NC0070157_Renewal (Application)_20220811

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ROY COOPER
GovernorII-
ELIZABETH S.BISER °^
Secretary
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
August 29, 2022
Dare County
Attn: Patrick Irwin, Utilities Director
PO Box 1000
Manteo, NC 27954-1000
Subject: Permit Renewal
Application No. NC0070157
Kill Devil Hills Reverse Osmosis WTP
Dare County
Dear Applicant:
The Water Quality Permitting Section acknowledges the August 11, 2022 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
D_E Q N of Envieal Quality iof W
./ WashingtonorthCarolina RegionaDepartmentl Office 943 Washingtonronmnt Square MDall visi Wan oshinatergtonResources North Carolina 27889
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This package contains Forms 1 & 2C for Dare County
NPDES Permit renewal Application for NC0070157
RECEIVED
Aub 2 6 2022
NCDEQIDWRINPDES

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2C \r.EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTION 1. OUTFALL LOCATION (40 CFR 122.21(g)(1))
1.1 Provide information on each of the facility's outfalls in the table below.
o Outfall Receiving Water Name Latitude Longitude
w. Number
co
c 002 Atlantic Ocean 36° 01' 58" N -75° 65' 28" W
° 0 II
0
II I
SECTION 2. LINE DRAWING (40 CFR 122.21(g)(2))
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
c -3 balance?(See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J R
o ✓❑ Yes ❑ No
SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(g)(3))
3.1 For each outfall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
**Outfall Number** 002
Operations Contributing to Flow
Operation Average Flow
Reverse Osmosis Water Treatment Plant RECEIVED 2.219 mgd
E 7 6 ZOZZ mgd
cu
V. mgd
NCDEQIDWRINPDES
co mgd
y
c Treatment Units
rn Description Code from Final Disposal of Solid or
0) (include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
'' retention time,etc.) by Discharge
Three 1.3 MGD Units&Two 1 MGD Units 1-S None
EPA Form 3510-2C(Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
3.1 **Outfall Number**
cont. Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
retention time,etc.) by Discharge
-0
c
C
0
U
c
m
0I
m
**Ouffall Number**
Operations Contributing to Flow
Operation LL p Average Flow
d
R mgd
cp
mgd
mgd
mgd
Description Final Disposal of Solid or
(include size,flow rate through each treatment unit, Code from Liquid Wastes Other Than
retention time,etc.) Table 2C-1
by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
d .cr) ❑ Yes ❑✓ No 4 SKIP to Section 4.
N 3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C(Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
SECTION 4. INTERMITTENT FLOWS(40 CFR 122.21(g)(4))
4.1 Except for storm runoff,leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑ Yes ✓❑ No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages,if necessary.
Outfall Operation Frecuency Flow Rate
Number (list) Average Average Long-Term Maximum Duration
Days/Week Months/Year Average Daily
days/week months/year mgd mgd days
days/week months/year mgd mgd days
u_
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5. PRODUCTION (40 CFR 122.21(g)(5))
5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No SKIP to Section 6.
5.2 Provide the following information on applicable ELGs.
ELG Category ELG Subcategory Regulatory Citation
.0
R
a
5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
0 Yes 0 No 4 SKIP to Section 6.
0
5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall
Number Operation,Product,or Material Quantity per Day Unit of
Measure
f0
co
's+
0
EPA Form 3510-2C(Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
SECTION 6. IMPROVEMENTS(40 CFR 122.21(g)(6))
6.1 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 ❑✓ No 4 SKIP to Item 6.3.
6.2 Briefly identify each applicable project in the table below.
Affected Final Compliance Dates
Brief Identification and Description of Outfalls Source(s)of
Project (list outfall Discharge Required Projected
number)
-c
c
ea
H
a)
a
rn
a
6.3 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 ❑ Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7))
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.
Table A.Conventional and Non-Conventional Pollutants
7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑ Yes ❑✓ No 4 SKIP to Item 7.3.
7.2 If yes, indicate the applicable outfalls below.Attach waiver request and other required information to the application.
Outfall Number Outfall Number Outfall Number
7.3 Have you completed monitoring for all Table A pollutants at each of your ouffalls for which a waiver has not been
requested and attached the results to this application package?
t ❑✓ Yes ❑ No; a waiver has been requested from my NPDES
permitting authority for all pollutants at all outfalls.
Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes ❑ No 4 SKIP to Item 7.8.
CD 7.5 Have you checked"Testing Required"for all toxic metals,cyanide, and total phenols in Section 1 of Table B?
❑ Yes ❑ No
7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified
in Exhibit 2C-3.
Primary Industry Category Required GC/MS Fraction(s)
(Check applicable boxes.)
0 Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile ❑Acid 0 Base/Neutral
se/ eutral ❑ Pesticide
EPA Form 3510-2C(Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
7.7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑ No
7.8 Have you checked"Believed Present"or"Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑ Yes ✓❑ No
7.9 Have you provided(1)quantitative data for those Section 1, Table B,pollutants for which you have indicated testing is
required or(2)quantitative data or other required information for those Section 1,Table B,pollutants that you have
indicated are"Believed Present"in your discharge?
✓❑ Yes ❑ No
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes -3 Note that you qualify at the top of Table B, ❑✓ No
d then SKIP to Item 7.12.
7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B, pollutants for which you have
Udetermined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5, Table B,
ti pollutants you have indicated are"Believed Present"in your discharge?
❑ Yes 0 No
w; Table C.Certain Conventional and Non-Conventional Pollutants
7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C
for all outfalls?
0 Yes ❑✓ No
t" 7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated
co "Believed Present"?
0 Yes 0 No
E Table D.Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for
all outfalls?
❑ Yes ❑✓ No
7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)by providing quantitative data, if available?
❑ Yes ❑✓ No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
0 Yes 4 Complete Table E. ✓❑ No 4 SKIP to Section 8.
7.17 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑ No
SECTION 8. USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9))
8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
0 Yes 0 No 4 SKIP to Section 9.
co
w 8.2 List the pollutants below.
0 1. 4. 7.
v 2. 5 8
N
3. 6. 9.
EPA Form 3510-2C(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
SECTION 9. BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(g)(11))
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge?
❑✓ Yes ❑ No 4 SKIP to Section 10.
,_ 9.2 Identify the tests and their purposes below.
5 Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
o Permitting Authority?
Quarterly Chronic Toxicity Pass/Fail ✓❑ Yes El NO
o
❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑✓ Yes ❑ No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm Environmental Chemist Inc.
Laboratory address 6602 Windmill Way,
Willmington,NC 28405
U
lO
C
Phone number
[phone]
Pollutant(s)analyzed Conductivity
Total Copper
Turbidity
Salinity
Total Dissolved Solids
SECTION 11.ADDITIONAL INFORMATION (40 CFR 122.21(g)(13))
11.1 Has the NPDES permitting authority requested additional information?
0 ❑ Yes ❑✓ No 4 SKIP to Section 12.
J
11.2 List the information requested and attach it to this application.
2 5.
3. 6.
EPA Form 3510-2C(Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
Dare County NRO WTP OMB No.2040-0004
SECTION 12. CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and (d))
12.1 In Column 1 below, mark the sections of Form 2C 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 complete all sections or provide attachments.
Column 1 Column 2
✓❑ Section 1: Outfall Location ✓❑ w/attachments
❑✓ Section 2: Line Drawing p w/line drawing 0 w/additional attachments
w/list of each user of
im Section 3:Average Flows and
Treatment El w/attachments El privately owned treatment
works
❑ Section 4: Intermittent Flows ❑ wl attachments
❑ Section 5: Production 0 w/attachments
w/optional additional
❑ sheets describing any
0Section 6: Improvements 0 wl attachments additional pollution control
plans
❑ w/request for a waiver and ❑ w/explanation for identical
supporting information outfalls
w
d w/small business exemption
d ❑ request El w/other attachments
N ❑ Section 7: Effluent and Intake El Table A p w/Table B
Characteristics
0
0 w/Table C ❑ w/Table D
d 0 w/Table E ❑ w/analytical results as an
O attachment
oSection 8: Used or Manufactured
❑ Toxics ❑ w/attachments
32 Section 9: Biological Toxicity
0 ✓❑ Tests 0 w/attachments
U
✓❑ Section 10: Contract Analyses ❑ w/attachments
❑✓ Section 11:Additional Information 0 w/attachments
Section 12: Checklist and
❑✓ Certification Statement 0 w/attachments
12.2 Certification Statement
I 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) Official title
Patrick Irwin Utilities Director
Signatur _--� Date signed
c --i. .,474,tiz--- —%-- ---' 08/23/2022
EPA Form 3510-2C(Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Dare County NRO WTP
TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))1
Effluent
Waiver Units Maximum Maximum Lon Term
Pollutant Requested Long-
Term
(specify) Daily Monthly Average Daily Number
Discharge Discharge Discharge Analysi
(required) (if available) (if available)
❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
Biochemical oxygen demand Concentration
1' El(BOD5)
Mass
Chemical oxygen demand Concentration
2' ❑(COD)
Mass
Concentration
3. Total organic carbon(TOC) ❑
Mass
Concentration
4. Total suspended solids(TSS) ❑
Mass
Concentration
5. Ammonia(as N) ❑
Mass
6. Flow ❑ Rate MGD 2.219 365
Temperature(winter) ❑ °C °C
7.
Temperature(summer) ❑ °C °C
pH(minimum) ❑ Standard units S.U. 7.53 60
8.
pH(maximum) ❑ Standard units s.u. 7.76 60
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e., methods)approved under 40 CFR 136 for the analysis of pollut
required under 40 CFR chapter I,subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C(Revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Dare County NRO WTP
TABLE B.TOXIC METALS, CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one) Effluent
Pollutant/Parameter Testing Units Long-Te
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum
Averag
DailyMonthly
Present Absent Daily
1 Discharge Discharge Dischar
(required) (if available)
(if availab
❑ Check here if you qualify as a small business per the instructions to Form 2C and,therefore,do not need to submit quantitative data for any o
2 through 5 of this table. Note, however,that you must still indicate in the appropriate column of this table if you believe any of the pollutants li
Section 1.Toxic Metals,Cyanide,and Total Phenols
1.1 Antimony,total 0 Concentration
0 El
(7440-36-0) Mass
1.2 Arsenic,total 0 Concentration
(7440-38-2) Mass
1.3 Beryllium,total 0 Concentration
El 0
(7440-41-7) Mass
1.4 Cadmium,total 00 Concentration
(7440-43-9) Mass
1.5 Chromium,total 0 Concentration
(7440-47-3) Mass
1.6 Copper,total 0 Concentration Mg .0476
El 0
(7440-50-8) Mass L
1.7 Lead,total 0 Concentration
0 El
(7439-92-1) Mass
1.8 Mercury,total 0 Concentration
(7439-97-6) Mass
1 9 Nickel,total 0 Concentration
(7440-02-0) Mass
1.10 Selenium,total 0 Concentration
(7782-49-2) Mass
1.11 Silver,total 0 Concentration
El 0
(7440-22-4) Mass
EPA Form 3510-2C(Revised 3-19)

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EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
W
Form U.S. Environmental Protection Agency
1 %%EPA Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and (f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 2
treatment works? 1.1. treating domestic sewage?
If yes, STOP. Do NOT complete i3 No If yes, STOP. Do NOT ❑ 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,
operation or a concentrated aquatic animal commercial, mining,or silvicultural facility that is
a production facility? currently discharging process wastewater?
Yes 4 Complete Form 1 No ✓❑ Yes 4 Complete Form No
n 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,
mining,or silvicultural facility that has not yet commercial, mining,or silvicultural facility that
commenced to discharge? discharges only nonprocess wastewater?
dEl Yes 4 Complete Form 1 No Yes-4 Complete Form No
and Form 2D. 1 and Form 2E.
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
0 Yes 4 Complete Form 1 ❑ No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2. NAME. MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
Dare County North Reverse Osmosis WTP
O 2.2 EPA Identification Number
w
0
-J
• 2.3 Facility Contact
V!
fE
Name(first and last) Title Phone number
QPatrick Irwin Utilities Director [phone]
Email address
[e-mail]
2.4 Facility Mailing Address
Street or P.O.box
600 Mustian Street
City or town State I ZIP code
Kill Devil Hills North Carolina 27948
EPA Form 3510-1(revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
N d 2.5 Facility Location
a Y Street, route number,or other specific identifier
Q 0 600 Mustian Street
rn
c o County name County code(if known)
Fo w
g 51 Dare
E City or town State ZIP code
Kill Devil Hills North Carolina 27948
SECTION 3. SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional)
H
0
U
co
U
z 3.2 NAICS Code(s) Description(optional)
to
U
U,
SECTION 4. OPIIRATOR INFORMATION (40 CFR 122.21(f)(4))
4.1 Name of Operator
Jordan Curies
4.2 Is the name you listed in Item 4.1 also the owner?
o ❑ Yes ❑✓ No
4.3 Operator Status
R ❑ Public—federal ❑ Public—state El Other public(specify)County
p ❑ Private ❑ Other(specify)
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
w Street or P.O. Box
E 0 600 Mustian Street
0 =
w City or town State I ZIP code
o V Kill Devil Hills North Carolina 27948
n Email address of operator
0 [e-mail]
SECTI01 5. INDWN LAND(40 CFR 122.21(f)(5))
0 5.1 Is the facility located on Indian Land?
C ❑Yes ❑✓ No
EPA Form 3510-1(revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0070157 Dare County NRO WTP OMB No.2040-0004
SECTION 6. EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
d m NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
water) fluids)
NC0070157
E
` w ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
x ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑ Other(specify)
SECTION 7. MAP(40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
0 specific requirements.)
2
❑✓ Yes ❑ No ❑ CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8. NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Revers osmosis water treatment facility.
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SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
6- d
�' ❑ Yes ❑✓ No + 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
2 40 CFR 125, Subparts I an
d d J mayhave additional application�� p a app cation requirements at 40 CFR 122.21(r).Consult with your
�, NPDES permitting authority to determine what specific information needs to be submitted and when.)
O
O la
V C
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.)
43
❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section
Section 301(n)) 302(b)(2))
❑ 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
NC0070157 Dare County NRO WTP 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 Column 2
✓❑ Section 1:Activities Requiring an NPDES Permit ❑ wl attachments
❑✓ Section 2: Name, Mailing Address,and Location ❑ w/attachments
❑ Section 3: SIC Codes ❑ w/attachments
✓❑ Section 4: Operator Information ❑ wl attachments
❑✓ Section 5: Indian Land ❑ w/attachments
❑✓ Section 6: Existing Environmental Permits ❑ wl attachments
❑✓ Section 7: Map ❑ toP pographic ❑ wl additional attachments
cn
c ❑✓ Section 8: Nature of Business El w/attachments
❑✓ Section 9:Cooling Water Intake Structures ❑ w/attachments
c.) ❑✓ Section 10: Variance Requests ❑ wl attachments
v
❑✓ Section 11: Checklist and Certification Statement ❑ w/attachments
Y
11.2 Certification Statement
U
I 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) Official title
Signature Date signed
c9/ 3/a o zz
EPA Form 3510-1(revised 3-19) Page 4

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Dare County North Reverse Osmosis WTP N
NPDES Permit NC0070157 *
600 Mustian Street, Kill Devil Hills 27948 i t5.0
0
0
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Receiving Stream:Atlantic Ocean Stream Class:SB
Stream Segment:99-(7) Sub-Basin#: 03-01-56 36.0158°N,-75.6528°W
River Basin:Pasquotank HUC:030102051704 SCALE NC Grid:C36SW
County:Dare 1:24,000 USGS Quad:Kitty Hawk,NC