NC0022985_Renewal (Application)_20220216

Carolina Water Service
of North CarolinaTM
February 16, 2022
Mr. Wren Thedford
NC DENR
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh NC 27699-1617
Re: Sapphire Valley WWTP
NPDES NC0022985
Renewal Request
Dear Mr. Thedford
Please find enclosed Application and attachments and consider this letter as our official request to
renew the NPDES permit for the facility referenced above.
If you should have any questions or need any additional information, please do not hesitate to call me at
704-319-0523 or by email at Tony.Konsui(Carolinawaterservicenc.com
Thank you in advance for your attention.
Sincer ly,
r�-
1,
Tony Konsul
Director, State Operations
• 4944 Parkway Plaza Blvd. Ste 375
• Charlotte, North Carolina 28217 • 800-525-7990

Carolina Water Service
of North Carolina"
February 16, 2022
Mr. Wren Thedford
NC DENR
Division of Water Resources
NPDES Unit
1617 Mail Service Center
Raleigh NC 27699-1617
Re: Fairfield Sapphire Valley Subdivision WWTP
NPDES NC0022985
Sludge Management Plan
Dear Mr. Thedford,
As sludge and other solids are generated at this facility, they are periodically removed by the licensed
contractor below.
W&S Maintenance
455 Cane Creek Road
Fletcher, NC 28732-7406
Phone: [phone]
-OR-
Mikes Septic Tank Service
P.O. Box 968
Leicester, NC 28748
Phone; 828-785-4364
if you should have any questions or need any additional information, please do not hesitate to call me at
704-319-0523 or by email at [e-mail] .
• 4944 Parkway Plaza Blvd. Ste 375
• Charlotte, North Carolina 28217 • 800-525-7990

Thank you in advance for your attention.
Sincerely,
\-Tfxvy Konsul
Director, State Operations

North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
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 ma result in denial of the a s a lication.
SECTION 1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1
Facility name
Sapphire Valley Wastewater Treatment Plant
Mailing address (street or P.O. box)
P.O. Box 240908
City or town
Charlotte
State
NC
ZIP code
28224-0908
Contact name (first and last)
Tony Konsul
Title
Director, State Operations
Phone number
[phone]
Email address
tony.konsul@carolinawatersei
Location address (street, route number, or other specific identifier)
3500 US Highway 64 West
•
Same as mailing
address
City or town
Sapphire Valley
State
NC
ZIP code
28774
1.2
Is this
•
application for a facility that has yet to commence discharge?
Yes .4 See instructions on data submission
requirements for new dischargers.
✓
No
Appilant lnfarrnatlen
o, w
Is applicant
v
different from entity listed under Item 1.1 above?
Yes •
No 4 SKIP to Item 1.4.
Applicant
Carolina
name
Water Service of North Carolina
Applicant
P.O.
address (street or P.O. box)
Box 240908
City
Charlotte
or town
State
NC
ZIP code
28224-0908
Contact
Tony
name (first and last)
Konsul
Title
Director, State Operations
Phone number
[phone]
Email address
tony.konsul@carolinawatersei
Is the
■
applicant the facility's owner, operator,
Owner
■
or both? (Check only one response.)
Operator 0
Both
To
❑
which entity should the NPDES permitting
Facility
authority send correspondence? (Check
Applicant ❑
only one response.)
Facility and applicant
(they are one and the same)
Existing Environmental Permlts
c)
Indicate
number
below any existing environmental
for each.)
permits.
(Check all that apply and print or type
the corresponding permit
�n9 ',r :� �. p
•
NPDES (discharges to surface
water)
NC0022985
•
RCRA (hazardous waste)
•
UIC (underground injection
control)
•
PSD (air emissions)
•
Nonattainment program (CM)
•
NESHAPs (CAA)
•
Ocean dumping (MPRSA)
•
Dredge or fill (CWA Section
404)
in
Other (specify)
WQCS00227
Page 1

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
Collection System and Population Served
Provide the collection system information requested below for the treatment works.
M lr lclpa lty
Served '
Populat ll
Served
Coln yt Type
l ' e) .
.
100 % separate sanitary sewer
0 Own 0 Maintain
792.2.5=1980
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own ❑ 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
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
Total
P-on
Seared
1980
❑ Unknown
Sanitarrr Sewer Syst+
0 Own 0 Maintain
Cnd
$ar1�'ar�r Sewer
Total percentage of each type of
sewer line (in miles)
100 0/a
0
�0
1.8
Is the
■
treatment works located in Indian
Yes
Country?
0
No
1.9
Does
■
the facility discharge to a receiving
Yes
water that flows through
•
Indian Country?
No
Design and Actual
Flow Rates
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
0.30 mgd
AnnAverage Flow Rates A Iral}
Two "wars Ago
LastYear
This Year
0.124 mgd
0.124 mgd
.085 mgd
Maxinl>lcam %i r Flow hates t��i
Two Years Ago
Last Year
This Year
0.342 mgd
0.548 mgd
0.147 mgd
Discharge Points
by
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
T der of arge Pops by Type
Tra ced EffluentUntreated
Iwf ent
� owsWBr
Bypasses
e y
1
Page 2

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
dutfsils and Other Discharge or Disposai Methods
{ le is haler Than to Wafers of the Slateof �i arr Pna
1.12
Does the POTW discharge wastewater to basins, ponds,
for discharge to waters of the State of North Carolina?
❑ Yes
or other
surface impoundments that do not have outlets
SKIP to Item 1.14.
0 No .4
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
urfa
pound er Locatl am Dls
rge Dab .
t.anarg+d
A rage Cfa� V tume
to Sua
innpoundment
orn nuous or ermltt+an#
gPd
0 Continuous
0 Intermittent
9Pd
0 Continuous
0 Intermittent
gpd
0 Continuous
❑ Intermittent
1.14
Is wastewater
applied to land?
4 SKIP to Item 1.16.
■ Yes
13 No
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
won
S
Average Da rVolume
APPnedterrn�t
t'onSnuous or
aeone
acres
gp
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gp d
❑ Continuous
❑ Intermittent
1.16
Is effluent transported
to another facility for treatment
prior to discharge?
4 SKIP to Item 1.21.
• Yes
'5 No
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?
4 SKIP to Item 1.20.
• Yes
■ No
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
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
Outfallsand Other Discharge or Disposal Methods Continued
N N O
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Recehring Fatfilty 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
Is the
not
■
wastewater disposed of in a manner other than
have outlets to waters of the State of North Carolina
Yes 0
those already mentioned in Items 1.14 through 1.21 that do
(e.g., underground percolation, underground injection)?
No 4 SKIP to Item 1.23.
Provide
information in the table below on these other disposal methods.
information on Other Disposal Methods
Demotion
'spout.Lo+catlo
of
Ilis posal She
Size of
Disposal asail Site
Amnial Average
Daily Disch
Volume
Continuous or intermittent
(clledc °
acres
g"
El Continuous
❑ Intermittent
acres
g"
❑ Continuous
❑ Intermittent
acres
g"
❑ Continuous
❑ Intermittent
1.23
Do
Consult
•
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))
1.24
Are
the
■
any operational or maintenance aspects (related
responsibility of a contractor?
Yes
to
0
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 S
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

SECTION
2. ADDITIONAL INFORMATION
NPDES Permit Number
NC0022985
(40 CFR 122.21(j)(1) and
Facility Name
Sapphire Valley
(2))
Modified Application Form 2A
Modified March 2021
2.1
Does
IN
the treatment works have a design flow greater
Yes
•
than or equal to 0.1 mgd?
No 4 SKIP to Section 3.
2.2
Provide the treatment works' current average daily
volume of inflow
Average Laity Volume oft3owand Iron
and infiltration.
gpd
ro
Indicate the steps the facility is taking to minimize
Wastewater sewer main replacement, manhole
CCTV of sewer mains.
rehabilitation,
inflow and infiltration.
smoke testing of sewer mains, lift station rehabilitation,
Topographlc
Map
2.3
Have
specific
MI
you attached a topographic map to this application
requirements.)
Yes
■
that contains all the required information? (See instructions for
No
E
is
2.4
Have
(See
0
you attached a process flow diagram or schematic
instructions for specific requirements.)
Yes
■
to this application that contains all the required information?
No
Scheduled Improvements and Schedules of Impleme on
2.5
Are
improvements to the facility scheduled?
Yes
■ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1. Preliminary Engineering of complete plant replacement
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
orA+cti�al Dales of ompletion fo r lmprovetnents
cl�edl l%d
improve ent
from bt e)
Aff sled
�
fir)
Begln
Co rluefion
{ + f'f'fY
Construction
(MM/DDI
End
I YY
Begln
Discharge
(MWD1 /YriY)
Mahood of
. Operational
Level
1.
2.
3.
4.
2.7
Have
response.
•
appropriate permits/clearances
Yes
concerning other federal/state requirements
• No
been obtained? Briefly explain your
■ None required or applicable
Explanation:
Preliminary engineering only completed at this time for budgeting purposes.
Page 5

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
SECTION 3. INFORMATION ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3)
to (5))
Descritniott of ° alls
w
Provide the following information for each outfall. (Attach additional
sheets if you have more than three outfalls.)
Ouffalt Number teal
Outfa
Outfall Number
State
North Carolina
County
Jackson
City or town
Sapphire Valley
Distance from shore
o ft.
ft.
ft.
Depth below surface
2 ft.
ft.
ft.
Average daily flow rate
0.127 mgd
mgd
mgd
Latitude
35° 07' 10" N
Longitude
83° 02' 16" W
"
Seasonal or Periodic Discharge Data
w w
Ca N
Do
■
any of the outfalls described under Item 3.1 have seasonal or
Yes
periodic
0
discharges?
No + SKIP to Item 3.4.
If so,
provide the following information for each applicable outfall.
Outfali Number
Outfall Number
Outfall Number
Number
discharge
of times per year
occurs
Average
discharge
duration of each
(specify units)
Average
discharge
flow of each
mgd
mgd
mgd
Months
occurs
in which discharge
Diffuser Type
W W
CT
Are
•
any of the outfalls listed under Item 3.1 equipped with a diffuser?
Yes
0
No + SKIP to Item 3.6.
Briefly describe the diffuser type at each applicable outfall.
Oulfall Number
Outfall Number
Outfalt Number
3.6
Does
one
19
the treatment works discharge or plan to discharge wastewater
or more discharge points?
Yes
•
to waters of the State of North Carolina from
No +SKIP to Section 6.
Page 6

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
Receiving Water Descriptlon
3.7
Provide the receiving water and related information (if known) for each outfall.
f Number t1p 1
a N
Outfaff Number
Receiving water name
Trays Island Creek
Name of watershed, river,
or stream system
Savannah
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.
uttaq Number `
Ou afl Number
© l Number
Highest Level of
Treatment (check all that
apply per outfall)
0 Primary
0 Equivalent to
secondary
❑ 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
NR
BOD5 or CBOD5
%
%
TSS
%
%
Phosphorus
❑ Not applicable
0 Not applicable
0 Not applicable
Nitrogen
❑ Not applicable
%
0 Not applicable
%
0 Not applicable
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
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.
Liquid sodium hypo -chlorite (12.5%) is used for disinfection and Sodium bi-sulfite tablets for de -chlorination.
Number
Cattail Num
0 l'Number
Disinfection type
(Liquid) Sodium Hypochlorite
Seasons used
all
Dechlorination used?
❑ Not applicable
0 Yes
IN No
•
•
■
Not applicable
Yes
No
•
•
•
Not applicable
Yes
No
Effluent Testing Data
3.10
Have
19
you completed monitoring for all Table A parameters and attached
Yes
•
the results to the app
No
ication package?
3.11
Have
discharges
■
you conducted any WET tests during the 4.5 years prior to
or on any receiving water near the discharge points?
Yes
the
19
date of the application on any of the facility's
No 4 SKIP to Item 3.13.
3.12
Indicate
discharges
the number of acute and chronic WET tests conducted since
by outfall number or of the receiving water near the discharge
the last permit reissuance of the facility's
points.
0 Number
{Number
Gotta Number
A
Chronic
Acute
Chranlc
Acute
Chronic
Number
water
of tests of discharge
Number
water
of tests of receiving
3.14
Does
reasonable
•
the POTW use chlorine for disinfection, use chlorine elsewhere
potential to discharge chlorine in its effluent?
Yes 4 Complete Table B, including chlorine.
19
in the treatment process, or otherwise have
No 4 Complete Table B, omitting chlorine.
3.15
Have
package?
151
you completed monitoring for all applicable Table B pollutants
Yes
•
and attached the results to this application
No
3.18
Have you completed monitoring for all applicable Table D pollutants
attached the results to this application package?
❑ Yes
0
required by your NPDES permitting authority and
No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number
NC0022985
Fadlity Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
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
tests to your NPDES permitting
No 4 Provide
authority?
results in Table E and SKIP to
• Yes
•
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Summary o il2esufts
3.22
Regardless of how you provided your WET testing
toxicity?
❑ Yes
data to the NPDES permitting authority,
did any of the tests result in
Item 3.26.
• No 4 SKIP to
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 4 SKIP to
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed
Table E for all applicable outfalls
and attached the results to the
Not
application package?
because previously submitted
the NPDES ermittin authori .
• Yes
• applicable
information to
Page 9

NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Modified Application Form 2A
Modified March 2021
Checklist and Ce cation Statement
N
1a $ 1 (,t
. a an.
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Cattuunn 3
Column 2
Section
1: Basic Application
for All Applicants
request(s)
additional attachments
0
MI w/ variance
• w/
Information
Section
2: Additional
• w/ topographic
map
attachments
MIw/
process flow diagram
0
Information
■ w/ additional
• w/ Table A • w/ Table D
3: Information on
Discharges
■ w/ Table
B ❑ w/ additional attachments
0 Section
Effluent
• w/ Table C
Section 4: Not Applicable
Section 5: Not Applicable
Section
6: Checklist and
Statement
wl attachments
Certification
Certification Statement
1 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.l 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)
Official title
Tony Konsul
Director, State Operations
Signat e )
„......„1\-1/
Date signed
Page 10

ai
NPDES Permit Number
NC0022985
O
0
N
(156) 2019-2021
N
ti
u
O
N
Temperature (summer)
156) 2019-2021
E
n�o
E
rn
Total suspended solids

Noumea Mppin auon roan a+
Modified March 2021
ML or MDI.
(include units)
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
J
J 0
a
Anafycai
Mettoti1
EPA Identification Number NPDES Permit Number Facility Name Outtall Number
NC0022985 Sapphire Valley 001
ferage Daffy DISCharge
Units Number of
Samples;
(156) 2019-2021
(312) 2019-2021
Z
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IChlorine
(total residual, TRC)2
Dissolved oxygen
Nitrate/nitrite
Kjeldahl nitrogen
Oil and grease
Phosphorus
Total dissolved solids
O
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EPA Form 3510-2A (Revised 3-19)

Modmed AppliCallon Fomt "LA
Modified March 2021
A alygcal ML or MU.Method+ (include units)
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
O ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
0 ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ML I0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
0 ML
0 MDL
Maximum Daily discharge
Pollutant
Value Units
ems, Cyanide, and Total Phenols Not A ppirab e
Hardness (as CaCO3)
Volatile Organic Compounds
▪ Antimony, total recoverable
▪ Arsenic, total recoverable
▪ Beryllium, total recoverable
ICadmium, total recoverable
Chromium, total recoverable
▪ Copper, total recoverable
▪ Lead, total recoverable
IMercury, total recoverable
Nickel, total recoverable
▪ Selenium, total recoverable
▪ Silver, total recoverable
▪ Thallium, total recoverable
▪ Zinc, total recoverable
▪ Cyanide
▪ Total phenolic compounds
iu
O
Acrylonitrile
▪ Benzene
Bromoform
a
EPA Form 3510-2A (Revised 3-19)

Modified Application Form 2A
Modified March 2021
An eat ML oriDL
Methods indutfe uni#s
❑ ML
❑ MDL
❑ ML I
0 MDL
❑ ML
O MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
0 ML
0 MDL
Sy Dischae Ave Daily Discharge
UniteValue Una Samples
Number of
▪ Chlorobenzene I 1
IChlorodibromomethane
Chloroethane
2-chloroethylvinyl ether
IChloroform
Dichlorobromomethane
▪ 1,1-dichloroethane
▪ 1,2-dichloroethane
trans-1,2-dichloroethylene
▪ 1,1-dichloroethylene
▪ 1,2-dichloropropane
▪ 1,3-dichloropropylene
▪ Ethylbenzene
▪ Methyl bromide
▪ Methyl chloride
▪ Methylene chloride
▪ 1,1,2,2-tetrachloroethane
Tetrachloroethylene
1,1,1-tnchloroethane
1,1,2-trichloroethane
N
c
o
i
a
CO
CO
EPA Form 3510-2A (Revised 3-19)

Modified Application Form 2A
Modified March 2021
Analytical SAL or 'VIOL
Method' (include units)
❑ML
❑ MDL
❑ ML I
❑ MDL
Acid -actable Compounds
p chloro m cresol I ❑ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
0 ML
0 MDL
0 ML
❑ MDL
e-Neutral Compounds
Acenaphthene ❑ ML 0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
0 ML
0 MDL
❑ ML
❑ MDL
0 ML
0 MDL
❑ ML
❑ MDL
oily Discharge Average Daily Discharge
Units Value Units Number of
Samples
▪ 2-chlorophenol
▪ 2,4-dichlorophenol
▪ 2,4-dimethylphenol
▪ 4,6-dinitro-o-cresol
0
c
a>
s
O.
0
a
v
N
■
▪ 2-nitrophenol
▪ 4-nitrophenol
IPentachlorophenol
Phenol
2,4,6-trichlorophenol
▪ Acenaphthylene
▪ Anthracene
▪ Benzidine
▪ Benzo(a)anthracene
IBenzo(a)pyrene
3,4-benzofluoranthene
EPA Fomi 3510-2A (Revised 3-19)

Modified Application Form 2A
Modified March 2021
Anatyttcal ML or MDL
Met�t� od{ (lndude units)
❑ML
❑ MDL
❑ ML I
0 MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
Maximum Daily Discharge
Pollutant
Value Drifts
Benzo(ghi)perylene
a>
c
a>
c
m
o
_
r ,
o
N
C
m
■
▪ Bis (2-chloroethoxy) methane
▪ Bis (2-chloroethyl) ether
▪ Bis (2-chloroisopropyl) ether
▪ Bis (2-ethylhexyl) phthalate
▪ 4-bromophenyl phenyl ether
▪ Butyl benzyl phthalate
▪ 2-chloronaphthalene
▪ 4-chlorophenyl phenyl ether
▪ Chrysene
▪ di-n-butyl phthalate
▪ di-n-octyl phthalate
▪ Dibenzo(a,h)anthracene
▪ 1,2-dichlorobenzene
▪ 1,3-dichlorobenzene
▪ 1,4-dichlorobenzene
a)
c
o
c
a)
-Q
2
o
o
'a
M
▪ Diethyl phthalate
▪ Dimethyl phthalate
▪ 2,4-dinitrotoluene
2,6-dinitrotoluene
CD
CO
CO
EPA Form 3510-2A (Revised 3-19)

Modified Application Form 2A
Modified March 2021
Artatow mt. or I DL
Method' lin tud(funits)
❑ ML
❑MDL
❑ ML I
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
0 MDL
❑ ML
0 MDL
0 ML
0 MDL
0 ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
❑ MDL
0 ML
0 MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
❑ MDL
EPA Identification Number NPDES Permit Number
NC0022985
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant'
Value Units
1,2-diphenylhydrazine
■ Fluoranthene
c
m
O
=
at
▪ Hexachlorobenzene
▪ Hexachlorobutadiene
▪ Hexachlorocyclo-pentadiene
▪ Hexachloroethane
▪ Indeno(1,2,3-cd)pyrene
IIsophorone
Naphthalene
▪ Nitrobenzene
m
c
E
as
n
2.
5
N
O`
"•
Z
■
N-nitrosodimethylamine
N-nitrosodiphenylamine
Phenanthrene
▪ Pyrene
1,2,4-trichlorobenzene
EPA Form 3510-2A (Revised 3-19)

United States
Environmental Protection Agency
Office of Water
Washington, D.C.
EPA Form 3510-1
Revised March 2019
Water Permits Division
&EPA Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to collect information
and complete Form 1 to be 2.9 hours for new applicants and 0.9 hours for applicants renewing
existing permits. This estimate includes time to review instructions, search existing data sources,
gather and maintain the needed data, and complete and review the collection of information.
New respondents must also prepare a topographic map. Send comments about the burden
estimate or any other aspect of this collection of information to the Chief, Information Policy
Branch (PM-223), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW,
Washington, DC 20460, and to the Office of Information and Regulatory Affairs, Office of
Management and Budget, 725 17th Street, NW, Washington, DC 20503, marked "Attention:
Desk Officer for EPA."

DESCRIPTION OF NPDES PERMIT APPLICATION FORMS
CONTENTS OF FORM 1 PACKAGE
The application forms for individual National Pollutant Discharge
Elimination System (NPDES) permits include the following:
Form 1—General Information (included in this package).
Form 2—Forms Based on Facility or Activity Type (not included
in this package):
2A. New and Existing Publicly Owned Treatment Works
2B. Concentrated Animal Feeding Operations and
Concentrated Aquatic Animal Production Facilities
2C. Existing Manufacturing, Commercial, Mining, and
Silvicultural Operations
2D. New Manufacturing, Commercial, Mining, and Silvicultural
Operations That Have Not Yet Commenced Discharge of
Process Wastewater
2E. Manufacturing, Commercial, Mining, and Silvicultural
Facilities Which Discharge Only Nonprocess Wastewater
2F. Stormwater Discharges Associated with Industrial Activity
2S. New and Existing Treatment Works Treating Domestic
Sewage
Form 1—General Instructions
Form 1—Line-by-Line Instructions
Form 1—Activities That Do Not Require Permits
Form 1—Glossary
Form 1—Application
FORM 1-GENERAL INSTRUCTIONS
Who Must Apply for an NPDES Permit?
With the exceptions described in "Form 1—Activities That Do Not
Require Permits," the federal Clean Water Act (33 U.S.C. 1251 et
seq.) prohibits any person from discharging pollutants into waters
of the United States without first having been issued a permit
under the NPDES program.
Who Must Complete Form 1?
All applicants, other than publicly owned treatment works
(POTWs) and treatment works treating domestic sewage
(TWTDS), must submit Form 1. If you operate one of the
following facilities, you must submit Form 1: concentrated animal
feeding operations and aquatic animal production facilities;
manufacturing, commercial, mining, and silvicultural operations;
or other industrial facilities.
At the state level, either the U.S. Environmental Protection
Agency (EPA) or an approved state agency administers the
NPDES permit program. If you are located in a jurisdiction in
which an EPA regional office administers the NPDES permit
program, you should use Form 1 and all other applicable forms
described in these instructions. If you are located in a jurisdiction
where a state administers the NPDES permit program, contact
the state to determine the forms you should complete. States
often develop their own application forms rather than use the
federal forms. See htto://www.eca.gov/npdes/npdes-state-
program-information for a list of states that have approved
NPDES permit programs and those that do not.
Exhibit 1-1 (see end of this section) provides contact information
for each of EPA's 10 regional offices. Since the exhibit's content is
subject to change, consult EPA's website for the latest information:
http://www.eca.gov/aboutepa#regional.
1-1
Upon your request, and based on information supplied by you,
EPA or the authorized NPDES state will determine whether you
are required to obtain a permit for a particular facility or activity.
Be sure to contact EPA or your state if you have a question.
Form 1 collects general information only. You must also complete
a more detailed application based on your proposed discharge
activity, as follows:
• If your facility is a concentrated animal feeding operation
or a concentrated aquatic animal production facility, you
must also complete Form 2B.
• If your facility is an existing manufacturing, commercial,
mining, or silvicultural facility that currently discharges
process wastewater, you must also complete Form 2C.
• If your facility is a new manufacturing, commercial, mining,
or silvicultural facility that has yet to commence discharge of
process wastewater, you must also complete Form 2D.
• If your facility is a new or existing facility (including
manufacturing, commercial, mining, and silvicultural
facilities) that discharges only nonprocess wastewater,
you must also complete Form 2E.
• If your facility is a new or existing facility whose discharge
is composed entirely of stormwater associated with industrial
activity —excluding discharges from construction activity
under 122.26(b)(14)(x) or (b)(15)—you must also complete
Form 2F. If the discharge is composed of stormwater and
non-stormwater, you must complete Form 2F and you must
also complete Forms 2C, 2D, and/or 2E, as appropriate. See
Form 2F's instructions for further details.

FORM1—GENERA
NSTRUCTIONS CONTINUED
Where to File Your Completed Form
° If you are inmjurisdiction withomoppmvodatateNPDES
permit program, file according bnthe instructions vnthe state
mnnu.
° Ifyou are inojurisdiction where EPA imthe NPDES
permitting authority (ie,the state ionot enNPDE8'
outhuhzadotate).moi|thocomp|ebsdopp|icaUon1hnnohothu
EPA regional office that covers the state inwhich your facility
iolocated (see Exhibit 1-1).
When twFile Your Completed Form
Because ofstatutory and regulatory requirements, the deadlines
for filing applications vary according toyour facility oractivity typo
and the type n[permit you need. The various permit application
deadlines are listed inExhibit 1-2etthe end of this section.
Fees
EPA does not require applicants to pay ofee for applying for
NPDESpermits. However, states that administer the NPDES
permit program may charge fees. Consult with state officials for
further information.
Public Availability wfSubmitted Information
EPA will make information from NPDESpermit application forms
available tothe public for inspection and copying upon request.
You may not claim any information onForm 1(or related
attachments) ooconfidential.
You may make oclaim ofconfidentiality for any information that
you submit huEPA that goes beyond the information required by
Form 1.|fyou donot assert oclaim ofconfidentiality et the time
you submit your information tothe NPDESpermitting authority,
EPA may make the information available to the public without
further notice toyou. EPA will handle claims ofconfidentiality in
accordance with the Agency's business confidentiality regulations
atPart 2nfTitle 4ofthe Code ofFederal Royulatiowx(CFR).
Completion ofForms
Print mtype inthe specified areas only. If you dnnot have enough
space onthe form toanswer oquestion, you may continue on
additional sheets, oonecessary, using oformat consistent with the
form.
The NPDESpermitting authority could consider your application
incomplete ifyou donot provide ananswer (or indicate ^NA^for
"not opp|ixah|e^)for all questions unForm 1and the applicable
Fnnn2.
Provide your EPA |danbfioudnnNumber from the Facility Registry
Service, NPDESpermit number, and facility name ot the top of
each page ofForm 1and any attachments. |fyour facility iunew
(io,not yet nonutructad).write nrtype "New Facility' inthe space
provided for the EPA Identification Number and NPDESnumber.
|fyou dunot know your EPA Identification Number, contact your
NPDESpermitting authority. See Exhibit 1-1for contact
information.
Donot leave any response areas blank unless the form directs
you hoskip them. |fthe form directs you bzrespond hoanitem that
does not apply tuyour facility oractivity, enter ^NA" for "not
applicable" toshow that you considered the item and determined
oresponse was not necessary for your facility.
The NPDEGpermitting authority will consider your application
complete when itand any supplementary material are received
and completed according to the authority's satisfaction. The
NPDESpermitting authority will judge the completeness m[any
application independently of the status ofany other permit
application or permit for the same facility or activity.
1'2

FORM 1—GENERAL INSTRUCTIONS CONTINUED
Exhibit 1-1. Addresses of EPA Regional Contacts and Covered States
REGION 1
U.S. Environmental Protection Agency, Region 1
5 Post Office Square, Suite 100, Boston, MA 02109-3912
Phone: [phone]; tot free: [phone]
Fax [phone]
Website: http://www.epa.gov/aboutepalepa-region-1-new-england
REGION 6
U.S. Environmental Protection Agency, Region 6
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733
Phone: [phone]; toll free: [phone]
Fax [phone]
Website: htlpJ/www.epa.00vlabouterra/epa-region-south-central
Covered states: Connecticut, Maine, Massachusetts, New Hampshire, Rhode
Island, and Vermont
Covered states: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
REGION 2
U.S. Environmental Protection Agency, Region 2
290 Broadway, New York, NY 10007-1866
Phone: [phone]; toll free: [phone]
Fax: [phone]
Website: httpJlwww.er a.ciov/abouteoa/eoa-region-2
REGION 7
U.S. Environmental Protection Agency, Region 7
11201 Renner Boulevard, Lenexa, KS 66219
Phone: [phone]; toll free: [phone]
Website: httpJ/www.eoa.gov/aboutepaleoa-region-7-midwest
Covered states: Iowa, Kansas, Missouri, and Nebraska
Covered states: New Jersey, New York, Virgin Islands, and Puerto Rico
REGION 3
U.S. Environmental Protection Agency, Regan 3
1650 Arch Street, Philadelphia, PA 19103-2029
Phone: [phone]; toll free: [phone]
Fax [phone]
Website: httpjlwww.epa.00vlaboutepa/epa-region-3-mid-atlantic
REGION 8
U.S. Environmental Protection Agency, Region 8
1595 Wynkoop Street, Denver, CO 80202-1129
Phone: [phone]; toll free: [phone]
Fax: [phone]
Website: http //www.epa.crovlabouteoalepa-region-8-mountains-and-plains
Covered states: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia,
and West Virginia
Covered states: Colorado, Montana, North Dakota, South Dakota, Utah, and
Wyoming
REGION 4
U.S. Environmental Protection Agency, Region 4
Sam Nunn Atlanta Federal Center
61 Forsyth Street, SW, Atlanta, GA 30303-8960
Phone: [phone]; toll free: [phone]
Fax: [phone]
Website: httpjlwww.epagov/aboutepalabout-epa-recton-4-southeast
REGION 9
U.S. Environmental Protection Agency, Region 9
75 Hawthorne Street, San Francisco, CA 94105
Phone: [phone]; toll free: (866) EPA -WEST
Fax: [phone]
Website: httrx/ www.eoa.gov/aboutepa/erra-region-9-pacific-southwest
Covered states: Arizona, California, Hawaii, Nevada, Guam, American Samoa,
and Trust Territories
Covered states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina,
South Carolina, and Tennessee
REGION 5
U.S. Environmental Protection Agency, Region 5
77 West Jackson Boulevard, Chicago, IL 60604-3507
Phone: [phone]; toll free: [phone]
Fax [phone]
Website: httpj/www.epa.gov/aboutepa/epa-region-5
REGION 10
U.S. Environmental Protection Agency, Region 10
1200 Sixth Avenue, Suite 900, Seattle, WA 98101
Phone: [phone]; toll free: (800) 4244372
Fax: [phone]
Website: httpJ/www.epa.qov/aboutepa/epa-region-10-pacific-northwest
Covered states: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin
Covered states: Alaska, Idaho, Oregon, and Washington
Exhibit 1-2.
Permit Application
Filing Dates for NPDES Permit Applications
When to File
180 days before your present NPDES permit expires or, if you are a
new discharger, 180 days before the date on which the discharge is
to commence unless the NPDES permitting authority has granted
permission for a later date.
2B
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.
2C
180 days before your present NPDES permit expires.
2D
180 days prior to startup.
2E
180 days before your present NPDES permit expires, or 180 days
prior to startup if you are a new facility.
2F
Construction: 90 days prior to date construction is to commence.
Nonconstruction:180 days before your present NPDES permit
expires or 180 days prior to startup if you are a new facility.
2S
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.
1-3

FORM 1—LINE-BY-LINE INSTRUCTIONS
Section 1. Activities Requiring an NPDES Permit
Item 1.1. Review the questions in Item 1.1 to determine if you are
required to submit Form 1. Be sure to check the Form 1—
Glossary for the legal definitions of any key terms.
If you answer "Yes" to a question in Item 1.1, then you do not
need to complete Form 1, but you must comply with the
application requirements specified.
Item 1.2. Respond to the questions in Items 1.2.1 to 1.2.5. If you
answer "Yes" to any question, you must complete Form 1 and the
Form 2 application specified. See Exhibit 1-2 for filing deadlines.
If you answer "No" to every question in Items 1.1 and 1.2, then
you do not need an NPDES permit, and you do not need to
complete and return any of the NPDES application forms.
Section 2. Name, Mailing Address, and Location
Item 2.1. Enter the facility's official or legal name. Do not use a
colloquial name.
Item 2.2. Provide your EPA Identification Number from the
Facility Registry Service if you have an existing facility. If you do
not know your EPA Identification Number, contact your NPDES
permitting authority. If your facility is new (i.e., not yet
constructed), write or type "New Facility."
Item 2.3. Give the name (first and last), title, work telephone
number, and email address of the person who is thoroughly
familiar with the operation of the facility and with the facts
reported in this application. The NPDES permitting authority will
contact the person listed if they have questions on the material
submitted.
Item 2.4. Give the complete mailing address of the office to which
the NPDES permitting authority should send correspondence.
This often is not the address used to designate the location of the
facility or activity.
Item 2.5. Give the address or location of the facility identified
under Item 2.1. If the facility lacks a street name or route number,
give the most accurate, alternative geographic information (e.g.,
section number or quarter section number from county records or
"at intersection of Routes 425 and 22"). Also provide the county
name, county code (if known), city or town, state, and zip code.
For concentrated aquatic animal production facilities, provide the
address or location of the production area (i.e., the location where
the animals are contained, grown, or held).
Section 3. SIC and NAICS Codes
Items 3.1 and 3.2. List, in descending order of significance, up to
four 4-digit standard industrial classification (SIC) codes and
North American Industrial Classification System (NAICS) codes
that best describe your facility in terms of the principal products or
services it produces or provides. If the SIC or NAICS codes do
not adequately describe your facility's products or services, you
have the option to provide additional descriptive information.
You can find SIC code numbers and descriptions in the
1987 Standard Industrial Classification Manual, prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the Government Printing
Office, Washington, D.C. An online version of the manual is also
available courtesy of the Occupational Safety and Health
Administration at htto://www.osha.gov/pls/imis/sic manual.html.
You can find NAICS code numbers and descriptions in the North
American Industrial Classification System Manual prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the National Technical
Information Service (NTIS) in Alexandria, Virginia. It is also
available online at http:llwww.census.gov/eos/www/naics/.
Use the latest edition of the manuals. If you have any questions
about the appropriate SIC or NAICS codes for your facility,
contact your NPDES permitting authority.
Section 4. Operator Information
Item 4.1. Give the legal name of the person, firm, public
organization, or other entity that operates the facility described in
this application. This may or may not be the same as the facility's
name. The operator of the facility is the legal entity that controls
the facility's operation rather than the plant or site manager. Do
not use a colloquial name.
Item 4.2. Indicate whether the entity listed in response to Item 4.1
also owns the facility by marking the appropriate box.
Item 4.3. Indicate the ownership status of the operator of the
facility by marking the appropriate box. If the facility is a federal
facility (i.e., owned by the U.S. government), check the box for
"Public —federal." If the facility is owned by a state government,
check the box for "Public —state." If the facility is owned by a
county government, municipal (e.g., city or town) government,
tribal government, school district, water district, or other local
govemment entity, check the box for "Other public" and specify
the type of government entity. If the facility is owned by a
corporation or other private entity, check the box for "Private." If
the facility has mixed ownership (e.g., public/private) or is not
owned by an entity of the types previously listed, check the box
for "Other" and specify the type of entity.
Items 4.4 to 4.6. Enter the telephone number, address, and email
address of the operator identified in Item 4.1.
Section 5. Indian Land
Item 5.1. Indicate whether the facility is located on Indian Land.
Section 6. Existing Environmental Permits
Item 6.1. Check the appropriate boxes and provide the permit
numbers for all relevant federal, state, and local environmental
permits or construction approvals received or applied for under
any of the programs listed below. If you have more than one
currently effective permit under a particular permit program for
your facility, list the additional permit numbers on the application
form or on a separate sheet of paper.
1-4

FORM 1—LINE-BYLINE INSTRUCTIONS CONTINUED
• Hazardous waste management program under the Resource
Conservation and Recovery Act (RCRA).
• Underground Injection Control (UIC) program under the Safe
Drinking Water Act (SDWA).
• NPDES program under the Clean Water Act (CWA).
• Prevention of Significant Deterioration (PSD) program under
the Clean Air Act (CAA).
• Nonattainment program under the CM.
• National Emission Standards for Hazardous Pollutants
(NESHAPs) preconstruction approval under the CM.
• Ocean dumping permits under the Marine Protection
Research and Sanctuaries Act (MPRSA).
• Dredge or fill permits under Section 404 of the CWA.
• Other federal, state, or local environmental permits.
Section 7. Map
Unless the facility is a concentrated animal feeding operation,
provide a topographic map(s) of the area extending at least one
mile beyond the property boundaries of the facility that clearly
shows the following:
• The legal boundaries of the facility.
• The location and serial number of each of your existing and
proposed intake and discharge structures.
• All hazardous waste management, storage, and disposal
facilities.
• Each well where you inject fluids underground.
• All wells, springs, surface water bodies, and drinking water
wells that are in the public record or otherwise known to you
and that are located in the map area.
If the facility has associated water intakes, discharge structures,
hazardous waste disposal sites, or injection wells and these items
are located more than one mile from the facility, include them on
the map if possible. If you cannot, attach additional sheets
describing the location of the structures, disposal site(s), or well(s)
and identify the U.S. Geological Survey (USGS) or other map
corresponding to the location(s).
On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude to the nearest second. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc. nasa.qov/latitudelonaitude-finderl),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., USGS).
On all maps of rivers, show the direction of the current. In tidal
waters, show the directions of ebb and flow tides.
You may develop your map by going to USGS's National Map
website at http://nationalmaD.govl. (For a map from this site, use
the traditional 7.5-minute quadrangle format. If none is available,
use a USGS 15-minute series map.) You may also use a plat or
other appropriate map. Briefly describe land uses in the map area
(e.g., residential, commercial). An example of an acceptable
location map is shown as Exhibit 1-3 at the end of these
instructions. Note: Exhibit 1-3 is provided for illustration only; it
does not show an actual facility.
If the facility is a concentrated animal feeding operation, you are
not required to provide the topographic map required by this
section of Form 1. Instead, you are required to provide a
topographic map as specified in Section 4 of Form 2B.
Item 7.1. Note that you have completed your topographic map
and attached it to the application.
Section 8. Nature of Business
Briefly describe the nature of your business (e.g., products
produced or services provided). See Examples 1 and 2.
Example 1
Facilities Subject to 40 CFR 426, Subparts F and G
Industry A is an auto tempered and auto laminated glass
manufacturing facility subject to effluent limitation guidelines
(ELGs) for the "Automotive Glass Tempering" and "Automotive
Glass Laminating" subcategories of the "Glass Manufacturing"
point source category at 40 CFR 426, subparts F and G. At the
facility, glass is cut and then passed through a series of
processes that grind and polish the edges, bend the glass, and
then temper the glass to produce side and back windows for
automobiles. Tempering involves heating the glass near the
melting point, then rapidly cooling it to increase its mechanical
and thermal endurance. The facility also produces automobile
windshields and undertakes processes that laminate a plastic
sheet between two layers of glass and that prepare the glass for
lamination (e.g., cutting, bending, and washing).
Example 2
Facility Not Subject to ELGs
Industry B undertakes batch -type resin manufacturing operations.
It has aboveground storage tanks for raw materials and finished
goods, resin loading operations, and warehouses for 55-gallon
drums of finished product. Industry B manufactures alkyd,
saturated and unsaturated polyester resins in batches using
reactor vessels and mix tanks. Most of the feedstock liquids are
pumped from storage tanks to the kettles and mixers via a closed
piping system. Additional feedstocks are added manually as
solids from bags and sacks via manways, which are located on
top of the kettles. The resin is then chemically reacted in the
kettles. After the reaction step finishes, the resin is transferred
from the kettles to the mix tanks, where solvents are added to
thin it. The primary byproduct of the reaction is water vapor
containing condensed soluble organics. The byproduct flows to
an isolation tank where the vapors are directed to an onsite
thermal oxidizer. The finished resin is then pumped through one
of three types of filtration systems into finished goods storage
tanks, 55-gallon drums, 350-gallon intermediate bulk container
totes, or directly into tanker trucks. A typical batch takes about 30
hours to complete.
1-5

FORM 1--UNE-3Y-L]NGINSTRUCTIONS CONTINUED
Section 9. Cooling Water Intake Structures
Item 9.1.Indicate whether the facility uses cooling wotecIfyeo
continue hoItem 8.2. Ifno, skip hoItem 1O.1.
Item 9.2.Identify the source nfthe cooling water. For example,
indicate whether the cooling water iofrom asurface water,
groundwater well, public water system, ortreated effluent that
would otherwise hodischarged hvawater ofthe U.S.
|fthe facility uses acooling water intake structure oodescribed in
4OCFR125.Subparts | and J.the facility may have additional
application requirements under 40CFR122.21(h.Note that the
information required by4OCFR132.31(h|onot requested ompart
ofForm 1. Contact your NPDEGpermitting authority hodetermine
the specifics ufwhat you should provide and when.
Section 10.Variance Requests
Anapplicant (other than mPOTW)may request ovariance from
otherwise applicable effluent limitations under certain conditions
described at4OCFR122.%1(m).
Item 1k1.|fknown otthe time ofapplication, check all ufthe
authorized variances that you plan horequest o,renew. Note that
you are not being asked husubmit any other information atthis
time. Contact your NPDESpermitting authority bdetermine the
specifics ofwhat you should provide and when. The ability ho
request ovariance ionot limited tothe time m[application, and on
applicant may request evariance consistent with statutory and
regulatory requirements.
Section 1i.Checklist and Certification
Item i1.1.Review the checklist provided. |nColumn 1.mark the
sections ofForm 1that you have completed and are submitting
with your application. |nColumn 2.indicate for each section
whether you are submitting attachments.
Item 11.2.The Clean Water Act provides for severe penalties for
submitting false information onthis application form. CWASection
309(c)(2)provides that, "Any person who knowingly makes any
false statement, representation, nrcertification inany application,
... shall upon conviction, bopunished byafine m[nnmore than
$1O.O0Ourbyimprisonment for not more than six months, nr
FEDERAL REGULATIONS AT40 CFRi23.2JREQUIRE THIS
APPLICATION TO8ESIGNED ASFOLLOWS:
A. For ocorporation, byaresponsible corporate officer. For the
purpose nfthis section, oresponsible corporate officer
means: (1)apresident, secretary, treasurer, orvice-president
nfthe corporation incharge ofuprincipal business function,
orany other person who performs similar policy- ordecision-
making fundinnaibrth000qporativn.or(2)thomonagorof
one ormore manufacturing, production, oroperating facilities,
provided the manager iwauthorized homake management
decisions which govern the operation ofthe regulated facility
including having the explicit nrimplicit duty ofmaking major
capital investment recommendations, and initiating and
directing other comprehensive measures to assure long term
environmental compliance with environmental laws and
mgu|oUuno; the manager can ensure that the necessary
systems are established nractions taken hugather complete
and accurate information for permit application requirements;
and where authority hosign documents has been assigned ur
delegated to the manager inaccordance with corporate
procedures.
B. For apartnership orsole proprietorship, byogeneral partner
nrthe proprietor, respectively.
C. For amunicipality, state, federal, orother public facility, by
either aprincipal executive mffioerurranking elected official.
For purposes ofthis section, oprincipal executive officer m[o
federal agency includes: (1)The chief executive offioerofthe
agency, nr(2)osenior executive offioorhaving responsibility
for the overall operations ofoprincipal geographic unit ufthe
agency (o.g,Regional Administrators of EPA).
1-G

XVIOTIVAIVI t01,
if UOCM444,04,T
Exhibit 1-3. Example Topographic Map
To
1-7
Locator; trap
Contra; Procoostla Co
CoTtra; Cty

FORM 1—ACTIVITIES THAT DONOT REQUIRE PERMITS
You are not required to obtain anNpDBpermit if your discharge
is in one of the following categories, as provided by the CWAend
Sections 510 and 312, some discharges exempted from the
federal NPIDES requirements may still be regulated by a state
permitting authority.)
° Any discharge nfsewage from vessels and any effluent from
properly functioning marine engines, laundry, shower, and
galley sink wastes, orany other discharge incidental to the
normal operation o[uvessel, including vessels n[the Armed
Forces within the meaning ofsection 312nfthe CVVAand
recreational vessels within the meaning ofsection 6O%(25)of
the CVVA.None n[these exclusions apply horubbish, trash,
garbage, orother such materials discharged overboard; nor
toother discharges when the vessel iaoperating |na
capacity other than 000means of transportation such au
when used ononenergy ormining facility, estorage facility
ormseafood processing facility, orwhen secured too
storage facility nroseafood processing facility, orwhen
secured tothe bed ofthe ocean, contiguous zone o,waters
m[the United States for the purpose ofmineral oroil
exploration ordevelopment.
~ Discharges o[dredged nrfill material into waters m[the
United States that are regulated under CVVASection 404.
° The introduction nfsewage, industrial wastes, nrother
pollutants into publicly owned treatment works byindirect
dischargers. Plans nragreements toswitch bthis method of
disposal |nthe future dnnot relieve dischargers of the
obligation hohave and comply with permits until all
discharges o[pollutants towaters m[the United States are
eliminated. (See also 48CFR122.47(b)jThis exclusion
does not apply to the introduction ofpollutants to privately
owned treatment works nrtoother discharges through pipes,
sewers, orother conveyances owned byostate, municipality,
orother party not leading hmtreatment works.
p Any discharge incompliance with the instructions o[unOn-
Scene Coordinator pursuant to4VCFR 300(The National Oil
and Hazardous Substances Pollution Contingency Plan) or
33CFR153.1O(e)(Pollution byOil and Hazardous
Substances).
• Any introduction o[pollutants from non point -source
agricultural and oi|viouKunu|activities, including stonnwater
runoff from orchards, cultivated crops, pastures, range lands,
and forest lands, but not discharges from concentrated
animal feeding operations oodefined in4OCFR12223.
discharges from concentrated aquatic animal production
facilities oydefined in48OFR122.23.discharges from
concentrated aquatic animal production facilities osdcfinod
in4OCFR122.24'discharges hooquuou|bumprojects uo
defined in4OCFR123.DS.and discharges from uilviuu|tum|
point sources oodefined in4OCFR182.27. Note: Per 4O
CFR122.28(b)(14)(ii).facilities classified within SIC 24.
Industry Group 241'that are rock crushing, gravel washing,
log sorting,ulog storage facilities operated inconnection
with ui|Wmu|hum|activities defined |n40CFR122.27(b)O)—(3)
and Industry Groups 242 through 249; 26 (except 265 and
and 373 (not included are all other types of silviculture
facilities) are considered stormwater discharges associated
with industrial activity, and are required to obtain an NPDES
permit.
* Return flows from irrigated agriculture.
* Discharges into oprivately owned treatment works, except eu
the NPDEGpermitting authority may otherwise require under
40CFR122/4(m).
° Discharges from awater transfer. 'Water transfer means un
activity that conveys orconnects waters ofthe United States
without subjecting the transferred water huintervening
industrial, municipal, orcommercial use. This exclusion does
not apply topollutants introduced bythe water transfer
activity itself hothe water being transferred.
1-8

FORMi—GLOSSARY
Note: This glossary includes terms used in the various NPIDESapplication forms, including Form 1.The definitions are from the NPIDES
regulations at4U0R128.2 unless otherwise specified. If you have any questions concerning the meaning ofany of these terms, contact
your NPDES permitting authority.
ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (other than an aquatic animal production facility) where the
following conditions are met;
° Animals (other than aquatic animals) have been, are, or will be stabled or confined and fed or maintained for a total of 45 days or
more |nany 12'mnnthperiod; and
° Crops, vegetation, forage growth, or post -harvest residues are not sustained in the normal growing season over any portion of the lot
or facility.
APPLICATION means the EPA standard national forms for applying for a pomnd including additions, revisions, mmodifications hothe
forms; or forms approved by EPA for use in approved states, including any approved modifications or revisions.
APPROVED PROGRAM or APPROVED STATE means a State or interstate program which has been approved or authorized by EPA
under part 128.
AQUACULTURE PROJECT (defined at § 122.25) means a defined managed water area which uses discharges of pollutants into that
designated area for the maintenance or productionofhemedob|efreshwoter.estuahno.ormahnep|onburanima|o.UES|GN/W[EO
PROJECT AREA means the portions of the waters of the United States within which the permittee or permit applicant plans to confine the
cultivated species, using a method or plan or operation (including, but not limited to, physical confinement) which, on the basis of reliable
scientific evidence, is expected to ensure that specific individual organisms comprising an aquaculture crop will enjoy increased growth
attributable to the discharge of pollutants, and be harvested within a defined geographic area.
AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month,
calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured during that
month.
AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week,
calculated as the sum of all daily discharges measured during a calendar week divided by the number of daily discharges measured during
that week.
BEST MANAGEMENT PRACTICES (BMPs) means schedules of activities, prohibitions of practices, maintenance procedures, and other
management pracfices to prevent or reduce the pollution of waters of the United States. BMPs include treatment requirements, operation
procedures, and practices to control plant site runoff, spillage or leaks, sludge or waste disposal, or drainage from raw material storage.
B|OSOL|DS(see sewage mbdgo).
BYPASS(dehnodetQ122.41(m))moenmthoinhmnUono|divors|onnfwostastnoommhnmonypnrtionx[ubaetmontfaoiUty.
COMBINED SEWER OVERFLOW (CSO) means a discharge from a combined sewer system (CSS) at a point prior to the Publicly Owned
Treatment Works (POTVV) Treatment Plant (defined ot§4U33(r)).
COMBINED SEWER SYSTEM (CSS) means a wastewater collection system owned by a State or municipality (as defined by section
5O2(4)nfthe CVVA)which conveys sanitary wastewaters (domestic, commercial and industrial wastewaters) and storm water through a
single -pipe system huoPublicly Owned Treatment Works (POTVV) Treatment Plant (as defined ot8403.3(h).
CONCENTRATED ANIMAL FEEDING OPERATION (defined ot§122.23)means onanimal feeding operation that iodefined onoLarge
CAFO or as a Medium CAFO by the terms of (A) or (B) below, or that is designated as a CAFO in accordance with 40 CFR 122.23(c). Two
ormore AFOmunder common ownership are considered tohoosingle AFOfor the purposesm[determining the number ufanimals mtan
operation, if they adjoin each other or if they use a common area or system for the disposal of wastes.
A. LARGE CONCENTRATED ANIMAL FEEDING OPERATION (LARGE CAFO)means onAFOthat stables orconfines oomany osnr
more than the numbers o[animals vpooifiodinany ofthe following categories:
i. 7DOmature dairy cows, whether milked ordry;
2. 1.00Oveal calves;
3. 1.OUOcattle other than mature dairy cows nrveal calves. Cattle includes but is not limited to heifers, steers, bulls and cow/calf
pairs;
4. 2.58Oswine each weighing 55pounds mmore;
5. 1O.00Oswine each weighing less than 55pounds;
1-8

FORM 1—GLOSSARY CONTINUED
K 500hmnws;
7. 1O,00Usheep mlambs;
9. 3O,0UUlaying hens mbroilers, ifthe AFOuses oliquid manure handling system;
10. 125,08Ochickens (other than laying hens).if the AFOuses other than sliquid manure handling system;
11. 82,OOOlaying hens, if the AFOuses other than oliquid manure handling system;
13. 3O.O0Oducks (if the AFOuses other than aliquid manure handling nysten);ur
13. 5.00Oducks (if the AFOuses aliquid manure handling oyutem).
B. MEDIUM CONCENTRATED ANIMAL FEEDING OPERATION CAFO)means any AFOwith the type and number of
animals that fall within any of the ranges listed below and which has been defined or designated as a CAFO. An AFO is defined as a
Medium CAFOif:
1. The type and number of animals that it stables and confines falls within any of the following ranges:
o. 2UOhoG88mature dairy cows, whether milked ordry;
b. 3UOhn8Q9veal calves;
n. 30ObuSS8cattle other than mature dairy cows mveal calves. Cattle includes but isnot limited hnheifers, steers, bulls and
nmw/caKpaim;
d. 7SUho%,4S9swine each weighing 55pounds ormore;
o. 3.O0Dbo8.S89swine each weighing less than S5pounds;
[ 15Obo48yhorses;
g. 3,0ODto&.989sheep urlambs;
h. 16,500to 54,99turkeys;
i. g,0OUb2S,99Alaying hens orbroilers, if the AFOuses aliquid manure handling system;
j. 37.5UOho124.88gchickens (other than laying hens).if the AFOuses other than aliquid manure handling system;
k. 25,000 to 81,999 laying hens, if the AFO uses other than a liquid manure handling system;
|. 1V.OUOho29.88Qducks (if the AFOuses other than aliquid manure handling uyotem);ore
m. 1,5UO|o4.8QBducks (if the AFOuses oliquid manure handling nyotem);and
2. Either one nfthe following conditions are met:
a. Pollutants are discharged into waters of the United States through a man-made ditch, flushing system, or other similar man-
madedovice;ur
b. Pollutants are discharged directly into waters of the United States which originate outsidoofandpeoomer,00mas.or
through the facility or otherwise come into direct contact with animals confined in the operation.
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY (defined at § 122.24) means a hatchery, fish farm, or other facility which
contains, grows, orholds aquatic animals ineither of the following categories, or which the Director designates as such on a case -by -case
basis:
A. Cold water fish species or other cold water aquatic animals including, but not limited to, the Salmonidae family of fish (e.g., trout and
salmon) in ponds, raceways, or other similar structures which discharge at least 30 days per year but does not include:
1. Facilities which produce less than 8.09Oharvest weight kilograms (approximately 2O.0UOpounds) ufaquatic animals per year;
and
2. Facilities which feed less than 2,272 kilograms (approximately 5,000 pounds) of food during the calendar month of maximum
hooding.
B. VVonn water fish upedoo nrother warm water oquoUo animals inu|uding, but not limited to. theAmaiuridae, Cohamhkclao. and
{yprinidaofamilies n[fish (e.g..respectively, ootfioh.sunfish, and minnows) inponds, raceways, orother similar structures which
discharge otleast 30days per year, but does not include;
1. Closed ponds which discharge only during periods nfexcess runoff, or
2. Facilities which produce less than 45,454 harvest weight kilograms (approximately 100,000 pounds) of aquatic animals per year.
14O

FORM 1—GLOSSARY CONTINUED
CWA means the Clean Water Act Pollution Control Act or Federal Water Pollution Control Act
Amendments of1972) Public Law 92-500.asamended by Public Law E5-217,Public Law 95-576, Public Law 96-483 and Public Law
87-117.33U.S.C.1251etseq.
CVKAAND REGULATIONS means the Clean Water Act (CVVA) and applicable regulations promulgated thereunder. |nthe case ofon
approved State program, itincludes State program requirements.
DAILY DISCHARGE means the "discharge of a pollutant" measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling. For pollutants with limitations expressed in units of mass, the "daily discharge" is
calculated as the total mass of the pollutant discharged over the day. For pollutants with limitations expressed inother units of
measurement, the "daily discharge" is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the "discharge u[opoUutonL^
DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an authorized representative. When there
is no "approved State program," and there is an EPA administered program, "Director means the Regional Administrator. When there is
an approved State program, "Director' normally means the State Director. In some circumstances, however, EPA retains the authority to
take certain actions even when there is an approved State program. (For example, when EPA has issued an NPDES permit prior to the
oppmva|n[a0obapmQmm.EPAmoymtainjuhadicUonovorthatpumnitaMerpmgmmoppmvo|.00u0183.1j|nuuuhcuoou.thohann
^Dieotor"means the Regional Administrator and not the State Director.
DISCHARGE (OF APOLLUTANT) means:
° Any addition ofany pollutant vrcombination ofpollutants towaters ufthe United States from any point source; vr
° Any addition of any pollutant or combination of pollutants to the waters of the contiguous zone or the ocean from any point source
other than a vessel or other floating craft which is being used as a means of transportation.
This definition includes discharges into waters of the United States from: surface runoff which is collected or channelled by man;
discharges through pipes, sewers, or other conveyances owned by a State, municipality, or other person which do not lead to a treatment
works; and discharges through pipes, sewers, or other conveyances, leading into privately owned treatment works. This term does not
include onaddition ofpollutants byany "indirect dioohmrgw�.
DISCHARGE MONITORING REPORT means the EPA uniform national form, including any subsequent additions, revisions, or
modifications for the reporting of self -monitoring results by permittees. DMRs must be used by "approved States" as well as by EPA. EPA
will supply DMRs to any approved State upon request. The EPA national forms may be modified to substitute the state agency name,
address, logo, and other similar information, as appropriate, in place of EPA's.
DRAFTPERM|TmoanoodmoumentpnepeedundorQ124.GindiouhngthoDimdor'otentadvedncisiontoiuxueordany.modify.nevnko
and reissue, terminate, or reissue a "permit." A notice of intent to terminate a permit, and a notice of intent todeny opermit, asdiscussed
in § 124.5, are types of "draft permits." A denial of a request for modification, revocation and reissuance, or termination, as discussed in
§1%4.5.iunot m"draft punniL^A"proposed pennif'iunot o"draft pennit.^
EFFLUENT LIMITATION means any restriction imposed by the Director on quantities, discharge rates, and concentrations of "pollutants"
which are "discharged" from "point sources" into "waters of the United States," the waters of the "contiguous zone," or the ocean.
EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administrator under section 304(b) of the CWA to adopt or
revise "effluent |imitatinnm.^
ENVIRONMENTAL PROTECTION AGENCY (EPA) means the United States Environmental Protection Agency.
FACILITY or ACTIVITY means any NPDES "point source" or any other facility or activity (including land or appurtenances thereto) that is
subject horegulation under the NPDESprogram.
GENERALPERM|?meunomnNPOES^pemnit"iuuuadundorQ122.28outhohzingeootegory ofdischarges under the CVVAwithin o
geographical area.
HAZARDOUS SUBSTANCE means any substance designated under 40 CFR part 116 pursuant to section 311 of the CWA.
|ND|ANCOUNTRY (or |NDANLANDS) means:
° All land within the limits of any Indian reservation under the jurisdiction of the United States Government, notwithstanding the
issuance of any patent, and, including rights -of -way running through the reservation;
° All dependent Indian communities with the borders of the United States whether within the originally or subsequently acquired territory
thereof, and whether within orwithout the limits ofustate; and
° All Indian allotments, the Indian titles to which have not been extinguished, including rights -of -way running through the same.
141

FORM 1—GLOSSARY CONTINUED
INDIAN TRIBE means any Indian Tribe, band, group, or community recognized by the Secretary of the Interior and exercising
governmental authority over a Federal Indian reservation.
INDIRECT DISCHARGE means a nondomestic discharger introducing "pollutants" to a "publicly owned treatment works."
LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(4)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census (Appendix F of 40 CFR 122); or
(ii) Located in the counties listed in appendix H of 40 CFR 122, except municipal separate storm sewers that are located in the
incorporated places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraphs (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(D) The nature of the receiving waters; and
(E) Other relevant factors; or
(iv) The Director may, upon petition, designate as a large municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii).
LOG SORTING AND LOG STORAGE FACILITIES (defined at § 122.27) means facilities whose discharges result from the holding of
unprocessed wood, for example, logs or roundwood with bark or after removal of bark held in self-contained bodies of water (mill ponds or
log ponds) or stored on land where water is applied intentionally on the logs (wet decking). (See 40 CFR 429, subpart I, including the
effluent limitations guidelines.)
MAJOR FACILITY means any NPDES "facility or activity" classified as such by the Regional Administrator, or, in the case of "approved
State programs," the Regional Administrator in conjunction with the State Director.
MAXIMUM DAILY DISCHARGE LIMITATION means the highest allowable "daily discharge."
MEDIUM MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(7)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 100,000 or more but less than 250,000, as determined by the 1990 Decennial
Census by the Bureau of the Census (appendix G of 40 CFR 122); or
(ii) Located in the counties listed in appendix I of 40 CFR 122, except municipal separate storm sewers that are located in the incorporated
places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraph (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraph (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(D) The nature of the receiving waters; or
(E) Other relevant factors; or
1-12

FORM 1—GLOSSARY CONTINUED
(iv) The Director may, upon petition, designate as a medium municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii) of this section.
MUNICIPALITY means a city, town, borough, county, parish, district, association, or other public body created by or under State law and
having jurisdiction over disposal of sewage, industrial wastes, or other wastes, or an Indian tribe or an authorized Indian tribal organization,
or a designated and approved management agency under section 208 of the CWA.
MUNICIPAL SEPARATE STORM SEWER (defined at § 122.26(b)(8)) means a conveyance or system of conveyances (including roads
with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels, or storm drains):
• Owned or operated by a State, city, town, borough, county, parish, district, association, or other public body (created by or pursuant to
State law) having jurisdiction over disposal of sewage, industrial wastes, stormwater, or other wastes, including special districts under
State law such as a sewer district, flood control district or drainage district, or similar entity, or an Indian tribe or an authorized Indian
tribal organization, or a designated and approved management agency under section 208 of the CWA that discharges to waters of the
United States.
• Designed or used for collecting or conveying stormwater.
• Which is not a combined sewer; and
• Which is not part of a POTW as defined at 40 CFR 122.2.
MUNICIPAL SLUDGE (see sewage sludge)
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) means the national program for issuing, modifying, revoking
and reissuing, terminating, monitoring and enforcing permits, and imposing and enforcing pretreatment requirements, under sections 307,
402, 318, and 405 of the CWA. The term includes an "approved program."
NEW DISCHARGER means any building, structure, facility, or installation:
• From which there is or may be a "discharge of pollutants;"
• That did not commence the "discharge of pollutants" at a particular "site" prior to August 13, 1979;
• Which is not a "new source;" and
• Which has never received a finally effective NPDES permit for discharges at that "site."
This definition includes an "indirect discharger" which commences discharging into "waters of the United States" after August 13, 1979. It
also means any existing mobile point source (other than an offshore or coastal oil and gas exploratory drilling rig or a coastal oil and gas
developmental drilling rig) such as a seafood processing rig, seafood processing vessel, or aggregate plant, that begins discharging at a
"site" for which it does not have a permit; and any offshore or coastal mobile oil and gas exploratory drilling rig or coastal mobile oil and gas
developmental drilling rig that commences the discharge of pollutants after August 13, 1979, at a "site" under EPA's permitting jurisdiction
for which it is not covered by an individual or general permit and which is located in an area determined by the Regional Administrator in
the issuance of a final permit to be an area of biological concern. In determining whether an area is an area of biological concern, the
Regional Administrator shall consider the factors specified in 40 CFR 125.122(a)(1) through (10).
An offshore or coastal mobile exploratory drilling rig or coastal mobile developmental drilling rig will be considered a "new discharger" only
for the duration of its discharge in an area of biological concern.
NEW SOURCE means any building, structure, facility, or installation from which there is or may be a "discharge of pollutants," the
construction of which commenced:
• After promulgation of standards of performance under section 306 of the CWA which are applicable to such source, or
• After proposal of standards of performance in accordance with section 306 of the CWA which are applicable to such source, but only
if the standards are promulgated in accordance with section 306 within 120 days of their proposal.
OWNER OR OPERATOR means the owner or operator of any "facility or activity" subject to regulation under the NPDES program.
PERMIT means an authorization, license, or equivalent control document issued by EPA or an "approved State" to implement the
requirements of this part and parts 123 and 124. "Permit" includes an NPDES "general permit" (§ 122.28). Permit does not include any
permit which has not yet been the subject of final agency action, such as a "draft permit" or a "proposed permit."
PESTICIDE DISCHARGES TO WATERS OF THE UNITED STATES FROM PESTICIDE APPLICATION means the application of
biological pesticides, and the application of chemical pesticides that leave a residue, from point sources to waters of the United States. In
the context of this definition of pesticide discharges to waters of the United States from pesticide application, this does not include
1-13

FORM 1—GLOSSARY CONTINUED
agricultural storm water discharges and return flows from irrigated agriculture, which are excluded by law (33 U.S.C. 1342(1); 33 U.S.C.
1362(14)).
PESTICIDE RESIDUE for the purpose of determining whether a NPDES permit is needed for discharges to waters of the United States
from pesticide application, means that portion of a pesticide application that is discharged from a point source to waters of the United
States and no longer provides pesticidal benefits. It also includes any degradates of the pesticide.
POINT SOURCE means any discemible, confined, and discrete conveyance, including but not limited to, any pipe, ditch, channel, tunnel,
conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, landfill leachate collection system, vessel or
other floating craft from which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff. (See § 122.3).
POLLUTANT means dredged spoil, solid waste, incinerator residue, filter backwash, sewage, garbage, sewage sludge, munitions,
chemical wastes, biological materials, radioactive materials (except those regulated under the Atomic Energy Act of 1954, as amended (42
U.S.C. 2011 et seq.)), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste
discharged into water. It does not mean:
• Sewage from vessels; or
• Water, gas, or other material which is injected into a well to facilitate production of oil or gas, or water derived in association with oil
and gas production and disposed of in a well, if the well used either to facilitate production or for disposal purposes is approved by
authority of the State in which the well is located, and if the State determines that the injection or disposal will not result in the
degradation of ground or surface water resources. Note: Radioactive materials covered by the Atomic Energy Act are those
encompassed in its definition of source, byproduct, or special nuclear materials. Examples of materials not covered include radium
and accelerator -produced isotopes. See Train v. Colorado Public Interest Research Group, Inc., 426 U.S. 1 (1976).
PRIMARY INDUSTRY CATEGORY means any industry category listed in the NRDC settlement agreement (Natural Resources Defense
Council et al. v. Train, 8 E.R.C. 2120 (D.D.C. 1976), modified 12 E.R.C. 1833 (D.D.C. 1979)); also listed in appendix A of part 122.
PRIVATELY OWNED TREATMENT WORKS means any device or system which is (1) used to treat wastes from any facility whose
operator is not the operator of the treatment works and (2) not a "POTW."
PROCESS WASTEWATER means any water which, during manufacturing or processing, comes into direct contact with or results from the
production or use of any raw material, intermediate product, finished product, byproduct, or waste product.
PROPOSED PERMIT means a state NPDES "permit" prepared after the close of the public comment period (and, when applicable, any
public hearing and administrative appeals) which is sent to EPA for review before final issuance by the State. A "proposed permit" is not a
"draft permit."
PUBLICLY OWNED TREATMENT WORKS or POTW (defined at § 403.3) means a treatment works as defined by CWA Section 212,
which is owned by a state or municipality (as defined by CWA Section 502(4)). This definition includes any devices or systems used in the
storage, treatment, recycling, and reclamation) of municipal sewage or industrial wastes of a liquid nature. This definition also includes
sewers, pipes, and other conveyances only if they convey wastewater to a POTW. The term also means the municipality as defined in
CWA Section 502(4), which has jurisdiction over the indirect discharges to and the discharges from such a treatment works.
REGIONAL ADMINISTRATOR means the Regional Administrator of the appropriate Regional Office of the Environmental Protection
Agency or the authorized representative of the Regional Administrator.
ROCK CRUSHING AND GRAVEL WASHING FACILITIES (defined at § 122.27) means facilities which process crushed and broken
stone, gravel, and riprap (See 40 CFR 436, subpart B, including the effluent limitations guidelines).
SCHEDULE OF COMPLIANCE means a schedule of remedial measures included in a "permit", including an enforceable sequence of
interim requirements (for example, actions, operations, or milestone events) leading to compliance with the CWA and regulations.
SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.
SEWAGE FROM VESSELS means human body wastes and the wastes from toilets and other receptacles intended to receive or retain
body wastes that are discharged from vessels and regulated under section 312 of the CWA, except that with respect to commercial
vessels on the Great Lakes this term includes graywater. For the purposes of this definition, "graywater" means galley, bath, and shower
water.
SEWAGE SLUDGE means any solid, semi -solid, or liquid residue removed during the treatment of municipal waste water or domestic
sewage. Sewage sludge includes, but is not limited to, solids removed during primary, secondary, or advanced waste water treatment,
scum, septage, portable toilet pumpings, type III marine sanitation device pumpings (33 CFR 159), and sewage sludge products. Sewage
sludge does not include grit or screenings, or ash generated during the incineration of sewage sludge.
1-14

FORM 1—GLOSSARY CONTINUED
SILVICULTURAL POINT SOURCE (defined at § 122.27) means any discernible, confined, and discrete conveyance related to rock
crushing, gravel washing, log sorting, or log storage facilities which are operated in connection with silvicultural activities and from which
pollutants are discharged into waters of the United States. This term does not include non -point source silvicultural activities such as
nursery operations, site preparation, reforestation and subsequent cultural treatment, thinning, prescribed burning, pest and fire control,
harvesting operations, surface drainage, or road construction and maintenance from which there is natural runoff. However, some of these
activities (such as stream crossing for roads) may involve point source discharges of dredged or fill material which may require a CWA
Section 404 permit (see 33 CFR 209.120 and part 233).
SITE means the land or water area where any "facility or activity" is physically located or conducted, including adjacent land used in
connection with the facility or activity.
SLUDGE -ONLY FACILITY means any "treatment works treating domestic sewage" whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d) of the CWA
which govem minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.
STATE means any of the 50 States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Commonwealth of the Northern Mariana Islands, the Trust Temtory of the Pacific Islands, or an Indian Tribe as defined in
these regulations which meets the requirements of § 123.31 of this chapter.
STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an "approved program," or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, "State Director"
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.
STORMWATER (or STORM WATER) (defined at § 122.26(b)(13)) means stormwater runoff, snow melt runoff, and surface runoff and
drainage.
STORMWATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY (defined at § 122.26(b)(14)) means the discharge from any
conveyance that is used for collecting and conveying stormwater and that is directly related to manufacturing, processing or raw materials
storage areas at an industrial plant. The term does not include discharges from facilities or activities excluded from the NPDES program
under this part 122. For the categories of industries identified in this section, the term includes, but is not limited to, stormwater discharges
from industrial plant yards; immediate access roads and rail lines used or traveled by carriers of raw materials, manufactured products,
waste material, or by-products used or created by the facility; material handling sites; refuse sites; sites used for the application or disposal
of process waste waters (as defined at 40 CFR 401); sites used for the storage and maintenance of material handling equipment; sites
used for residual treatment, storage, or disposal; shipping and receiving areas; manufacturing buildings; storage areas (including tank
farms) for raw materials, and intermediate and final products; and areas where industrial activity has taken place in the past and significant
materials remain and are exposed to stormwater. For the purposes of this paragraph, material handling activities include storage, loading
and unloading, transportation, or conveyance of any raw material, intermediate product, final product, by-product or waste product. The
term excludes areas located on plant lands separate from the plant's industrial activities, such as office buildings and accompanying
parking lots as long as the drainage from the excluded areas is not mixed with stormwater drained from the above described areas.
Industrial facilities (including industrial facilities that are federally, State, or municipally owned or operated that meet the description of the
facilities listed in paragraphs 1 through 14 below) include those facilities designated under the provisions of 40 CFR 122.26(a)(1)(v). The
following categories of facilities are considered to be engaging in "industrial activity" for purposes of 40 CFR 122.26(b)(14):
1. Facilities subject to stormwater effluent limitations guidelines, new source performance standards, or toxic pollutant effluent standards
under 40 CFR Subchapter N (except facilities with toxic pollutant effluent standards which are exempted under paragraph 11 below);
2. Facilities classified as Standard Industrial Classification 24, Industry Group 241 that are rock crushing, gravel washing, log sorting, or
log storage facilities operated in connection with silvicultural activities defined in 40 CFR 122.27(b)(2)—(3) and Industry Groups 242
through 249; 26 (except 265 and 267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441, 373; (not included are all other types of
silvicultural facilities);
3. Facilities classified as Standard Industrial Classifications 10 through 14 (mineral industry) including active or inactive mining
operations (except for areas of coal mining operations no longer meeting the definition of a reclamation area under 40 CFR 434.11(1)
because the performance bond issued to the facility by the appropriate SMCRA authority has been released, or except for areas of
non —coal mining operations which have been released from applicable State or Federal reclamation requirements after
December 17, 1990) and oil and gas exploration, production, processing, or treatment operations, or transmission facilities that
discharge stormwater contaminated by contact with or that has come into contact with, any overburden, raw material, intermediate
products, finished products, byproducts or waste products located on the site of such operations; (inactive mining operations are
mining sites that are not being actively mined, but which have an identifiable owner/operator; inactive mining sites do not include sites
1-15

FORM 1-GLOSSARY CONTINUED
where mining claims are being maintained prior to disturbances associated with the extraction, beneficiation, or processing of mined
materials, nor sites where minimal activities are undertaken for the sole purpose of maintaining a mining claim);
4. Hazardous waste treatment, storage, or disposal facilities, including those that are operating under interim status or a permit under
subtitle C of RCRA;
5. Landfills, land application sites, and open dumps that receive or have received any industrial wastes (waste that is received from any
of the facilities described under this subsection) including those that are subject to regulation under subtitle D of RCRA;
6. Facilities involved in the recycling of materials, including metal scrapyards, battery reclaimers, salvage yards, and automobile
junkyards, including but limited to those classified as Standard Industrial Classification 5015 and 5093;
7. Steam electric power generating facilities, including coal handling sites;
8. Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221-25), 43, 44, 45, and 5171 which have
vehicle maintenance shops, equipment cleaning operations, or airport deicing operations. Only those portions of the facility that are
either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication),
equipment cleaning operations, airport deicing operations, or which are otherwise identified under paragraphs 1-7 or 9-11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system, used in the
storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved
pretreatment program under 40 CFR 403. Not included are farm lands, domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility, or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing, grading and excavation, except operations that result in the disturbance of less than five acres
of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34
(except 3441), 35, 36, 37 (except 373), 38, 39, and 4221-25.
TOXIC POLLUTANT means any pollutant listed as toxic under section 307(a)(1) or, in the case of "sludge use or disposal practices," any
pollutant identified in regulations implementing section 405(d) of the CWA.
TREATMENT WORKS TREATING DOMESTIC SEWAGE (TWTDS) means a POTW or any other sewage sludge or waste water
treatment devices or systems, regardless of ownership (including federal facilities), used in the storage, treatment, recycling, and
reclamation of municipal or domestic sewage, including land dedicated for the disposal of sewage sludge. This definition does not include
septic tanks or similar devices. For purposes of this definition, "domestic sewage" includes waste and waste water from humans or
household operations that are discharged to or otherwise enter a treatment works. In States where there is no approved State sludge
management program under section 405(f) of the CWA, the Regional Administrator may designate any person subject to the standards for
sewage sludge use and disposal in 40 CFR 503 as a "treatment works treating domestic sewage," where he or she finds that there is a
potential for adverse effects on public health and the environment from poor sludge quality or poor sludge handling, use or disposal
practices, or where he or she finds that such designation is necessary to ensure that such person is in compliance with 40 CFR 503.
UPSET (defined at § 122.41(n)) means an exceptional incident in which there is unintentional and temporary noncompliance with
technology based permit effluent limitations because of factors beyond the reasonable control of the permittee. An upset does not include
noncompliance to the extent caused by operational error, improperly designed treatment facilities, inadequate treatment facilities, lack of
preventive maintenance, or careless or improper operation.
VARIANCE means any mechanism or provision under section 301 or 316 of the CWA or under 40 CFR 125, or in the applicable "effluent
limitations guidelines" which allows modification to or waiver of the generally applicable effluent limitation requirements or time deadlines of
the CWA. This includes provisions which allow the establishment of alternative limitations based on fundamentally different factors or on
sections 301(c), 301(g), 301(h), 301(i), or 316(a) of the CWA.
WATERS OF THE UNITED STATES as defined at § 122.2.
WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test.
1-16

EPA Identification Number
NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Form Approved 03/05/19
OMB No. 2040-0004
Form
1
NPDES
*IrEPA
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))
Apll Sriitadltc rnit F'I
1.1.1
Is the facility a new or existing publicly owned
treatment works?
If yes, STOP. Do NOT complete p
Form 1. Complete Form 2A.
No
12
1..
Is the facility a new or existing treatment works
treating domestic sewage?
If yes, STOP. Do NOT No
complete Form 1. Complete
Form 2S.
AIntsedto It Fcdrn t
1.2.1
Is the
operation
production
•
facility a concentrated animal feeding
or a concentrated aquatic animal
facility?
Yes 4 Complete Form 1 p
and Form 2B.
No
1.2.2 Is
the
commercial,
currently
•
facility an existing manufacturing,
mining, or silvicultural
discharging process wastewater?
Yes 4 Complete Form
1 and Form 2C.
facility
p
that is
No
1.2.3
Is
mining,
commenced
0
the facility a new manufacturing, commercial,
or silvicultural facility that has not
to discharge?
Yes 4 Complete Form 1 p
and Form 2D.
yet
No
1.2.4
Is the
commercial,
discharges
facility a new or existing manufacturing,
mining, or silvicultural
only nonprocess wastewater?
Yes 4 Complete Form
1 and Form 2E.
facility
p
that
No
•aC
1.2.5
Is the
discharge
associated
discharge
non-stormwater?
•
facility a new or existing facility
is composed entirely of stormwater
with industrial activity or
is composed of both stormwater
Yes 4 Complete Form 1
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15.
whose
whose
p
and
No
SECTION
2. NAME,
MAILING ADDRESS, AND LOCATION (40 CFR 122.21(f)(2))
. .............. .................
Name, Mailing Address, and Lotation
N N N N
Flaky
Sapphire Valley Wastewater Treatment Plant
EPA ldentaion Number
Faiciy t►�ltaet
Name (first and last)
Tony Konsul
Title
Director, State Operations
Phone number
[phone]
Email address
[e-mail]
Falc ley iill Ad ress
Street or P.O. box
P.O. Box 240908
City or town
Charlotte
State
NC
ZIP code
28224-0908
EPA Form 3510-1 (revised 3-19)
Page 1

EPA Identification Number
NPDES Permit Number
NC0022985
Street, route number, or other specific identifier
3500 US Highway 64 East
County name
Jackson
County code (if known)
City or town State
Sapphire Valley NC
SECTION 3. SIC AND NAICS CODES (40 CFR 122.21(f)(3))
SECTION 4. OPERATOR INFORMATION (40 CFR 122.21(f)(4))
Carolina Water Service of North Carolina
Facility Name
Sapphire Valley
Is the name you listed in Item 4.1 also the owner?
D Yes ❑ No
Operator Status
❑ Public —federal ❑ Public —state
❑r Private ❑ Other (specify)
Phone Number of Operator
[phone]
Operator Address
Street or P.O. Box
4944 Parkway Plaza Blvd Suite 375
City or town
Charlotte
State
NC
Email address of operator
[e-mail]
SECTION 5. INDIAN LAND (40 CFR 122.21(f)(5))
5.1 Is the facility located on Indian Land?
❑ Yes O No
EPA Form 3510-1 (revised 3-19)
Form Approved 03/05/19
OMB No. 2040-0004
28774
❑ Other public (specify)
ZIP code
28217
Page 2

EPA Identification Number
NPDES Permit Number
NC0022985
SECTION 6. EXISTING ENVIRONMENTAL PERMITS (40 CFR 122.21(f)(6))
❑ NPDES (discharges to surface
water)
NC0022985
0 PSD (air emissions)
❑ Ocean dumping (MPRSA)
SECTION 7. MAP (40 CFR 122.21(f)(7))
Facility Name
Sapphire Valley
0 RCRA (hazardous wastes)
❑ Nonattainment program (CAA)
0 Dredge or fill (CWA Section 404)
Form Approved 03/05/19
OMB No. 2040-0004
❑ UIC (underground injection of
fluids)
O NESHAPs (CAA)
❑ Other (specify)
7.1 Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
El Yes 0 No 0 CAFO—Not Applicable (See requirements in Form 2B.)
SECTION 8. NA7URE OF BUSINESS (40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Private waster utility company providing domestic water and wastewater service to the Sapphire Valley area
subdivisions located in Jackson County NC.
SECTION 9. COOLING WATER INTAKE STRUCTURES (40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
O Yes El No 4 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.)
SECTION 10. VARIANCE REQUESTS (40 CFR 122.21(f)(10))
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.)
0 Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA
Section 301(c) and (g))
❑ Not applicable
❑ Thermal discharges (CWA Section 316(a))
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
NC0022985
Facility Name
Sapphire Valley
Form Approved 03/05/19
OMB No. 2040-0004
SECTION
11. CHECKLIST AND
CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
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
c%
✓
Section 1: Activities Requiring an NPDES Permit
IN
w/ attachments
IS
Section 2: Name, Mailing Address, and Location
IN
w/ attachments
■
Section 3: SIC Codes
■
wl attachments
ES
Section 4: Operator Information
■
wl attachments
ES
Section 5: Indian Land
■
wl attachments
t2
Section 6: Existing Environmental Permits
■
wl attachments
Ei
Section 7: Map
0
ap topographic
•
wl additional attachments
t2
Section 8: Nature of Business
■
w/ attachments
■
Section 9: Cooling Water Intake Structures
IN
w/ attachments
■
Section 10: Variance Requests
■
w/ attachments
Ei
Section 11: Checklist and Certification Statement
■
w/ attachments
11.2
Certification Statement
1 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)
Tony Konsul
Official title
Director, State Operations
Signature
\.
Date signed
rK.---
2-1 lot z022—
EPA Form 3510-1 (revised 3-19)
Page 4

errxo-W e3"21e-W e32401li errrw
411
Sapphire Valley WWTP
I ---I I- 1
J
0 30 E0 W 120 150
Mears
"CONFIDENTIAL & PROPRIETARY INFORMATION"
DISCLAIMER: This map is not a survery.
CWSNC makes no guarantee, Implicit or
impked, about the accuracy of this data.
Map Produced By: SPQ A
Date: 2/1nO22