NC0037001_Application_20161011

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit
NC0037001
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name Rockingham County Schools
Facility Name Bethany Elementary Schools
Mailing Address 511 Harrington Highway
City Eden
State / Zip Code North Carolina 27288
RECElVEC/ coEQi vR
OCT 11 ?016
Water Quality
Permftunq Sactio;t
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 6371 NC Highway 65
City Reidsville
State / Zip Code North Carolina 27320
County Rockingham
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
n/a
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NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial ❑ Number of Employees
Residential ❑ Number of Homes
School X Number of Students/Staff 798
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
N/A School/Bethany
Number of persons served: 497
5. Type of collection system
X Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes X No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
Huffines Mill Creek
8. Frequency of Discharge: ❑ Continuous X Intermittent
If intermittent:
Days per week discharge occurs: 4 Duration: Time Differs
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
See: Also Supplement page (2A)
Note: Sludge and solids are removed from the septic tank as needed
2 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow .010 MGD
Annual Average daily flow .0025 MGD (for the previous 3 years)
Maximum daily flow .0053 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes XNo
12. Effluent Data
NEW APPLICANTS: Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples, for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maximum and monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average over
the past 36 months for parameters currentlr.1 in our permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
45.0 mg/L
30.0 mg/L
2/month
Fecal Coliform
400/100 mL
200/100 mL
2/month
Total Suspended Solids
45.0 mg/L
30.0 mg/L
2/month
Temperature (Summer)
n/a
n/a
weekly
Temperature (Winter)
n/a
n/a
weekly
pH
>6.0
>6.0
2/monthly
13. List all permits, construction approvals and/or applications:
Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
Permit Number
NC003.7001
14. APPLICANT CERTIFICATION
I certify that I am familiar with the
best of my knowledge and belief such
Sonja K. Parks
Printed name of Person Signing
Signature Applicant
Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
Permit Number
information contained in the application and that to the
information is true, complete, and accurate.
Assistant Superintendent, Rockingham County Schools
Title
/®/ate3//6
D
North Carolina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement representation, or certification in any
application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the Environmental Management
Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be
guilty of a misdemeanor punishable by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001
provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both, for a similar offense.)
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