NCS000610_Application_20220331

O'K3tio5
EPA Identification Number
NPDES Permit Number
Facility Name
C` �11.�Q�
Form Approved 03/05/11
l� OMB No. 2040-0004
Coca��y�1
,&
U.S. Environmental Protection Agency
Form
1
:.EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION!
•! 1
1.1 Applicants Not
Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete No
If yes, STOP. Do NOT 0✓ No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
E
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
a
production facility?
currently discharging process wastewater?
cYes
-* Complete Form 1 No
Yes 4 Complete Form 0 No
a
and Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
rn
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
E
commenced to discharge?
discharges only nonprocess wastewater?
Yes 4 Complete Form 1 Qr No
❑ Yes 4 Complete Form No
Of
and Form 2D.
1 and Form 2E. —
y
1.2.5
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
RECEIVED
X
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?.
MAR 312022
�✓ Yes 4 Complete Form 1 ❑ No
and Form 2F
unless exempted by
DEKR-Starrmyater Program
40 CFR
122.26(b)(14)(x) or
(b)(15).
SECTIONDD
AND LOCATION (40
2.1
Facility Name
GOLDSTON LUMBER SUPPLY
0
2.2
EPA Identification Number
a
J
COC 210446
v
2.3
Facility Contact
Name (first and last)
Title
Phone number
y
JODYRAGAN
VICE PRESIDENT
[phone]
a
Email address
[e-mail]
2.4
Facility Mailing Address
A
Street or P.O. box
z
2963 NC HUIY 751
City or town
State
ZIP code
APEX
NC
27523
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Faci@ty Name
Form Approved 03105119
OMB No. 20404ON
2.5
Facility Location
Street, route number, or other specific identifier
a _
2304 SOUTH MAIN STREET
co
County name
County code (if known)
+� o
CHATHAM
°f 0
City or town
State ZIP code
cc-a
Z.
GOLDSTON
NC 27252
SECTION•D
40 CFR
SIC Codes)
Description (optional)
3.1
2429
SPECIAL PRODUCT SAWMILL
2491
WOOD PRESERVING
�d
0
t�
ca
c�
z
3.2
NAILS Code(s)
Description (optional)
321114
LUMBER AND TIMBER TREATING
t�
N
SECTIONOPERATOR
INFORMATION (40
Name of 0 `erator
4.1
LEE HANKINS
0
4.2
Is the name you listed in Item 4.1 also the owner?
❑ Yes 0 No
4.3
Operator Status
0
❑ Public —federal ❑ Public —state ❑ Other public (specify)
o
❑✓ Private ❑ Other (specify)
4.4
Phone Number of Operator
[(9:19) 272-8574
4.5
--0 erator.Address
G
Street or P.O. Box
�a
m
3602 SILK HOPE GUM SPRINGS RD
City or town
State
ZIP code
0
PITTSBORO
NC
27312
.M
Email address of operator
;,
O
[e-mail]
SECTION,0
Is the facility located on Indian Land?
5.1
❑ Yes ❑ No
EPA Form 3510-1 (revised 3-19) Page 2

i
EPA Identification Number
E
0
LU a
CD
c
NPDES
Facility Name
6.1 1 Existing En.rironmental. Permits (check all1hat apply and print or ty
❑ NPDES (discharges to surface ❑ RCRA (hazardous wastes)
water)
❑ PSD (air emissions) ❑ Nonattainment program (C
❑ Ocean dumping (MPRSA) 1 ❑ Dredge or fill (CWA Sectioi
Form Approved 03/05/19
OMB No. 2040-0004
the corresponding permit number for each)
❑ UIC (underground injection of
fluids)
❑ NESHAPs (CAA)
X) ❑ Other (specify)
7.1 Have you attached a topographic map containing all required information to this application? (See instructions for
C specific requirements.)
0 Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
8.1 Describe the nature of your business.
a�
c
m
0
eo
z
9.1 Does your facility use cooling water?
❑ Yes 0 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
a, 0 40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
= W NPDES permitting authority to determine what specific information needs to be submitted and when.)
Owe
O�
V �
SECTIONE VARIANCE REQUESTS41
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.)
m ❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
°C Section 301(n)) 302(b)(2))
m
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑ Not applicable
EPA Form 3510-1 (revised 3-19)
Page 3

EPA
Identification
Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No. 2040-0004
SECTIONAND
11.1
- • 1 CFR . a
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
Column 2
❑✓ Section 1: Activities Requiring an NPDES Permit
❑ wl attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ wl attachments
0 Section 3: SIC Codes
❑ w/ attachments
✓❑ Section 4: Operator information
❑ w/ attachments
Section 5: Indian Land
❑ wl attachments
❑ Section 6: Existing Environmental Permits
❑ w/ attachments
d
❑ Section 7: Map
topographic 0 wl additional attachments
0
S
map
m
0
0 Section 8: Nature of Business
❑ wl attachments
0 Section 9: Cooling Water Intake Structures
❑ w/ attachments
c�
❑ Section 10: Variance Requests
❑ wl attachments
.o
c
❑ Section 11: Checklist and Certification Statement
❑ wl attachments
�C
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. 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 tale
J--, C � ROJ QLr\
J
V ) C-e-
Signatur
Date signed
EPA Form 3510-1(revised 3-19)
Page 4

EPA Identification Number NPOES Permit Number Fadrty Name Form Approved 03/05/19
COC210446 GOLDSTON LUMBER SUPPLY, LLC OMB No. 2040-OON
Form U.S Environmental Protection Agency
2F 1100EPA Application for NPDES Permit to Discharge Wastewater
NPDES STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY
SECTION• • • 40 CFR
1.1 Provide information on each of the facili 's outfalls in the table below
Outfall Receiving Water Name Latitude Longitude
Number
1 CEDAR CRK TO DEEP RIVER 3T 35 147 79° 19, 4r
c
0
2 CEDAR CRK TO DEEP RIVER 35° 39 12" 79° 19' 40r
a
0
3 CEDAR CRK TO DEEP RIVER 35' 3S' id, 79' 19' 36N
O
O / IJ
- I IJ O q
SECTION 2. IMPROVEMENTS -
2.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes 0 No 4 SKIP to Section 3.
2.2 Briefly identify each applicable project in the table below.
IS Identification and Affected Outfalls Final Compliance Dates
Description of Project (Iistautfallnumbers) Source(s) of Discharge
Required Projected
N _
E'
O,
R
E.
2.3 Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (Optional Item)
❑ Yes ❑ No
EPA Form 3510 2F (Revised 3-19) Page 1

EPA Identificatton Number NPDES Permit Number Facility Name Form Approved 03/05119
COC210446 I I GOLDSTON LUMBER SUPPLY, LLC I OMB No. 2040-0004
3.1 Have you attached a site drainage map containing all required information to this application? (See instructions for
specific guidance.)
o ® Yes ❑ No
3
0
CO)
a
0
CL
4.1 1 Provide information on the facility's pollutant sources in the table below.
outfall Impervious Surface Area Total Surface Area Drained -
Number (within a mile radius of the %ditty) (within a mile radius of the facility)
specify units specify units
specify units specify units
specify units specify units
specify units specify units
specify units specify units
specify units specify units
4.2 1 Provide a narrative description of the facility's significant material in the space below. (See instructions for content
requirements.)
WOOD TREATMENT
4.3 Provide the location and a description of existing structural and non-structural control measures to reduce pollutants in
stormwater runoff. See instructions forspecificguidance.)
Stormwater Treatment
Codes.
Outfap from
Number Control Measures and Treatment Exhibit
2F-1
gist)
SELF CONTAINED COVERED DRIP PAD
COVERED MAKE UP WATER STORAGE
EQUIPMENT TO BE STORED UNDER COVERED AREA
EPA Form 3510-2F (Revised 3-19) Page 2

' t•
tee? �i o 1 I ;:; �• • -
t 7.
• :.:' � lid +.• 'AL
� •• •..
• r - . °g an Office
_ 2.8SSwti s• Main gas cutoff
A ` �ti •' i - S .
Cr
kK
t - Treatin►s Plan Saw
• --
Yard 0
Jr
�Ab/. 97 •.-
�s� c Gas- -
•
Wat 'cLtt�f .i
y
-! - w Foxe-' ?� ;z r• :� . _
_ f b - =---• SCAL 1 = 200
EXTERIOR ; O 6 • .� Ca
ke /,(dt-�tn �" ....... . . . . . ....... ound Stopes ..... a
Well . irection
Fence............ .. - ' ' ' ' ' ' Stream or reek .........:-..'
Gate . . _ • . —�1— Drain Lines or Culverts .
........
• - • • • • (with direction of flow) lmpoundm nt Location ... .
Railroad ......... .... +H I l ,- Ult Pump ...... .......... Q
Drain Inlet ..........4 ......... Q Surface ................ �--�
Manhole ........... ......... Q Underground .. ......... _ 4 - -� -
Proposed ike or Bens
lam rYtab �e L� �`5 �► — 3 —

f •
r
�NtR 1
-a -
• :. Office .-
2.8S5 we - Cutoff
a ��
SavuMili � i' � ��� •'a
Treatang Plan-:y-
3.
• • �� � '•� Rl• "fit
nA sg�_ �. Yard 0 1 - t�.•'.1
jan:-
.�771.
,�- Finished goods
- inventory Lag storage " Wat _ , •:
•
- SCALE In — 200'
EXTERI R CONTOURMTERVAL
JIUEKVAL
1Q' .
Re drgn t t
Y O well .......................... irection Ground Stokes
Fence............ .... ��--
Gate ............. Drain Lines or Culverts Stream or Creek ....•..::.•.:
Railroad ......... .... -i (with direction of flow) Impoundment Location - . : • . • - ' O
- Surface — lit Pump . • .. - • • P
Drain Inlet ........ . - . - ...... ® ............... r Betm
Manhole ........... .........
© underground ............. 4-4- oposed Dike o • - • -
F1,gwn4able ' LI'Tas`ds AA-, Goldston Lumber land use area

GOLDSTON LIMBER, INC.
SITE RUNOFF CONTROL
Draw map showing the surrounding area for about one can be contained. Locate where and how runoff maybe
mile in all directions. Extend the map in the direction of th blocked by dikes. dams, shutting off flit pumps, etc. Show
site drainage so that drainage can be traced until it reache a surrounding land use (residential, cornfield, etc.). Show places
nearest large body of water if runoff can be impounded on of public assembly, such as schools, churches. Use symbols
off site show loca 'on and approx mate number of oallons ., below. Sh w North arrow.
or Cc
u
4 r - n Office
2.8 ss in gas Cutoff
'w
./V u .7 • Fue Os.l`' • Shop
! jam. . �'• � � o ^ � � � 'S•..
vokle(s
Kin =-•� '=;.:.
x�. A Dp,`�� ler oo =.
_�.�•'" Tank Farm
i '• 'r.
Sawmill
TreatinPlang : r ;
• s Covered' Drip Pad
Yard 0 i
•� Remanufacturing Plant
Gas
Q- Wate cuff.
r Electr•cal .t
• - Fire
SCALE 1" = 200'
EXT ERVY
R - a ¢�'`—•Jt. • °� �' CONTOUR INTERVAL 10 t
�Qedmn`_� vvett ....... name-"'• f irection Ground Slopes ... •-•••�•�
Fence ............ ... • '�' Stream or Creek ...........
- - Gate ............. .... —��-- Drain Lines or Culverts -
-�+t+H-t- (with direction of flow) Impoundment Location O
Railroad ........_. .... S ................�_ Lift Pump ..................... P
Drain Inlet ....................... Q Surface _
• �
• 11ei� i �i
�QM
roposed Dike or Berm
Underground ...........-aP
Yanhole.....�, ....
(e fit` ds — s -"
AK
otsor`s'

It
41
.�vc •- ,-yam/ -� � y I Y ,�� _,.-.. ,
P
r n
Y � , �• y . P..'y.
jr,�yea •• rr a 5. l -��
f
Ab
a . .
Ps
i
t
• e
AUNTY, NC
Parcel Number:
9209
Deed Book:
Deed Page:
825
0374
Map Number:
9606-28-8989.000
Owner Name:
SHIELDS PAUL J & SARA G
Plat Book::
i"%rn
21
P O BOX 219
Plat Page:
)4 S. Main Street - Goldston Lumber
caneerr CCityity: :
GOLDST
Deed Acres:
20.546
Owner State:
NC
Physical Address:
2304 BELLEVUE ST N
Owner Zip:
272520000
Improvement Value:
143603
•provided on mle map na preperea lw rro lrnenlpry of reel propeM found wlmin
Tax Year
Land Value:
92046
no y,Wamar•awa01Wr mwrdedpai., daada,mdo0arpW10ra a
.. mu mu�wrartamradpnai p_ro+a•pr+r •ad anpua wrm.pwawed
Description:
GO3-1
Fire District:
200 One Inch =400 Feet
e Illlp seerA. pryxry apge¢el, survry, a la zmmg veriAwMn.
Township Code:

EPA Identification Number NPDES Permit dumber Facility Name Form Approved 03/05/19
COC210446 GOLDSTON LUMBER SUPPLY, LLC OMB No.2040-0004
SECTIONsN STORMWATER DISCHARGES +t CFR 122,26(c)(1)(j)(C))
5.1 l certify under penalty of law that the outfall(s) covered by this application have been tested or evaluated for the
presence of non-stonnwater discharges. Moreover, ! certify that the outfalls identified as having non-stonnwater
discharges are described in either an accompanying NPDES Form 2C, 2D, or 2E application.
Name (print or type first and last name) I Official title
Signature
Date signed
w 5.2 Provide the testing information requested in the table below.
Outfa[I
Ma Onsite Drainage Points
Description of Tessting:Method Used. Dates) of Testing Dlre.ccdy Observed
o Number
. During Test
m
R
3
0
o,
0
z
C.
L
O
,x
0
m
J
r
C
t�
ii
c
a,
I6.1 I Describe any significant leaks or spills of toxic or hazardous pollutants in the last three years.
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
7.1 Is this a new source or new discharge?
o❑ Yes + See instructions regarding submission of ❑ No + See instructions regarding submission of
d
estimated data. actual data.
v� Tables A, B, C, and b
y 7.2 Have you completed Table A for each outfall?
o
❑ Yes ❑ No
EPA Form 3510-2F (Revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03105/19
COC210446
GOLDSTON LUMBER SUPPLY, LLC
OMB No.20404M
7.3
Is the facility subject to an effluent limitation guideline (ELG) or effluent limitations in an NPDES permit for its process
wastewater?
❑ Yes ❑ No 4 SKIP to Item 7.5.
7.4
Have you completed Table B by providing quantitative data for those pollutants that are (1) limited either directly or
indirectly in an ELG and/or (2) subject to effluent limitations in an NPDES permit for the facility's process wastewater?
❑ Yes ❑ No
7.5
Do you know or have reason to believe any pollutants in Exhibit 2172 are present in the discharge?
❑ Yes ❑ No 4 SKIP to Item 7.7.
7.6
Have you listed all pollutants in Exhibit 217--2 that you know or have reason to believe are present in the discharge and
provided quantitative data or an explanation for those pollutants in Table C?
❑ Yes ❑ No
7.7
Do you qualify for a small business exemption under the criteria specified in the Instructions?
❑ Yes +SKIP to Item 7.18. ❑ No
7.8
Do you know or have reason to believe any pollutants in Exhibit 2173 are present in the discharge?
❑ Yes ❑ No 4 SKIP to Item 7.10.
7.9
Have you listed all pollutants in Exhibit 2F 3 that you know or have reason to believe are present in the discharge in
:r.
Table C?
o'
El Yes ❑ No
c.�
o.
7.10
Do you expect any of the pollutants in Exhibit 2F-3 to be discharged in concentrations of 10 ppb or greater?
Yes ❑ No 4 SKIP to Item 7.12.
7.11
Have you provided quantitative data in Table C for those pollutants in Exhibit 2173 that you expect to be discharged in
m
concentrations of 10 ppb or greater?
❑ Yes ❑ No
7.12
Do you expect acrolein, acrylonitrile, 2,4-dinitrophenol, or 2-methyl-4,6-dinitrophenol to be discharged in concentrations
of 100 ppb or greater?
❑ Yes ❑ No + SKIP to Item 7.14.
7.13
Have you provided quantitative data in Table C for the pollutants identified in Item 7.12 that you expect to be
discharged in concentrations of 100 ppb or greater?
❑ Yes ❑ No
7.14
Have you provided quantitative data or an explanation in Table C for pollutants you expect to be present in the
discharge at concentrations less than 10 ppb (or less than 100 ppb for the pollutants identified in Item 7.12)?
❑ Yes ❑ No
7.15
Do you know or have reason to believe any pollutants in Exhibit 2F-4 are present in the discharge?
❑ Yes ❑ No 4 SKIP to Item 7.17.
7.16
Have you listed pollutants in Exhibit 217-4 that you know or believe to be present in the discharge and provided an
explanation in Table C?
❑ Yes No
7.17
Have you provided information for the storm event(s) sampled in Table D?
❑ Yes ❑ No
EPA Form 3510-2F (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
COC210446
GOLDSTON LUMBER SUPPLY, LLC
OMB No. 2040-0004
.p
Used or
Manufactured Toxics
7.18
Is any pollutant listed on Exhibits 2F 2 Through 2F-4 a substance or a component of a substance used or
manufactured as an intermediate or final product or byproduct?
❑ Yes ❑ No 4 SKIP to Section 8.
0
7.19
List the pollutants below, including TCDD if applicable.
10
1. CCA 4. 7.
2. CA 5. 8.
0
3. 6. 9.
SECTION
i BIOLOGICAL
TOXICITY TESTING DATA I -
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on
8.1
any of your discharges or on a receiving water in relation to your discharge within the last three years?
iv
c
❑ Yes ❑ No 4 SKIP to Section 9.
8.2
Identify the tests and their purposes
below.
Test(s)
Purpose of Tests)
Submitted to NPDES
PermiNin Authc '
Date Submitted
x
t=
❑ Yes ❑ No
❑ Yes ❑ No
o
0
❑ Yes ❑ No
ao
CONTRACTSECTION 9.
ANALYSIS INFORMATION,i CFR
Were any of the analyses reported in Section 7 (on Tables A through C) performed by a contract laboratory or
9.1
consulting firm?
❑ Yes ❑ No 4 SKIP to Section 10.
9.2
Provide information for each contract
laboratory or consulting firm
below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
A
la
C
w
H
Laboratory address
Jq
Phone number
c�
Pollutant(s) analyzed
EPA Form 3510-2F (Revised 3-19) Page 5

�riveo r- rom W ou, von J
CCA Type
Treatina SnI"fts ..
HAZARDOUS INGREDIENTS
Chromic Acid
Cupric Oxide
Arsenic Pentoxide
Water
(Percentag
According to solution
Strength)
Minimum 90%
WARNING
skin, or if inhaled or swallowed. Avoid Wear gloves impervious to the wood treatment formulz
Wash thoroughly after skin contact and where dermal contact is expected (e.g., Handling fresh
:co products or using restrooms. manually opening cylinder doors).
ducts during those parts of the applica- ENVIRONMENTAL HAZARDS
to the wood treatment formulation (e.g,, Do not discharge effluent containing this product into la
Dors, moving trams out of cylinders, estuaries, oceans or other waters unless in accordance
hly treated wood). ments of a National Pollutant Discharge Elimination Sw
permit and the permitting authority has been notified in
othing (e.g., Gloves, overalls, jackets, discharge. Do not discharge effluent containing this prc
n and handling of inorganic arsenicals systems without previously notifying the local sewage to
)prene, NBR (blpa-n), and polyethylene. authority. For guidance contact your State Water Boara
of the EPA.
TORS ONLY SIDE MATERIAL SAFETY DATA SHEET FOR FURTHER INFORMATION

Wolman@
For Industri
(CAmoB
I Use Only
INGREDIIENTS:
TIVE INGREDIENTS:
Copper (elemental)'
Tebuconazole: alpha-(2-(4-chlorophe yl)
ethyl-alpha-(1,1-dimethylethyl)-1H-1, ,4-
triazole-1-ethanol
INERT INGREDIENTS:
Total t
`Mixed inorganic copper complexes may be expressed as coy yr
elemental equivalent.
KEEP OUT OF REACH OF CHILDREN
ANGER
IFS WED:
all a poison control center or doc
• Do not induce vomiting unless told
or doctor.
• Have person sip a glass of water it
• Do not give anything by mouth to 4
IF ON SKIN OR CLOTHING:
• Take off contaminated cloturing.
• Rinse skin immediately with plenty
• Call a poison control center or doc
IF IN EYES:
• Hold eye and rinse slowly and gen
• Remove contact lenses, if present,
X
U_
immediately for treatment _rc .
do so by poison control cent:.
,able t() swallow
r unconscibus person.
)t water for minutes
)r for treatment advice.
with water for 15-20 minutes,
Ier the first 5 minutes, then

EPA tdentificatron
Number NPDES Permit Number Facility Name Form Approved 03/05/19
COC210446
GOLDSTON LUMBER SUPPLY, LLC OMB No. 2040-0004
SECTIONt
CHECKLIST
10.1
AND CERTIFICATION, .t
In Column 1 below, mark the sections of Form 2F 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 com fete all sections or provide attachments.
Column 1
Column 2
0 Section 1
❑ wl attachments (e.g., responses for additional outfalls)
❑� Section 2
❑ wl attachments
❑✓ Section 3
❑ wl site drainage map
El Section 4
❑ wl attachments
❑ Section 5
❑ w/ attachments
❑ Section 6
❑ w/ attachments
...
Or
0 Section 7
❑ Table A ❑ wl small business exemption request
_
❑ Table B ❑ wl analytical results as an attachment
0
❑ Table C ❑ Table D
❑ Section 8
❑ wlattachments
❑ Section 9
❑ w/attachments (e.g., responses for additional contact laboratories or firms)
❑ Section 10
❑
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10.2
Certification Statement
l 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 tine
and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
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Signatu
Date signed
EPA Form 3510 2F (Revised 3-19) Page 6