WQ0018708_Permit Renewal_20170310

Environmental
Quality
State of North Carolina
Division of Water Resources
Water Quality Regional Operations Section
Staff Report
To: ❑ NPDES Unit ® Non -Discharge Unit
Attn: David Goodrich
From: Jim Barber
Fayetteville Regional Office
Application No.: WQ0018708
Facility name: Baytree Lakes
Note: This form has been adapted from the non -discharge facility staff report to document the review of both non -
discharge and NPDES permit applications and/or renewals. Please complete all sections as they are applicable.
I. GENERAL AND SITE VISIT INFORMATION
1. Was a. site visit conducted? ® Yes or ❑ No
a. Date of site visit: 02/17/17
b. Site visit conducted by: Jim Barber, Kent White and Tony Honeycutt '
c. Inspection,report attached? ❑ Yes or ® No
d. Person contacted: EnviroLink and their contact information: (252) 235 - 2132 ext.
e. Driving directions: ' From Fayetteville take Hwy 53 to Elizabethtown. Turn left onto Hwy 701 toward White
Lake/Clinton. At the intersection of Hwy 701 and Hwy 41 turn right. Drive approx. 4.5 miles and the Baytree Lakes
office is on the right. The entrance to the WWTP is across Hwy 41.
2. Discharge Point(s): N/A
Latitude: N/A Longitude:
Latitude: N/A Longitude:
3. Receiving stream or affected surface waters: Lake Drain
Classification: C Sw
River Basin and Subbasin No.: Cape Fear/Colly Creek/Lake Drain (181-68-17=1 Lake Drain)
Describe receiving stream features and pertinent downstream uses: !agriculture, primarily blueberry farms
II. PROPOSED FACILITIES: NEW APPLICATIONS
1. Facility Classification: , (Please attach completedrating sheet to be:attached to issued permit)
Proposed flow:
Current permitted flow:
2. Are the new treatment facilities adequate for the type of waste and disposal 'system? ❑ Yes or ❑ No
If no, explain:
3. Are site conditions (soils, depth to water -table, etc) consistent with the submitted reports? ❑ Yes ❑ No ❑ N/A
If no, please explain:
4. Do theplans and site maprepresent the actual site roe lines, wells etc.)? p (property rty) . El Yes ❑ No ❑ N/A
If no, please explain:
FORM: WQROSSR 04-14 Page 1 of 8

;5. Is the proposed residuals management plan adequate? ❑ Yes ❑ No ❑ N/A
If no, please explain:
6. Are the proposed application rates (e.g., hydraulic, nutrient) acceptable? ❑ Yes ❑ No ❑ N/A
If no, please explain:
7. Are there any setback conflicts for proposed treatment, storage and disposal sites? ❑ Yes or ❑ No
If yes, attach a map showing conflict areas.
8. Is the proposed or existing groundwater monitoring program adequate? ❑ Yes ❑ No ❑ N/A
If no, explain and recommend any changes to the groundwater monitoring program:
9. For residuals, will seasonal or other restrictions be required? ❑ Yes n No N/A
If yes, attach list of sites with restrictions (Certification B)
Describe the residuals handling and utilization scheme:
10. Possible toxic impacts to surface waters:
11. Pretreatment Program (POTWs only):
III. EXISTING FACILITIES: MODIFICATION AND RENEWAL APPLICATIONS
1. Are there appropriately certified Operators in Charge (ORCs) for the facility? ® Yes ❑ No ❑ N/A
ORC: Tony Baldwin Certificate #: SI-29101 Backup ORC: Anthony Branch Certificate #:SI-990486
2. Are the design, maintenance and operation of the treatment facilities adequate,jfor the type of waste and disposal
system? ❑ Yes or ® No
If no, please explain:
Description of existing facilities: 20,000 GPD (0.02 MGD) extended aeration plant with approximate 1 ac
polishing pond (approx. 90 day storage at 20,000 GPD) and 5.08 ac spray irrigation field with four zones
Proposed flow: current permitted flow 20,000 GPD (past permit approvals granted for 40,000 and 30,000 GPD,
not constructed)
Current permitted flow: 20,000 GPD
Explain anything observed during the site visit that needs to be addressed by tile permit, or that may be important'
for the permit writer to know (i.e., equipment condition, function, maintenance, a change in facility ownership,
etc.). Facility is currently under an NOV for exceeding flow in the system; which follows up an NOV issued in
2016 for freeboard and floating total violations. Lake Creek Corp. d/b/a Baytree Lakes has not upgraded the
treatment facilities per the permits issued in 2000 (40,000 GPD upgrade) or 2009 (30,000 GPD upgrade reducing
the 2000 permit for monitoring reasons). See additional comments starting on page 6 of 6 under Additional
Review Items. :1
3. Are the site conditions (e.g., soils, topography, depth to water table, etc.) maintained appropriately and adequately
assimilating the waste? ® Yes or ❑ No
If no, please explain:
4. Has the site changed in any way that may affect the permit (e.g., drainage added, new wells inside the compliance
boundary, new development, etc.)? ❑ Yes or ® No
If yes, please explain:
5. Is the residuals management plan adequate? ® Yes or ❑ No
If no, please explain: Most sludge is wasted into holding tanks that are part of the extended aeration plant. A
septage hauler is contracted to pump the holding tank and transport to a local POTW. •
6. Are the existing application rates (e.g., hydraulic, nutrient) still acceptable? ® Yes or n No
If no, please explain:
7. Is the existing groundwater monitoring program adequate? ® Yes ❑ No ❑ N/A
If no, explain and recommend any changes to the groundwater monitoring program:
FORM: WQROSSR 04-14 Page 2 of 8

8. Are there any setback conflicts for existing treatment, storage and disposal sites? ❑ Yes or ® No
If yes, attach a map showing conflict areas.
9. Is the description of the facilities as written in the existing permit correct?; E Yes or ❑ No. -
If no, please explain: .Baytree has not constructed any new infrastructure described in the permit to allow for
incoming -flow into the plant to increase to 30,000 gallons/day; hence the past and recent history of NOV's for
exceeding permitted flow into the plant.
10. Were monitoring wells properly constructed and located? ® Yes ❑ No ❑ N/A
If no, please explain:
FORM: WQROSSR 04-14 i Page 3 of 8

11. Are the monitoring well coordinates correct in BIMS? ® Yes ❑ No ❑ N/A
If no, please complete the following (expand table if necessary):
Monitoring Well
Latitude
1
Longitude
o ,
„
I
,
O ,
,,.
O ,
„
0 ,
„
O ,
„
0 ,
II
0 ,
„
(
1'
0 ,
II
12. Has a review of all self -monitoring data been conducted (e.g., DMR, NDMR, NDAR, GW)? ® Yes or ❑ No
Please summarize any findings resulting from this review: NOV's have been issued in the past and a current
NOV is outstanding with regards to flows into the plant/treatment system. Seel additional comments on page 6 of
6 concerning this issue. •
Provide input to help the permit writer evaluate any requests for reduced monitoring, if applicable.
13. Are there any permit changes needed in order to address ongoing BIMS violations? ® Yes or ❑ No
If yes, please explain: See additional comments on page 6 of 6.
14. Check all that apply:
❑ No compliance issues ' ❑ Current enforcement action(s) ❑ Currently under JOC
® Notice(s) of violation ❑'Currently under SOC 0 Currently under moratorium
Please explain and attach any documents that may help clarify answer/comments (i.e., NOV, NOD, etc.)
If the facility has had compliance problems during the permit cycle, please explain the status. Has the RO been
working with the Permittee? Is a solution underway or in place?
Have all compliance dates/conditions in the existing permit been satisfied? ❑ Yes ® No ❑ N/A
If no, please explain: Current NOV issued 7 Feb 2017 (received by owner oni 22 Feb. 2017). FRO is awaiting
response from the permittee to the NOV and intend to proceed to enforcement action with penalty.
15. Are there any issues related to compliance/enforcement that should be resolved before issuing this permit?
® Yes ❑No❑N/A
If yes, please explain: See additional comments on page 6 of 6.
16. Possible toxic impacts to surface waters; N/A
17. Pretreatment Program (POTWs only): N/A
FORM: WQROSSR 04-14 j Page 4 of 8

IV. •REGIONAL OFFICE RECOIVIlVIENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ® Yes or ❑ No
If yes, please explain: See comments starting on page 6 of 6.
2. List any items that you would like the NPDES Unit or Non -Discharge Unit Central Office,to obtain through an
additional information request:
Item
Reason;i
3. List specific permit conditions recommended to be removed from the permit when issued:
Condition
Reason1',
4. List specific specialconditions or compliance schedules recommended t6be included in the permit when issued:
Condition
Reason
5. Recommendation:
® Hold, pending receipt and review of additional information by regional office
® Hold, pending review of draft permit by regional office
❑ Issue upon receipt of needed additional information
❑ Issue
❑ Deny (Please state asons:
6. Signature of report preparers I Signature of r gio1 supervisor: l 1� ►iyt, % z9rZ- i� 121��> Au.,
Date: R 1/ D 1/
FORM: WQROSSR 04-14
Page 5 of 8

V. ADDITIONAL REGIONAL STAFF REVIEW ITEMS
The Baytree Lakes development started in the early 1970's (1972 according to the Baytree/Lake Creek Corporation
website). The first few homes built had on -site septic systems and water supply wells.
The first wastewater treatment permit issued for the development was an NPDES discharge permit (NC0036404
original issue date of 28 May 1982). The facility operated under the NPDES permit until 15 August 2005, when
rescission of the permit was granted. In place of the NPDES permit, a Non -Discharge spray irrigation permit was
issued on 22 August 2001. Baytree chose to go the ND route for future wastewater management due to the existing
extended aeration plant not being able to meet effluent quality standards in the NPDES permit, along with being
hydraulically overloaded due to flows into the plant being above 20,000 GPD.
The spray irrigation system was not constructed until 2005 and put into operation in July 2005. As part of the new ND
permit, an upgraded wastewater treatment plant was also designed and approved so the facility could increase its
treatment capacity from the original 20,000 GPD to 40,000 GPD. Treatment plant upgrades did not occur in 2005 and
have not been constructed to date, hence the facility still being limited to 20,000 GPD operational capacity.
In 2008 Baytree submitted a revised WWTP design to change the flow to 30,000 GPD to avoid additional sampling
requirements under the newly adopted 2T rules for facilities treating more than 30,000 GPD. A permit was issued on
3 Feb. 2009 for the construction of an upgraded WWTP for treatment of 30,000 GPD. To date this upgrade has not
been constructed and no timetable exists to construct the upgraded treatment works.
Baytree Lakes is currently under an NOV for flow violations relating to wastewater received at the extended aeration
treatment plant. Response to said NOV has not been received and the final day to respond is 15 March 2017. Baytree
has had other NOV's in the past for flow into the plant above 20,000 GPD (annual average), freeboard exceedances
and floating total exceedances.
Past Baytree ORC's have contended and acknowledged that the problem with flow exceedances at the facility is due
to Inflow & Infiltration into the collection system. They content that the I & I problem is related to improper or poor
construction practices related to connecting homes to the main collection system piping. Groundwater also plays a roll
in I & I at the site due to year round groundwater tables being between 1' to 3' below ground surface.
After reviewing the Fayetteville files (both ND and NPDES) and BIMS;'along with doing some research using Bladen
County GIS in conjunction with Google Earth, the first collection system permit (WQCSD0103) was issued on 1
March 2000. This permit evidently addressed collection system infrastructure installed in association with the NPDES
permit issued in 1982. On 10 August 2000 a gravity sewer extension permit (W00018706) was issued that allowed
for a total of 15,200 GPD into the Baytree collection and sewer system. This 2000 permit referenced that this sewer
extension would serve 38 lots (homes) in conjunction with whatever number of homes that existed,prior to 2000. Also
in the cover letter and in the conditions of the permit was language that stated "a no -tap moratorium shall be
imposed on the subject property if the treatment works expansion has not been completed'by the time the flows
reach 20,000 gallons per day". In 2005 another sewer extension permit was issued (W00029523 issue date 12
December 2005). This permit added an additional flow of 11,880 gallons per day'to serve 33 lots (homes) using an
average flow of 360 gallons/day (3-bedroom home) for a grand total of 27,080 GPD (not including I & 1). In the last
NPDES permit issued on 30 May 2002; the total number of homes being served by the Baytree system (under the
NPDES permit) as stated in the Exhibit A was 104. Of the 104 homes in Baytree, 40 homes were considered
second/seasonal. So in 2003; using the numbers supplied in the Exhibit A of the NPDES permit and the assumed flow
of 360 GPD, the possible total flow into the collection/treatment system could be.23,040 GPD (64 homes x 360 PGD).
In reviewing the Bladen County GIS website in 2009/2010 there were 149 homes identified and the Baytree real
estate office. In reviewing the Bladen County GIS website in March 2017; there are 166 homes identified, 1 office
and 3 structures, owned by the Baytree Lakes POA (clubhouses, bathhouses, etc.). Based on the number of homes
identified and using the assumption that approximately 40% of the homes are 'second/seasonal, that total flow into the
Baytree collection/treatment system could be 36,000 GPD (100 homes x 360 GPD). This doesn't take into account the
Baytree real estate office, I & I, POA structures or the 60 seasonal homes. If all structures area taken into account,
then maximum monthly flows could be 61,200 GPD (170 homes/structures x 360 PGD, not including I & l). Also
note that there are approximately 338 empty plated lots existing, along with 7 ior 8 large parcels of land adjacent to the
Baytree development that are owned by Red Bird Land Company LLC.
FORM: WQROSSR 04-14 Page 6 of 8

.With the above information provided (copies of all permits referenced are available if requested), the Fayetteville
Regional office recommends that the permit for this facility not be renewed until 'the following issues have been
adequately addressed:
1). Permit fees for permit W00018708 are still not up-to-date. Four years of permit fees from 2009 to 2012 have
recently been paid. Four years of permit fees are still outstanding covering the years from 2013 to 2016, with
$5240.00 still being owed. The 2017 bill has not been issued due to the billing month being in August:
2). According to the Bladen County GIS website, the current owner of the property that the wastewater treatment
works are on is Red Bird Land Company LLC. Undeveloped tracts of land adjacent to the Baytree development, along
with several lots in the development are also owned by Red Bird Land Company LLC. The request for staff report -
cover page lists the applicant as Lake Creek Corporation and D.S. Jones Jr. signed the application (Steve Jones Sr.
died on 12 Oct. 2016) on behalf of Lake Creek Corporation and there is no mention in the application that Red Bird
Land Company LLC is the owner of the land that has the spray irrigation system,) treatment plant and lagoon or the
collection system within the Baytree development per the Bladen County GIS.,
3). Based on the most recent NOV issued (copy enclosed along with the last inspection report with this staff report)
for flow exceedances and the history of non-compliance at the facility and Lake Creek's failure to upgrade the
treatment plant as approved in two past permit submittals: the Fayetteville Regional Office highly recommends that
conditions be placed in the spray irrigation permit as follows:
A). A no -tap moratorium will be in place starting with the receipt of the permit and shall be in place until upgrades are
made to the Baytree Lakes development collection and treatment system to allow for greater flows into the system of
up to 30,000 GPD (24,000 GPD for planning purposes and 27,000 GPD for design submittal purposes). This shall also
include limiting any expansion requests to existing homes or structures served by the Baytree collections and
treatment system.
Copies of the permit should be mailed to the following list of recipients in conjunction with Steve Jones, Jr.:
Bladen County Manager
106 E. Broad Street
Bladen County Courthouse — Room 105
Elizabethtown, NC 28337
Attn: Greg Martin, County Manager
Bladen County Building Inspections Department
450 Smith Circle
Elizabethtown, NC 28337
Attn: Matthew Chadwick, Director
Bladen County Utilities Department
272 Smith Circle
Elizabethtown, NC 28337
Attn: Randy Garner, Director
FORM: WQROSSR 04-14 Page 7 of 8

Baytree Lakes POA
640 Bay Tree Drive
Harrells, NC 28444
Attn: Charles Atkinson, President
Attn: Jim Crayton, Property Manager
Red Bird Land Company LLC
109 Willesden Drive
Cary, NC 27513-5567
Attn: Jack J. Carlisle
Red Bird Land Company LLC
115 Courthouse Drive
Elizabethtown, NC 28337
4). An accurate map, prepared by a NC Professional Engineer or Professional Larid Surveyor, of the sewer system for
all collection lines (gravity and force main), pump stations, manholes, etc. forall infrastructure installed to date. No
maps exist in the Fayetteville Regional office that depict the current approved collection system per the permit
extensions issued on 10 August 2000 and 12 December 2005.
5). In conjunction with the map, provide copies of all engineer's certifications' for; all infrastructure installed and in use
today. According to BIMS; there is a partial certification for 6244' of gravity and force main sewer extension out of
9530' permitted in the 12 December 2005. This partial certification was received on 18 April 2007. No certification
documents exist in the Fayetteville files for the 10 August 2000 approval.
Once Central Office permitting has had the opportunity to review the staff report and information provided; if a
conference call is necessary to discuss, please email a date and time that would be acceptable to you to schedule the
call. A copy of this staff report will also be provided to Jon Risgaard for discussion.
FORM: WQROSSR 04-14
Page 8 of 8

0 sic earth
meters
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DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
WATER QUALITY REGIONAL OPERATIONS SECTION
NON -DISCHARGE APPLICATION REVIEW REQUEST FORM
January 18, 2017
To: FRO-WQROS: Trent Allen
From: David Goodrich, Water Quality Permitting Section - Non -Discharge Permitting Unit
�`CEIvED
DEQ/DWR
JAN 2 0 2017
GcjA I�'�M
WQROS
FAYETTEVILLE REGIONAL OFFICE
Permit Number: WQ0018708 Permit Type: Wastewater Irrigation
Applicant: Lake Creek Corporation Project Type: Renewal
Owner Type: Organization Owner in RIMS? Yes
Facility Name: Baytree Lakes Facility in BIMS? Yes
Signature Authority: D. Stephen Jones Title: President
Address: 33 West Bay Ridge Road, Harrells, North Carolina 28444 County: Bladen
Fee Category: Non -Discharge Major Fee Amount: $0
Comments/Other Information: WWTF is owned by Redbird Land Company, LLC - They should be the Permittee
unless there is an agreement between them and Lake Creek Corporation.
Attached, you will fmd all information submitted in support of the above -referenced application for your review,
comment, and/or action. Within 45 calendar days, please take the following actions:
® Return this form completed. ® Return a completed staff report.
❑ Attach an Attachment B for Certification. ❑ Issue an Attachment B Certification.
When you receive this request form, please write your name and dates in the spaces below, make a copy of this sheet, and
return it to the appropriate Central Office Water Quality Permitting Section contact person listed above.
RO-WQROS Reviewer:
Date: 3/ / O tj7
z
FORM: WQROSNDARR 09-15 Page 1 of 1

Water Resources
ENVIRONMENTAL QUALITY
January 18, 2017
D. STEPHEN JONES — PRESIDENT
LAKE CREEK CORPORATION
33 WEST BAY RIDGE ROAD
HARRELLS, NORTH CAROLINA 28444
Dear Mr. Jones:
ROY COOPER
Governor
WILLIAM G. ROSS, JR.
Acting Secretary
S. JAY ZIMMERMAN
Director
Subject: Acknowledgement of
Application No. WQ0018708
Baytree Lakes
Wastewater Irrigation System
Bladen County
The Water Quality Permitting Section acknowledges receipt of your permit application and
supporting documentation received on January 17, 2017. Your application package has been assigned the
number listed above, and the primary reviewer is David Goodrich.
Central and Regional Office staff will perform a detailed review of the provided application, and
may contact you with a request for additional information. To ensure maximum efficiency in processing
permit applications, the Division of Water Resources requests your assistance in providing a timely and
complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete application. If you have any questions, please contact
David Goodrich at [phone] or [e-mail].
Sincerely,
Nathaniel D. Thornburg, Supervisor
Division of Water Resources
cc: Fayetteville Regional Office, Water Quality Regional Operations Section
Permit File WQ0018708
-!-•"Nothing Compares=.
State of North Carolina I Environmental Quality I Water Resources I Water Quality Permitting I Non -Discharge Permitting
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-807-6332

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
INSTRUCTIONS FOR FORM: NDSR 06-16 & SUPPORTING DOCUMENTATION
This form is for renewal without modification for all non -discharge system permits, except Residuals Management permits.
For more information, visit the Water Quality Permitting Section's A.,,n-Diceharg, Perinittitv C.`ni,
A. Non -Discharge System Renewal (FORM: NDSR 06-16) Application (All Application Packages):
❑ Submit one original and one copy of the completed and appropriately executed Non -Discharge System Renewal (FORM:
NDSR 06-16) application.
❑ The Applicant's Certification shall be signed in accordance with 1A NCAC 021 .0106(b). Per I5A NCAC 02T .0106Ce1, an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the
criteria in I5A NCAC 02T .0106111- ;.
B. Existing Permit (All Application Packages):
❑ Submit two copies of the most recently issued permit.
C. Certificate of Public Convenience and Necessity (All Application Packages for Privately -Owned Public Utilities):
❑ Per 1 NCAC 02T .0115fa)( l ), provide two copies of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
D. Operation and Maintenance Agreement (All Application Packages for Single -Family Residences):
❑ Submit one original and one copy of the signed Operation and Maintenance Agreement (I OR\'l: SFRWWIS O&M).
E. Operational Agreements (All Application Packages for Ilome/Property Owners' Associations and Developers of lots to be sold):
Y Home/Property Owners' Associations
❑ Per ISA NCAC 021' .01 l cJ, submit an original and one copy of the properly executed Operational Agreement ( FORM:
F10A).
❑ Per l 5 \ NCAC 02T .0115(c), submit an original and one copy of the proposed or approved Articles of incorporation,
Declarations and By-laws.
> Developers of lots to be sold
❑ Pert 5A._NCIC 921.01 ;_5(bl, submit an original and one copy of the properly executed Operational Agreement (FORM;
DIN).
F. Site Map (All Application Packages for permits originally issued or modified after September 1, 2006):
0 Submit two copies of an updated site map in accordance with ISA NCAC 02T .0105(d).
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED TO:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
3122 N. SALISIIUR% ST.
RALEIGH, NORTH, CAROLINA 27604
FAX NUMBER: [phone]
RECEIVEDINCDEQIDWR
JAN 1 7 2017
Non -Discharge
Permitting Unit
INSTRUCTIONS FOR FORM: NDSR 06-16 & SUPPORTING DOCUMENTATION Page 1 of 1

J
DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 06-16
I. PERMITTEE INFORMATION:
I. Permittee's name: Lake Creek Corporation
2. Signature authority's name: D, Stephen Jones per l iA NCAC 02T .0I06(b)
3. Permittee's mailing address: 33 West Bay Ridge Road
City: Harrells State: NC Zip: 28444-
4. Permittee's contact information: Phone number: (7°46-C76_84 Z Email Address: [e-mail]
11. FACILITY INFORMATION:
1. Facility name: Baytree Lakes
2. Facility's physical address: ,VC /N(yhw*y 41/
City: Harrells State: NC Zip: 28444- County: $kadebn ictdCn
III. PERMIT INFORMATION:
1. Existing permit number: WQ0018708 and most recent issuance date: 2/3/09
2. Existing permit type: Wastewater Irrigation
3. Has the facility been constructed? ® Yes or ❑ No
Title: President
RECEIVEDINCDEQIDV
JAN 1 7 2017
Non -Discharge
Permitting Unit
Applicant's Certification per ISA il2T.0106(h):
5, \ i like-S. RtS ( Cl e �l± attest that this application for
(Signature Authority's name & title from Application Item 1.2.)
C(i ro 0 2l
facility name from Application Item II.I.)
has been reviewed by me and is accurate and complete to the best of my knowledge..1 understand that any discharge of wastewater
from this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil
penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water Resources should a
condition of this permit be violated. 1 also understand that if all required parts of this application package are not completed and that
if all required supporting information and attachments are not included, this application package will be returned to me as incomplete.
1 further certify that the Applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater
facility without proper closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are
compliant with any active compliance schedule, and do not have any overdue annual fees per 15.i, NCA:' OAT .01 O5(e).
NOTE — In accordance with General Statutes 1.43-" 5.6 \ and 13-.2 1, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $ 10,000 as w11 as civil penalties up to $25,000 per violation.
Signature:
FORM: NDSR 06-16
Date:
Page I of 1