NCG500648_Permit (Issuance)_20151013

North Carolina Department of Environmental Quality
Pat McCrory, Governor Donald R. van der Vaart, Secretary
October 13, 2015
Mr. Mark Rabon
Carolinas Healthcare System
2001 Vail Ave
Charlotte, NC 28207
Subject: Renewal of General Permit NCG500000
Carolinas Medical Center - Mercy
Certificate of Coverage NCG500648
Mecklenburg County
Dear Permittee:
The Division has renewed the subject General Permit. In response to your request for an updated
Certificate of Coverage (CoC), the Division hereby issues the updated version of NCG500648 under General
Permit NCG550000. It is issued pursuant to the requirements of North Carolina General Statue 143-215.1
and the Memorandum of Agreement between North Carolina and the US Environmental Protection agency
dated October 15, 2007 [or as subsequently amended].
If any parts, measurement frequencies or sampling requirements contained in this General Permit
are unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, the certificate of coverage shall be final and binding.
Please take notice that this Certificate of Coverage is not transferable except after notice to the
Division. The Division may require modification or revocation and reissuance of the certificate of coverage.
Contact the Mooresville Regional Office prior to any sale or transfer of the permitted facility.
Regional Office staff will assist you in documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain any other State, Federal, or Local
governmental permit that may be required. If you have any questions concerning the requirements of the
General Permit, please contact Charles Weaver of the NPDES staff [919 807-6391 or
[e-mail]].
for S. Jay Zimmerman, c r
Division of Water esources
cc: Mooresville Regional Office
NPDES file
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org
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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG500000
CERTIFICATE OF COVERAGE NCG500648
DISCHARGE OF NON -CONTACT COOLING WATER, COOLING TOWER AND BOILER
BLOWDOWN, CONDENSATE, EXEMPT STORMWATER, COOLING WATERS ASSOCIATED
WITH HYDROELECTRIC OPERATIONS, AND SIMILAR WASTEWATERS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and
the Federal Water Pollution Control Act, as amended,
Carolinas Healthcare System
is hereby authorized to discharge from a facility located at
Carolinas Medical Center - Mercy
2001 Vail Ave
Charlotte
Mecklenburg County
to receiving waters designated as an unnamed tributary to Brier Creek, a class C stream in
subbasin 03-08-34 of the Catawba River Basin in accordance with the effluent limitations,
monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof.
This certificate of coverage takes effect October 13, 2015.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day October 13, 2015
or ay Zimmerman, Director,
ivision of Water Resources
By Authority of the Environmental Management Commission

ATLI
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Thomas A. Reeder John E. Skvarla, III
Govemor Director Secretary
NOTICE OF RENEWAL INTENT
(Required by 15A NCAC 02H .0127(d)I;'term definition see 15A NCAC 02H .0103(19)1
Application for renewal of existing coverage under General Permit NCG500000
Existing Certificate of Coverage (CoC): NCG5000648
(Press Tab to navigate form)
1) Mailing address of facility owner/operator: (address to which all correspondence should be mailed)
Company Name
Owner Name
Street Address
City
Telephone #
Email Address
Carolinas Medical Center- Mercy
Carolinas Healthcare System
2001 Vail Avenue
Charlotte State NC ZIP Code 28207 -
704 - 304 - 5000 Fax # N A -
[e-mail]
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone #
Email Address
Carolinas Medical Center- Mercy
Mark Rabon
2001 Vail Avenue
Charlotte
Mecklenburg
704 - 304 - 5800 Fax # N A -
[e-mail]
3) Description of Discharge:
a) Is the discharge directly to the receiving stream?
Yes
❑ No — Please submit a
State NC
ZIP Code 28207 -
RECEIVEDIDENR/D\t
Water Quality
Permitting Sector
site map with the pathway to the potential receiving waters clearly marked. This
includes tracing the pathway of the storm sewer to the discharge point, if the storm sewer is the only
viable means of discharge.
b) Number of discharge outfalls (ditches, pipes, channels, etc. that convey wastewater from the property): 1
Page 1 of 3

NCG500000 Renewal Application
c) What type of wastewater is discharged? Indicate which discharge points, if more than one.
® Non -contact cooling water Outfall (s) #: 001
® Boiler Blowdown Outfall (s) #: 001
❑ Cooling Tower Blowdown Outfall (s) #:
® Condensate Outfall (s) #: 001
❑ Other Outfall (s) #:
(Please describe "Other"):
d) Volume of discharge per each discharge point (in GPD):
#001: 8640 GPD #002: GPD #003: GPD #004: GPD
4) Please check the type of chemical's] added to the wastewater for treatment, per each separate discharge
point (if applicable, use separate sheet):
❑ Chlorine ❑ Biocides
❑ Corrosion inhibitors ❑ Algaecide
❑ Other ® None
If any box other than None is checked, a completed Biocide 101 Form and manufacturers' information on the
additive must be submitted to the following address for approval:
NC DENR / DWR / Environmental Sciences Section
Aquatic Toxicology Unit
1621 Mail Service Center
Raleigh, NC 27699-1621
5) Is there any type of treatment being provided to the wastewater before discharge? (Le., retention ponds,
settling ponds, etc.)
❑ Yes - Please include design specifics (i.e., design volume, retention time, surface area, etc.) with submittal
package. Existing treatment facilities should be described in detail.
® No
6) Discharge Frequency:
a) The discharge is: ® Continuous ❑ Intermittent ❑ Seasonal
i) If the discharge is intermittent, describe when the discharge will occur:
ii) If seasonal, check the month(s) the discharge occurs:
❑ Jan ❑ Feb ❑ Mar. ❑ Apr ❑ May ❑ Jun ❑ Jul ❑ Aug. ❑ Sept. ❑ Oct. ❑ Nov. ❑ Dec.
b) How many days per week is there a discharge? 7
c) Please check the days discharge occurs: ® Sat. ® Sun. ® Mon. ® Tue. ® Wed. ® Thu. ® Fri.
RECEIVEDID, NR/Dwp
01, 2 9 _:,,
Water Quality
Permitting Section
Page 2 of 3

NCG500000 Renewal Application
Additional Application Requirements:
The following information must be included in duplicate [original + 1 copy] with this application or it
will be returned as incomplete.
➢ Site map. If the discharge is not directly to a stream, the pathway to the receiving stream must
be clearly indicated. This includes tracing the pathway of a storm sewer to its discharge point.
> Authorization for representatives. If this application will be submitted by a consulting
engineer (or engineering firm), include documentation from the Permittee showing that the
consultant submitting the application has been designated an Authorized Representative of the
applicant, per 15A NCAC 021-1 .0138(b)(l ).
CERTIFICATION
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true,? complete, and accurate.
Printed Name of Person Signing: /�G�I/� /��e hf' Title: 5 jor
(Please review NCAC 0211 .0106(e) for authorized signing officials) G
Sig • ture of Applicant
North Carolina General Statute § I43-215.6E provides that:
Any person who knowingly makes any false statement representation, or certification in any application, record,
report, plan, or other document filed or required to be maintained under this Article or a rule implementing this
Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case
under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device
or method required to be operated or maintained under this Article or rules of the Commission implementing this
Article, shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars
($10,000). 18 U.S.C. Section 1001 provides a punishment by a fine or imprisonment not more than 5 years, or both,
for a similar offense.
Click here to enter a date.
Date Signed
This Notice of Renewal Intent does NOT require a separate fee.
The permitted facility already pays an annual fee for coverage under NCG500000.
Mail the original and one copy of the entire package to:
NC DENR / DWR / Water Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Attn: Charles Weaver
Page 3 of 3

1:12500 scale
G 0.1 0.2 03 04 0.5 Miles
0 0 0 2 0 3 0,4 .5 Kilometers
SOURCE: CHARLOTTE EAST, NC 7.5 MINUTE TOPOGRAPHIC QUADRANGLE, 1991
TOPOGRAPHIC SITE LOCATION MAP
CAROLINA MEDICAL CENTER - MERCY
2001 VAIL AVENUE
CHARLOTTE, NORTH CAROLINA
Figure
1

Carolinas Medical Center
July 20, 2015
Mr. Charles Weaver
NCDENR Division of Water Quality
Water Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SUBJECT: Carolinas Medical Center - Mercy
2001 Vail Avenue
NPDES Permit # NCG00648
Notice of Intent Renewal
Dear Mr. Weaver:
Please find attached the NPDES renewal documentation for the CMC-Mercy facility located
at 2001 Vail Avenue in Charlotte, North Carolina. We have attached one original and one
copy of the required documents.
Please contact me at [phone] if you have any questions or need any additional
information.
Sincer y,
. Mark Rabon
Carolinas Healthcare System
RF:CFIVEDIDFNR/DWR
ME r°° ?Olt)
Water Quality
Permitting Sectior

Carolinas Medical Center
July 20, 2015
Mr. Charles Weaver
NCDENR Division of Water Quality
Water Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SUBJECT: Carolinas Medical Center - Mercy
2001 Vail Avenue
NPDES Permit # NCG00648
Notice of Intent Renewal
Dear Mr. Weaver:
RECEIVEDIDENRIDWR
JUL 2 2 2015
Water Q Sect arF
Permittt g
Please find attached the NPDES renewal documentation for the CMC-Mercy facility located
at 2001 Vail Avenue in Charlotte, North Carolina. We have attached one original and one
copy of the required documents.
Please contact me at [phone] if you have any questions or need any additional
information.
Sincer y,
Mr. Mark Rabon
Carolinas Healthcare System