Opportunity/Affirmative Action Employer
Internet: http://www.ncwaterquality,org
Phone: [phone] / FAX [phone]
[e-mail]
50% Recycled/10% Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NCG560000
CERTIFICATE OF COVERAGE NCG560034
TO DISCHARGE PESTICIDE PRODUCTS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision 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
City of Clinton
Clinton Mosquito Control
is hereby authorized to discharge pesticides related to
Mosquito and flying insect pest control
to waters of the State in accordance with the effluent limitations, monitoring requirements, and
other conditions set forth in Parts I, II, III and IV hereof.
This Certificate of Coverage covers all pesticide discharge events after April 12, 2012.
This Certificate of Coverage shall expire October 31, 2016.
Signed this day April 11, 2012
'or Ckiles Wakild, P.E., Director
ivision of Water Quality
By Authority of the Environmental Management Commission

5-6 00 3 t-7
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
NOTICE OF INTENT
Application for coverage under General Permit NCG560000
(Please print or type)
1) Mailing address* of applicant':
Company Name �. � o'c 0.-V%r\ �u n
Owner Name
Street Address 1� 0 74 1 cka1
City i1-t-0 - State NC_ ZIP Code -IN 3a 9
Telephone Number 1 O — 59 a i'kLo Fax: °11 D-- Scl O — 3t a?
Email address SCt�flfvzJe e�1 L,�►f11v11 f\C_ . Ll
' Address to iNhich 3l1 permit correspondence should to mailed
'Applicants gereraiii include totfl (1) the ent'!y',b:dEi control aver the financing for, or the decision to perform pesticide applications, including the
_;Li: r to modify those deCis';ns, t'at results in a discharge 'oiators of the State and (2) the entity with day-to-day operational controlof
or who performs
(e t!'o art: ccit... . of pe .'odes) that are Pc': ..•'si3r'J _ :n'iure cor, pliarr_e ,' ih the permit (e g they are authorized to direct workers to carry Cut
..... i'..Cs r _gt,iren! t tno - .}r perform such, soli il. a:i ti _, :el i a:;)
2) Description of Discharge:
a) For what type[s] of pesticide -related discharge are you requesting coverage?
, Mosquito / flying insect pest control Acres: R.S o 0 c0
(adulticide applications only)
❑ Aquatic Weed / Algae -control Acres 'N` (� ti j��'Hjj� a��/p
� � b��iJ12
❑ Aquatic Weed / Algae control Linear miles: N4fl
❑ Aquatic Nuisance Animal Control Acres: C�`fl 1 APR 4 2012
�c�fPK=Vb'/� EI R
1
0 Aquatic Nuisance Animal Control Linear miles:RANCH
pnINT SOURCE g�ALliY
❑ Forest Canopy Pest Control Acres: f\1 {�
0 Intrusive Vegetation Control Linear miles: 'n,
3) Have you prepared a Pesticide Discharge Management Plan? o No
(The plan must be prepared no later than April 1. 2012.)
[certification and signature shall be completed on the following page]
Page 1 or 2

NCG560000 application„
Certification
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing:
Title:
v.. c. _ o t
qc,ti.$301-#24\
3oI
(Sign • / 'Applic. t) (Date Signed)
North Carol' • a General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan or other document
filed 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.)
Mail this original and one copy, along with a check payable to NC DENR for
$100.00, to:
Mr. Charles H. Weaver
NC DENR / DWQ / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
ELECTRONIC SUBMISSIONS:
If you wish to complete and submit this application electronically, submit it to:
i' .gar [ _(0,,J._ ti_._.a_;:..
Your application can be received and reviewed electronically. However, the Certificate of
Coverage (CoC) cannot be issued until the application fee is received.
ELECTRONIC RECEIPT OF COC
Do you wish to receive your CoC electronically? o Yes
If Yes, your CoC will be sent to the e-mail address your provide.
If No, the CoC and a copy of permit NCG560000 will be sent to you via U.S. Mail.
Page 2 of 2

North Carolina Department of Health and Human Services
Division of Public Health
Request for Application-261
(July 1, 2012 through April 30, 2013)
State Aid for Mosquito Control
Date issued: March 15, 2012
Deadline for Returning Original Completed Application, and Signature Pages Close of business:
April 6, 2012
State Aid for Mosquito Control
NCDHHS-Division of Public Health
Environmental Health Section
Environmental Health Services Branch
1632 Mail Service Center
Raleigh, North Carolina 27699-1632
Telephone: [phone]

CONTENTS
Page
Contents 2
Application for State Aid for Mosquito Control 3
Mosquito Control Needs Statement 4
Nation Pollution Discharge Elimination Requirements 5
Mosquito Control Local Operating Budget 6
Mosquito Application -Salary Information 7
Requesting Authority from County/Municipal Board 8
Additional Information 9

NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
APPLICATION FOR STATE AID FOR MOSQUITO CONTOL
FISCAL YEAR 2012-13
Name of Organization: (Applicant)
Street Address:
City:
C\: (1-\-0
State:
NC
County:
Se. rloin
Nine -digit Zip Code:
2 1?3Ace.
Federal I.D. Number:
54, ^ u, o01204
Phone Number:
011 O -- S 9'a -- 1 °1 lv l
Fax Number:
Contact Person:
S •e --' vCe.v. ate\,\
Alternate Contact:
:��n C e t4
E--Mail Address:
VC-e-v.t\A.e..1%`@ C..‘yo.c.Cxa1}'of1 NL. LA
Alternate's E-mail Address:
-abr r .-k- an Cl i,c Cl;n-k Ac.LA. (
Please supply ALL information requested
Unless otherwise requested, the following specifications shall become part of any agreement between the applicant and its
Local Health Department/District.
The applicant agrees to the following:
1. To conduct mosquito control activities as specified in the attached work plan. Any addendum to the work plan
shall have prior written approval of the local health director before becoming a part of this agreement.
2. To assume such responsibility for claims for damage resulting from the operation of the program as is necessary
to absolve the state of any of its departments, agencies or employees from any liability whatsoever from such
claims.
3. To use funds exclusively for mosquito control in accordance with the American Mosquito Control Association
Best Management Practices for Integrated Mosquito Management.
4. To perform all mosquito control activities under the direction of a competent supervisor, and to apply pesticides
under the supervision of a licensed applicator.
5. To submit reports in the format specified by its Local Health Department/District as directed by each Local
health Department documenting expenditures and work performed.
a. Applicant must maintain necessary program and fmancial records to facilitate:
1. The verification of net expenditures by fiscal audits.
2. The conduct of program review.
3. The submission of required reports.
b. Expenditure reports will be submitted through an invoice with a spreadsheet detailing expenses. All
invoices will be submitted for payment to the Local Health Department. The certification statement must
be on the spreadsheet, signed by the person in authority.
6. To request and obtain any permits required by local, state, or federal governments.

MOSQUITO CONTROL NEEDS STATEMENT
e,7- �� �,, 31301 1a )
Name o Program Date
1. How many permanent residents does your mosquito control program serve?
10 0 People (This is usually the number of residents of your area.)
2. How many temporary residents (tourist, etc.) does your mosquito control program serve?
,Qt., o People
3. How many square miles does your mosquito control program serve?
3 Co Square miles (Total square miles in your program's area.)
4. How many requests for mosquito control assistance (complaints) did you receive last year?
& Citizen Requests
5. How many staff are licensed category B pesticide applicators?
6 How many ULV sprayers are owned and calibrated annually by the program?
7. Estimate the percentage of your total budget that goes toward controlling each of the following
Integrated Mosquito Management (IMM) strategies. Refer to the AMCA's BMP's for definitions of
each Category
1. Surveillance
2. Public Education Community Outreach.
3. Biological Control Measures.
4. Physical Control or Source Reduction
5. Chemical Control Measures
a. Larvicides
b. Adulticides
5 Rio
IC
3( %
50 %
I0
TOTAL (100%) %

National Pollution Discharge Elimination Requirements
Effective October 31, 2011 the United States Environmental Protection Agency implemented the National
Pollution Discharge Elimination System (NPDES) legislation regulating mosquito control activities in the
United States. The North Carolina Division of Water Quality (NCDWQ) Point Source Branch is charged with
administering this program.
The annual treatment threshold for adult mosquito control established under this permit is 15,000 acres of
treatment area cumulatively in one calendar year. For more information about the North Carolina Pesticide
General Permit NCGP560000, access the N.C. Division of Water Quality website link below:
http://ports.l.ncdenr.org/web/wq/swp/ps/npdes
Please enter the answers to the information below as they apply to your Mosquito Control
Program.
Total adulticide acres applied by your program last year Ct5000 acres
My mosquito program is required to submit a Notice of intent to NCDWQ (Yes or No) �2 S
My mosquito program does not meet the annual 15,000 acre treatment threshold and is not required to submit a
Notice of Intent (Yes or No) 3Q.S .
Please record the Certificate of Coverage (CoC) if issued to your program by NCDWQ

a /7 0-1
MOSQUITO CONTROL LOCAL OPERATING BUDGET
FISCAL YEAR (July 1, 2012 through June 30, 2013)
(Applicant)
01 ArC,- 30, 'ZO J ?i
(Date)
In the budget columns below, provide individual amounts for applicable line items and a total for the budget columns. This
information is required for eligibility certificate and allocation computations. Include only LOCAL budgeted amounts.
*Do not included expenses that are being reimbursed by other sources.
ITEM DESCRIPTION
CLASSIFICATION
ITEM
NUMBER
$ Total
wa.c._, A
5..lec; .Q.S
CHEMICAL
1 o0 o
f i '5
Fj 041.
0 d
0 0
LARVICIDES
CHEMICAL
%So bo
OFFICE SUPPLIES
OFC SUPL
aoo c,
EMPLOYEE TRAVEL
EMP TRAVEL
a,o -o
an ' 00
TELEPHONE
TEL SVC
Q00 O
POSTAGE
POSTAGE
q`3o0
7 ; 0 0
EQUIPMENT REPAIRS
EQPT REP
- `a 00 0
a.4. n o
MOTOR VEHICLE SUPPLIES
AUTO SUPL
q�Voo
►'SDO i00
MOTOR FUEL AND FUEL
LUBRICANT
TOTALS $ 9)i31} . 00
s

REQUESTING AUTHORITY FROM COUNTY/MUNICIPAL BOARD
By:
e,11ld Vj h%---
Name of Coun or Municipal Boa
ignature of t orized Official
Typed or Printed Name ofAJuthorized Official
Pg-Pc51 c- Wot% 5 D,:--r.ch
Typed or Printed Official Title of Above
Date:
3 3o-/Z
If your proposed mosquito control work plan involves the use of chemicals, you must list the name and license
number of your public health pesticide applicator below. If your proposed work does not include the use of any
chemicals, then you do not need to list the applicator.
PI WV"' 0 A SVe---r
Name of Licensed Applic for (Please Print)
o3a-Li9o4
North Carolina License Number

•
Mosquito Application — Salary Information
SALARIES of all employees who will work under this agreement:
List position title for each employee working in mosquito control, number of hours dedicated to mosquito
control activities, salary rate per hour and the total salary for mosquito control activities projected for the
position for the contract period in each row below:
POSITION TITLE
HOURS
SALARY RATE PER HOUR
TOTAL SALARY
NPDES Decision Maker
$
$
Vector Control Supervisor
$
$
Water Management
Supervisor
NO
$
$
Operator
$
$
Vector Control Operator
$
$
Seasonal Labor
N l A
$
$
Secretary
$
$
Biologist
N ift
$
$
TOTAL: l l 5 a• (.' kp
Retention Schedule:
Applicant — 2years
DHHS-10 years and follow Records Disposition
Schedule issued by Division of Archives & History