NC0020559_Renewal (Application)_20221128

„s.STATE
ROY COOPER
Governor •
ELIZABETH S.BISER
Secretary ”
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
November 28, 2022
City of Henderson
Attn: Clarissa Lipscomb, Director of Water Resources
PO Box 1434
Henderson, NC 27536-1434
Subject: Permit Renewal
Application No. NC0020559
Henderson WRF
Vance County
Dear Applicant:
receipt ofyourpermit renewal application
The Water QualityPermittingSection acknowledges the November 28, 2022, ece t
9 PPP
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,
�j1A/W
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
EQ^v North Carolina Department of Environmental Quality .Division of Water Resources
�O!/p Raleigh Regional Office 13800 Barrett Drive I Raleigh.North Carolina 27609
919.791.4200

y
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
Form U.S.Environmental Protection Agency
2A 4-1.EPA Application for NPDES Permit to Discharge Wastewater
NPDES NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION 1.BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.21(j)(1)and(9))
1.1 Facility name
Henderson Water Reclamation Facility
Mailing address(street or P.O.box)
PO Box 1434
City or town State ZIP code
o Henderson NC 27536
Contact name(first and last) Title Phone number Email address
ChristyLipscombWater Resources Director [phone] clarissalipscomb@henderson.i
Location address(street,route number,or other specific identifier) ❑ Same as mailing address
1646 West Andrews Avenue
w
City or town State ZIP code
Henderson NC 27536
1.2 Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑ No
requirements for new dischargers.
1.3 Is applicant different from entity listed under Item 1.1 above?
❑ Yes ❑r No 4 SKIP to Item 1.4.
Applicant name
Applicant address(street or P.O.box)
0
o0 City or town State ZIP code
Contact name(first and last) Title Phone number Email address
Q
a
1.4 Is the applicant the facility's owner,operator,or both?(Check only one response.)
❑ Owner ❑ Operator 1=1 Both
1.5 To which entity should the NPDES permitting authority send correspondence?(Check only one response.)
Facility and applicant
El Facility El Applicant
(they are one and the same)
1.6 Indicate below any existing environmental permits.(Check all that apply and print or type the corresponding permit
.07
number for each.)
Existing Environmental Permits
,❑ NPDES(discharges to surface ❑ RCRA(hazardous waste) ❑ UIC(underground injection
water) control)
E NC0020559
❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
a
*IT)
y ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section ❑ Other(specify)
404)
Stormwater NCG110075
EPA Form 3510-2A(Revised 3-19) Page 1

1
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
1.7 Provide the collection system information requested below for the treatment works.
Municipality Population Collection System Type Ownership Status
Served Served (indicate percentage)
Henderson 15,000 %separate sanitary sewer 0 Own 0 Maintain
Z %combined storm and sanitary sewer 0 Own 0 Maintain
y 0 Unknown 0 Own 0 Maintain
c Part of Vance 1,400 %separate sanitary sewer 0 Own 0 Maintain
T., County %combined storm and sanitary sewer 0 Own 0 Maintain
a El Unknown 0 Own 0 Maintain
a %separate sanitary sewer 0 Own 0 Maintain
%combined storm and sanitary sewer 0 Own 0 Maintain
E ❑ Unknown 0 Own 0 Maintain
C; %separate sanitary sewer 0 Own 0 Maintain
y %combined storm and sanitary sewer 0 Own 0 Maintain
`o 0 Unknown 0 Own 0 Maintain
Total 16,400
Population
ci Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of %
sewer line(in miles)
Z' 1.8 Is the treatment works located in Indian Country?
c
o
o ElYes ElNo
v
c 1.9 Does the facility discharge to a receiving water that flows through Indian Country?
co
c ❑ Yes I No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
4.14 mgd
o
y Annual Average Flow Rates(Actual)
< ' Two Years Ago Last Year This Year
c
ix
c o 2.176 mgd 2.475 mgd 2.20 mgd
co
w LT MaximumDaily Flow Rates(Actual)
c Two Years Ago Last Year This Year
8.645 mgd 5.421 mgd 7.005 mgd
v, 1.11 Provide the total number of effluent discharge points to waters of the United States by type.
c Total Number of Effluent Discharge Points by Type
-
a n Constructed
En I- Treated Effluent Untreated Effluent Combined Sewer Bypasses Emergency
W >. Overflows
0
-0 Overflows
_N
C 1
EPA Form 3510-2A(Revised 3-19) Page 2
,

a
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
Outfalls Other Than to Waters of the United States
1.12 Does the POTW discharge wastewater to basins,ponds,or other surface impoundments that do not have outlets for
discharge to waters of the United States?
❑ Yes ❑ No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume Continuous or Intermittent
Location Discharged to Surface
Impoundment (check one)
❑ Continuous
gpd 0 Intermittent
❑ Continuous
gpd ❑ Intermittent
❑ Continuous
Ul
gpd ❑ Intermittent
6
. 1.14 Is wastewater applied to land?
2 ❑ Yes ❑ No 4 SKIP to Item 1.16.
c 1.15 Provide the land application site and discharge data requested below.
y Land Application Site and Discharge Data
Continuous or
`o Location Size Average Daily Volume Intermittent
Es' (check(check one)
c acresgpd ❑ Continuous
❑ Intermittent
acresgpd 0 Continuous
❑ Intermittent
0
acresgpd 0 Continuous
❑ Intermittent
7 1.16 Is effluent transported to another facility for treatment prior to discharge?
o ❑ Yes ❑✓ No 4 SKIP to Item 1.21.
1.17 Describe the means by which the effluent is transported(e.g.,tank truck,pipe).
1.18 Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19 Provide information on the transporter below.
Transporter Data
Entityname Mailingaddress(street or P.O.box)
City or town State ZIP code
Contact name(first and last) Title
Phone number Email address
EPA Form 3510-2A(Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No,2040-0004
1.20 In the table below, indicate the name,address,contact information, NPDES number,and average daily flow rate of the
receiving facility.
Receiving Facility Data
-0 Facility name Mailing address(street or P.O.box)
a,
.2 City or town State ZIP code
0
v
Contact name(first and last) Title
0
t
Phone number Email address
cNPDES number of receiving facility(if any) 0 None Average daily flow rate mgd
0
co
0 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do not
have outlets to waters of the United States(e.g.,underground percolation,underground injection)?
L ❑ Yes El No 4 SKIP to Item 1.23.
0 1.22 Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal Annual Average
o Location of Size of Continuous or Intermittent
Method Dis osal Site Dis osal Site Daily Discharge
Description p p Volume (check one)
0 Continuous
acres gpd ❑ Intermittent
acres gpd
0 Continuous
❑ Intermittent
acres gpd 0 Continuous
0 Intermittent
1.23 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)?(Check all that apply.
0 Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
41) ❑ Discharges into marine waters(CWA ❑ Water quality related effluent limitation(CWA Section
Section 301(h)) 302(b)(2))
0 Not applicable
1.24 Are any operational or maintenance aspects(related to wastewater treatment and effluent quality)of the treatment works
the responsibility of a contractor?
El Yes ❑ No+SKIP to Section 2.
1.25 Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1 Contractor 2 Contractor 3
Contractor name
(company name) Granville Farms Inc
Mailing address
(street or P.O.box) PO Box 1396
o` City,state,and ZIP
code Oxford NC 27565
Contact name(first and
t� last) Andy Smith
Phone number [phone]
Email address [e-mail]
Operational and Hauls digested sludge from
maintenance the plant and land applies at
responsibilities of agronomic rates
contractor
EPA Form 3510-2A(Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
SECTION 2.ADDITIONAL INFORMATION(40 CFR 122.21(j)(1)and(2))
c Outfalls to Waters of the United States
2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
rn
❑r Yes ❑ No 4 SKIP to Section 3.
`0 2.2 Provide the treatment works'current average daily volume of inflow Average Daily Volume of Inflow and Infiltration
and infiltration. 195,000
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
c The City of Henderson has secured funding from state funding in order to address I&I issues within the Sandy Creek Basin
which contributes a major portion of I&I flow.
0
2.3 Have you attached a topographic map to this application that contains all the required information?(See instructions for
03 a. specific requirements.)
o)�
0
0 E Yes ❑ No
E 2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
o
t° (See instructions for specific requirements.)
LL o ❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
ID Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
c
7) 1 New Laboratory
m I
2.New Generator
E
0 0
3.Septic Recieving Station
m
4.
fN
2 2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
E Scheduled Affected Begin End Begin Attainment of
o Outfalls Operational
Improvement Construction Construction Discharge
(from above) (list outtall (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) Level
number) (MM/DD/YYYY)
1.
r
2
3.
4.
2.7 Have appropriate permits/clearances concerning other federal/state requirements been obtained?Briefly explain your
response.
❑ Yes 1 No ❑ None required or applicable
Explanation:
these improvements are still in the trying to obtain funding stage
EPA Form 3510-2A(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
SECTION 3.INFORMATION ON EFFLUENT DISCHARGES(40 CFR 122.21(j)(3)to(5))
3.1 Provide the following information for each outfall.(Attach additional sheets if you have more than three outfalls.)
Outfall Number 1 Outfall Number Outfall Number
State North Carolina
to
County Vance
O City or town Henderson
Distance from shore N/A ft. ft. ft.
a.
Depth below surface N/A ft. ft. ft.
Average daily flow rate N/A mgd mgd mgd
Latitude 36° 21' 01" NO
Longitude 78° 24 4o" "u
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o ❑ Yes Cl No 4 SKIP to Item 3.4.
3.3 If so,provide the following information for each applicable outfall.
y Outfall Number Outfall Number Outfall Number
Number of times per year
•
0 discharge occurs
a Average duration of each
discharge(specify units)
Average flow of each
9
discharge mgd mgd mgd
in Months in which discharge
occurs
3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑ No 4 SKIP to Item 3.6.
3.5 Briefly describe the diffuser t)pe at each applicable outfall.
n
Outfall Number Outfall Number Outfall Number
-
(n
I �
c vi 3 6 Does the treatment works discharge or plan to discharge wastewater to waters of the United States from one or more
discharge points?
w 0 Yes ❑ No 4SKIP to Section 6.
EPA Form 3510-2A(Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
OMB No.2040-0004
3.7 Provide the receiving water and related information(if known)for each outfall.
Outfall Number 1 Outfall Number Outfall Number
Receiving water name Nutbush Creek
Name of watershed,river,
c or stream system arm of Kerr Lake:Roanoke Rig,
Fa. U.S.Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin Roanoke
en
U.S.Geological Survey
8-digit hydrologic 03010102
cataloging unit code
Critical low flow(acute) cfs cfs cfs
Critical low flow(chronic) .2 cfs cfs cfs
Total hardness at critical mg/L of mg/L of mg/L of
low flow NA CaCO3 CaCO3 CaCO3
3.8 Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number 1 Outfall Number Outfall Number
Highest Level of 0 Primary 0 Primary 0 Primary
Treatment(check all that 0 Equivalent to 0 Equivalent to 0 Equivalent to
apply per outfall) secondary secondary secondary
❑ Secondary 0 Secondary 0 Secondary
0 Advanced 0 Advanced 0 Advanced
❑ Other(specify) 0 Other(specify) 0 Other(specify)
oxidation ditch
Design Removal Rates by
Outfall
BOD5 or CBOD5 99.1
d
E
m TSS 98.9 %
I
❑ Not applicable 0 Not applicable 0 Not applicable
Phosphorus 92.9 %
0 Not applicable ❑Not applicable 0 Not applicable
Nitrogen % o °
73.4
Other(specify) 0 Not applicable 0 Not applicable 0 Not applicable
EPA Form 3510-2A(Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
3.9 Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season,describe below.
-0
0
U
Outfall Number 1 Outfall Number Outfall Number
0
• Disinfection type•� YP Ultra Violet Light Disinfection
System
0
Seasons used All
fE
Dechlorination used? 0 Not applicable ❑ Not applicable ❑ Not applicable
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package?
0 Yes ❑ No
3.11 Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑r Yes ❑ No 4 SKIP to Item 3.13.
3.12 Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number Outfall Number Outfall Number
Acute Chronic Acute Chronic Acute Chronic
Number of tests of discharge
water
Number of tests of receiving
water
3.13 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
El Yes ❑ No 4 SKIP to Item 3.16.
3.14 Does the POTW use chlorine for disinfection,use chlorine elsewhere in the treatment process,or otherwise have
reasonable potential to discharge chlorine in its effluent?
d ❑ Yes 4 Complete Table B,including chlorine. ❑ No 4 Complete Table B,omitting chlorine.
3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
El Yes ❑ No
3.16 Does one or more of the following conditions apply?
• The facility has a design flow greater than or equal to 1 mgd.
• The POTW has an approved pretreatment program or is required to develop such a program.
• The NPDES permitting authority has informed the POTW that it must sample for the parameters in Table C,must
sample other additional parameters(Table D),or submit the results of WET tests for acute or chronic toxicity for
each of its discharge outfalls(Table E).
Yes 4 Complete Tables C, D,and E as
❑ applicable. ❑ No 4 SKIP to Section 4.
3.17 Have you completed monitoring for all applicable Table C pollutants and attached the results to this application
package?
Yes ❑ No
3.18 Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
attached the results to this application package?
� Yes ❑
No additional sampling required by NPDES
permitting authority.
EPA Form 3510-2A(Revised 3-19) Page 8

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
3.19 Has the POTW conducted either(1)minimum of four quarterly WET tests for one year preceding this permit application
or(2)at least four annual WET tests in the past 4.5 years?
No 4 Complete tests and Table E and SKIP to
0 Yes ❑ Item 3.26.
3.20 Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21 Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s)Submitted Summary of Results
(MM/DD/YYYY)
a
0
3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
o toxicity?
❑ Yes 0 No 4 SKIP to Item 3.26.
w3.23 Describe the cause(s)of the toxicity:
d
w
3.24 Has the treatment works conducted a toxicity reduction evaluation?
0 Yes ❑ No 4 SKIP to Item 3.26.
3.25 Provide details of any toxicity reduction evaluations conducted.
3.26 Have you completed Table E for all applicable outfalls and attached the results to the application package?
CI Yes ❑ Not applicable because previously submitted
information to the NPDES .•rmittin.authorit .
SECTION 4. INDUSTRIAL DISCHARGES AND HAZARDOUS WASTES(40 CFR 122.21(j)(6)and(7))
4.1 Does the POTW receive discharges from SIUs or NSCIUs?
❑ Yes ❑ No 4 SKIP to Item 4.7.
4.2 Indicate the number of SIUs and NSCIUs that discharge to the POTW.
Number of SIUs Number of NSCIUs
y 1
� I
O
P- 4.3 Does the POTW have an approved pretreatment program?
_ El Yes ❑ No
, 4.4 Have you submitted either of the following to the NPDES permitting authority that contains information substantially
rnidentical to that required in Table F:(1)a pretreatment program annual report submitted within one year of the
application or(2)a pretreatment program?
0
cn ❑ Yes El No 4 SKIP to Item 4.6.
4.5 Identify the title and date of the annual report or pretreatment program referenced in Item 4.4.SKIP to Item 4.7.
HWRF Industrial Pretreatment Report-March 2022
c
4.6 Have you completed and attached Table F to this application package?
ElYes ❑ No
EPA Form 3510-2A(Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
4.7 Does the POTW receive,or has it been notified that it will receive,by truck,rail,or dedicated pipe,any wastes that are
regulated as RCRA hazardous wastes pursuant to 40 CFR 261?
❑ Yes El No 4 SKIP to Item 4.9.
4.8 If yes,provide the following information:
Annual
Hazardous Waste Waste Transport Method Amount of
Number (check all that apply) Waste Units
Received
❑ Truck 0 Rail
❑ Dedicated pipe ❑ Other(specify)
c
c
0
U
d ❑ Truck ❑ Rail
❑ Dedicated pipe ❑ Other(specify)
N
O
'a
N ❑ Truck 0 Rail
❑ Dedicated pipe ❑ Other(specify)
u,
4.9 Does the POTW receive,or has it been notified that it will receive,wastewaters that originate from remedial activities,
including those undertaken pursuant to CERCLA and Sections 3004(7)or 3008(h)of RCRA?
O
0 Yes 0 No 4 SKIP to Section 5.
-74 4.10 Does the POTW receive(or expect to receive)less than 15 kilograms per month of non-acute hazardous wastes as
specified in 40 CFR 261.30(d)and 261.33(e)?
❑ Yes 4 SKIP to Section 5. 0 No
4.11 Have you reported the following information in an attachment to this application:identification and description of the
site(s)or facility(ies)at which the wastewater originates;the identities of the wastewater's hazardous constituents;and
the extent of treatment,if any,the wastewater receives or will receive before entering the POTW?
❑ Yes 0 No
SECTICN 5.COMBINED SEWER OVERFLOWS(40 CFR 122.21(j)(8))
E
5.1 Does the treatment works have a combined sewer system?
❑ Yes ❑ No 4SKIP to Section 6.
5.2 Have you attached a CSO system map to this application?(See instructions for map requirements.)
a 0 Yes ❑ No
5.3 Have you attached a CSO system diagram to this application?(See instructions for diagram requirements.)
0 Yes El No
EPA Form 3510-2A(Revised 3-19) Page 10

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
5.4 For each CSO outfall,provide the following information.(Attach additional sheets as necessary.)
CSO Outfall Number CSO Outfall Number CSO Outfall Number
City or town
0
a State and ZIP code
o County
.o
a Latitude °
0
0
N Longitude ° ° " °
c.)
Distance from shore ft. ft. ft.
Depth below surface ft. ft. ft.
5.5 Did the POTW monitor any of the following items in the past year for its CSO outfalls?
CSO Outfall Number CSO Outfall Number CSO Outfall Number
Rainfall ❑ Yes ❑ No ❑ Yes Cl No ❑ Yes ❑No
a)
c
`0 CSO flow volume ❑ Yes El No ❑ Yes ❑ No ❑ Yes ❑ No
CSO pollutant ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No
o concentrations
c.> Receiving water quality 0 Yes ❑ No 0 Yes 0 No ❑ Yes 0 No
CSO frequency ❑ Yes ❑ No ❑ Yes 0 No ❑ Yes ❑ No
Number of storm events ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No
5.6 Provide the following information for each of your CSO outfalls.
CSO Outfall Number CSO Outfall Number CSO Outfall Number
Number of CSO events in events events events
% the past year
m
a
c Average duration per hours hours hours
d event ❑Actual or❑ Estimated 0 Actual or 0 Estimated ❑Actual or 0 Estimated
w million gallons million gallons million gallons
o Average volume per event
co
0 Actual or 0 Estimated 0 Actual or 0 Estimated 0 Actual or 0 Estimated
Minimum rainfall causing inches of rainfall inches of rainfall inches of rainfall
a CSO event in last year 0 Actual or 0 Estimated 0 Actual or 0 Estimated 0 Actual or 0 Estimated
EPA Form 3510-2A(Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Fackity Name Form Approved 03/0519
OMB No 2040-0004
5.7 Provide the information in the table below for each of your CSO outfalis:
CSO Outfall Number_ CSO Outfall Number_ CSO Outfall Number
Receiving water name
Name of watershed/
stream system
d U.S.Soil Conservation ❑Unknown 0 Unknown 0 Unknown
Service 14-digit
watershed code
i > (if known)
Name of state
management/river basin
rn U.S.Geological Survey 0 Unknown 0 Unknown 0 Unknown
8-Digit Hydrologic Unit
II Code(if known)
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
exam• -
SECTION 6.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
6.1 In Column 1 below,mark the sections of Form 2A 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
in Section 1 Basic Application
Information for All Applicants ❑ w!variance request(s) ❑ wl additional attachments
❑ Section 2:Additional E] w/topographic map ❑ w/process flow diagram
Information 0 w/additional attachments
❑ w/Table A 0 wl Table D
Section 3:Information on w/Table 13
❑ Effluent Discharges 0 ❑ w/Table E
0 w/Table C 0 wl additional attachments
Section 4:Industrial Q w/SIU and NSCIU attachments ❑ w!Table F
'n ❑ Discharges and Hazardous
Wastes ❑ w/additional attachments
❑1,5
Section 5:Combined Sewer ❑ wl CSO map ❑ w/additional attachments
Overflows 0 w/CSO system diagram
Section 6:Checklist and ❑ w/attachments •
° Certification Statement
Y 6 2 Certification Statement
f 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 title
•
Signature // Date signed
///af e/o1 OittA_
EPA Form 3510-2A(Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE A.EFFLUENT PARAMETERS FOR ALL POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of
Value Units Value Units Method' (include units)
Samples
Biochemical oxygen demand
El ML
o BOD5 or❑CBODs 11.1 mg/I 15.1 mg/I 257 SM 5210B-2001 2.0 0 MDL
(report one)
0 ML
Fecal coliform 3700 #/100 ml 134.6 #/100 ml 257 SM 9222 D-1997 1#/100 0 MDL
Design flow rate 4.14 MGD 1.89 MGD
pH(minimum) 6.1 s.u.
pH(maximum) 7.3 s.u.
Temperature(winter) 23.8 C 182
Temperature(summer) 26.7 C 183
Total suspended solids(TSS) 29.2 mg/I 5.01 mg/I 257 SM 2540 D-1997 2.5 0 ML
0 MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A(Revised 3-19) Page 13

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE B. EFFLUENT PARAMETERS FOR ALL POTWS WITH A FLOW EQUAL TO OR GREATER THAN 0.1 MGD
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of y
Value Units Value Units Method, (include units)
Samples
0 ML
Ammonia(as N) 17.6 mg/I .701 mg/I 250 iM 4500 NH3 D-199i .1 0 MDL
Chlorine 0 ML
(total residual,TRC)2 - ❑MDL
0 ML
Dissolved oxygen 11.1 mg/I 8.24 mg/I 250 SM 4500 0 G-2001 •1 0 MDL
0 ML
Nitrate/nitrite 11.5 mg/I 3.41 mg/I 12 EPA 353.2 .1 0 MDL
0 ML
Kjeldahl nitrogen 3.35 mg/I 1.08 mg/I 12 t0 N ORG C-1997,EP/ •5.•2 0 MDL
0 ML
Oil and grease <5 mg/I <5 mg/I 12 EPA 1664E 5 0 MDL
0 ML
Phosphorus .833 mg/I .137 mg/I 52 EPA 365.3,EPA 200.7 .1,.020 0 MDL
•
Total dissolved solids 368 mg/I 240 mg/I 3 SM 2540C 10 ❑0 ML
MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection,do not use chlorine elsewhere in the treatment process,and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A(Revised 3-19) Page 15

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Y
Value Units Value Units Number of Method1 (include units)
Samples
Metals,Cyanide,and Total Phenols
0 ML
Hardness(as CaCO3) 64 mg/L 50 mg/L 20 SM 2340B 1 ❑MDL
0 ML
Antimony,total recoverable .0005 mg/L .0005 mg/L 3 EPA 200.8 .0005 0 MDL
0 ML
Arsenic,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .002 0 MDL
Beryllium,total recoverable ND mg/L ND mg/L 3 EPA 200.8 .0005 0 ML
MDL
0 ML
Cadmium,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .00015 0 MDL
O ML
Chromium,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .002 ❑MDL
0 ML
Copper,total recoverable .002 mg/L .002 mg/L 20 EPA 200.8 .002 0 MDL
0 ML
Lead,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .0005 0 MDL
0 ML
Mercury,total recoverable ND mg/L ND mg/L 1 EPA 245.1 .0002 0 MDL
0 ML
Nickel,total recoverable .004 mg/L .0085 mg/L 20 EPA 200.8 .0005 0 MDL
Selenium,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .001 0
0 MML
DL
Silver,total recoverable ND mg/L ND mg/L 20 EPA 200.8 .0005 ❑0 ML
MDL
Thallium,total recoverable ND mg/L ND mg/L 3 EPA 200.8 .0005 00 ML
MDL
0 ML
Zinc,total recoverable .518 mg/L .134 mg/L 20 EPA 200.8 .005 ❑MDL
0 ML
Cyanide .007 mg/L .007 mg/L 3 EPA 335.4 .005 0 MDL
0 ML
Total phenolic compounds .019 mg/L .015 mg/L 3 EPA 420.1 .010 ❑MDL
Volatile Organic Compounds
a ML
Acrolein ND ug/L ND ug/L 3 EPA 200.8 50 0 MDL
0 ML
Acrylonitrile ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Benzene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
Bromoform ND ug/L ND ug/L 3 i EPA 200.8 1 ❑MDL
EPA Form 3510-2A(Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
0MB No.2040-0004
TABLE C.EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant _ yt.
Value Units Value Units Number of Method1 (include units)
Samples
o ML
Carbon tetrachloride ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
Chlorobenzene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
ML
Chlorodibromomethane ND ug/L ND ug/L 3 EPA 200.8 1 ❑❑MDL
0 ML
Chloroethane ND ug/L ND ug/L 3 EPA 200.8 5 0 MDL
0 ML
2-chloroethylvinyl ether ND ug/L ND ug/L 3 EPA 200.8 5 0 MDL
0 ML
Chloroform ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
0 ML
Dichlorobromomethane ND ug/L ND ug/L 3 EPA 200.8 1 O MDL
0 ML
1,1-dichloroethane ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
•
0 ML
1,2-dichloroethane ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
trans-1,2-dichloroethylene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
1,1-dichloroethylene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
1,2-dichloropropane ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
ML
1,3-dichloropropylene ND ug/L ND ug/L 3 EPA 200.8 1 ❑O MDL
0 ML
Ethylbenzene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
Methyl bromide ND ug/L ND ug/L 3 EPA 200.8 5 ❑MDL
0 ML
Methyl chloride ND ug/L ND ug/L 3 EPA 200.8 5 ❑MDL
0 ML
Methylene chloride ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
1,1,2,2-tetrachloroethane ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
0 ML
Tetrachloroethylene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
Toluene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
1,1,1-trichloroethane ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
ML
1,1,2-trichloroethane ND ug/L ND ug/L 3 EPA 200.8 1 ❑❑MDL
EPA Form 3510-2A(Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
0MB No.2040-0004
TABLE C.EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Yt
Value Units Value Units Number of Method1 (include units)
•
Samples
o ML
Trichloroethylene ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
Kt
Vinyl chloride ND ug/L ND ug/L 3 EPA 200.8 5 0 MDL
Acid-Extractable Compounds
El ML
p-chloro-m-cresol ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
O ML
2-chlorophenol ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
2,4-dichlorophenol ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
0 ML
2,4-dimethylphenol ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
4,6-dinitro-o-cresol ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
2,4-dinitrophenol ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
0 ML
2-nitrophenol ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
0 ML
4-nitrophenol ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
Pentachlorophenol ND ug/L ND ug/L 3 EPA 200.8 1 00 ML
MDL
O ML
Phenol ND ug/L ND ug/L 3 EPA 200.8 1 0 MDL
0 ML
2,4,6-trichlorophenol ND ug/L ND ug/L 3 EPA 200.8 1 ❑MDL
Base-Neutral Compounds
a ML
Acenaphthene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
Acenaphthylene ND ug/L ND ug/L 3 EPA 200.8 10 00 ML
MDL
0 ML
Anthracene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Benzidine ND ug/L ND ug/L 3 EPA 200.8 50 ❑MDL
Benzo(a)anthracene ND ug/L ND ug/L 3 EPA 200.8 10 00 ML
MDL
0 ML
Benzo(a)pyrene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
3,4-benzofluoranthene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
EPA Form 3510-2A(Revised 3-19) Page 19

•
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
0MB No.2040-0004
TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method' (include units)
Value Units Value Units Samples
0 ML
Benzo(ghi)perylene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
El ML
Benzo(k)fluoranthene ND ug/L ND ug/L 3 EPA 200.8 10❑MDL
0 ML
Bis(2-chloroethoxy)methane ND ug/L ND ug/L 3 EPA 200.8 10❑MDL
0 ML
Bis(2-chloroethyl)ether ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Bis(2-chloroisopropyl)ether ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
ML
Bis(2-ethylhexyl)phthalate ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
4-bromophenyl phenyl ether ND ug/L _ ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Butyl benzyl phthalate ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
2-chloronaphthalene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
4-chlorophenyl phenyl ether ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Chrysene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
di-n-butyl phthalate ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
di-n-octyl phthalate ND ug/L ND ug/L 3 EPA 200.8 10 p ML
MDL
0 ML
Dibenzo(a,h)anthracene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
1,2-dichlorobenzene ND ug/L ND ug/L 3 EPA 200.8 10 0 MML
DL
0 ML
1,3-dichlorobenzene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
1,4-dichlorobenzene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
171 ML
3,3-dichlorobenzidine ND ug/L ND ug/L 3 EPA 200.8 50 ❑MDL
0 ML
Diethyl phthalate ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Dimethyl phthalate ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
2,4-dinitrotoluene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
2,6-dinitrotoluene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
EPA Form 3510-2A(Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE C.EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Method1 (include units)
Value Units Value Units Samples
0 ML
1,2-diphenylhydrazine ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Fluoranthene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Fluorene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
Hexachlorobenzene ND ug/L ❑ML
g/ ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Hexachlorobutadiene ND ug/L ND ug/L 3 EPA 200.8 10 ❑MDL
0 ML
Hexachlorocyclo-pentadiene ND ug/L ND ug/L 3 EPA 200.8 50 0 MDL
ML
Hexachloroethane ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Indeno(1,2,3-cd)pyrene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Isophorone ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Naphthalene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Nitrobenzene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
N-nitrosodi-n-propylamine ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
N-nitrosodimethylamine ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
N-nitrosodiphenylamine ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Phenanthrene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
0 ML
Pyrene ND ug/L ND ug/L 3 EPA 200.8 10 0 MDL
1,2,4-trichlorobenzene ND ug/L ND ug/L 3 EPA 200.8 10 0 MML
DL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I,Subchapter N or 0.See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A(Revised 3-19) Page 21

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE D.ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING AUTHORITY
Pollutant Maximum Daily Discharge Average Daily Dischar a Analytical ML or MDL
(list) Value Units Value Units Number of Method1 (include units)
Samples
ElNo additional sampling is required by NPDES permitting authority.
❑ML
❑MDL
❑ML
❑MDL
0 ML
❑MDL
❑ML
0 MDL
❑ML
0 MDL
❑ML
0 MDL
❑ML
❑MDL
❑ML
❑MDL
❑ML
0 MDL
❑ML
❑MDL
❑ML
0 MDL
❑ML
❑MDL
❑ML
❑MDL
0 ML
❑MDL
❑ML
I ❑MDL
❑ML
❑MDL
❑ML
❑MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required
under 40 CFR chapter I,subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A(Revised 3-19) Page 23

This page intentionally left blank.

1
EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample.Copy the table to report additional test results.
Test Information
■ Test Number 1 Test Number 2 Test Number 3
Test species Ceriodaphnia dubia Ceriodaphnia dubia Ceriodaphnia dubia
Age at initiation of test <24 <24 <24
Outfall number 1 1 1
Date sample collected 07/13/2020 10/04/2021 01/10/2022
Date test started 07/15/2020 10/06/2021 01/12/2022
Duration 23.9 hours 23.9 hours 24 hours
Toxicity Test Methods
Test method number
Manual title he ChronicToxicit of Effluents and Receiving Wi he ChronicToxicit of Effluents and Receiving W<'he ChronicToxicit of Effluents and Receiving Wa
Edition number and year of publication Fourth,2002 Fourth,2002 Fourth,2002
Page number(s) 1-335 1-335 1-335
Sample Type
Check one: ❑ Grab ❑ Grab ❑ Grab
2 24-hour composite 0 24-hour composite ID 24-hourcomposite
Sample Location
Check one: ❑ Before Disinfection ❑ Before Disinfection 0 Before disinfection
CI After Disinfection 0 After Disinfection CI After disinfection
❑ After Dechlorination ❑ After Dechlorination ❑ After dechlorination
Point in Treatment Process
Describe the point in the treatment process Effluent Effluent Effluent
at which the sample was collected for each
test.
Toxicity Type
Indicate for each test whether the test was 0 Acute ❑Acute ❑ Acute
performed to asses acute or chronic toxicity,
or both. (Check one response.) Chronic Chronic Chronic
❑ Both ❑ Both ❑ Both
EPA Form 3510-2A(Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample.Copy the table to report additional test results.
Test Number 1 Test Number 2 Test Number 3
Test Type
Indicate the type of test performed.(Check one 0 Static ❑ Static ❑ Static
response.)
❑r Static-renewal 0 Static-renewal ❑� Static-renewal
0 Flow-through ❑ Flow-through ❑ Flow-through
Source of Dilution Water
Indicate the source of dilution water.(Check 0 Laboratory water ❑ Laboratory water ❑ Laboratory water
one response.)
❑� Receiving water CI Receiving water 0 Receiving water
If laboratory water,specify type.
If receiving water,specify source. Lake Bryant Lake Bryant Lake Bryant
Type of Dilution Water
Indicate the type of dilution water. If salt 11 Fresh water CI Fresh water El Fresh water
water,specify"natural"or type of artificial
sea salts or brine used. CI Salt water(specify) CI water(specify) ❑ Salt water(specify)
Percentage Effluent Used
Specify the percentage effluent used for all 9oi°
concentrations in the test series. 90% 90% °
Parameters Tested
Check the parameters tested. CI pH ❑ Ammonia 0 pH ❑ Ammonia Cl pH ❑ Ammonia
❑ Salinity ❑ Dissolved oxygen ❑ Salinity ❑ Dissolved oxygen ❑ Salinity ❑ Dissolved oxygen
❑ Temperature ❑ Temperature ❑ Temperature
Acute Test Results
Percent survival in 100%effluent % % %
LCso
95%confidence interval % % %
Control percent survival % a/° %
EPA Form 3510-2A(Revised 3-19) Page 26

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
OMB No.2040-0004
TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample.Copy the table to report additional test results.
Test Number 1 Test Number 2 Test Number 3
Acute Test Results Continued
Other(describe)
Chronic Test Results
NOEC
IC25 %
Control percent survival %
Other(describe)
Quality Control/Quality Assurance
Is reference toxicant data available? ❑ Yes 0 No 0 Yes 0 No 0 Yes 0 No
•
Was reference toxicant test within
acceptable bounds? 0 Yes 0 No ElYes ElNo ElYes ❑ No
What date was reference toxicant test run
(MM/DD/YYYY)?
Other(describe)
EPA Form 3510-2A(Revised 3-19) Page 27

This page intentionally left blank.

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
TABLE F.INDUSTRIAL DISCHARGE INFORMATION
Response space is provided for three Sills.Copy the table to report information for additional SIUs.
SIU 1 SIU SIU
Name of SIU
Mars Petcare
Mailing address(street or P.O. box) 845 Commerce Drive
City,state,and ZIP code Henderson NC 27537
Description of all industrial processes that affect Facility and Manufacturing Equipment
or contribute to the discharge. Cleaning
List the principal products and raw materials that Pet foods
affect or contribute to the SIU's discharge. Grains and meats
Indicate the average daily volume of wastewater
discharged by the SIU. 9100 gpd gpd gpd
How much of the average daily volume is
attributable to process flow? 4277 gpd gpd gpd
How much of the average daily volume is
attributable to non-process flow? 4823 gpd gpd gpd
Is the SIU subject to local limits?
El Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No
Is the SIU subject to categorical standards?
El Yes CI No ❑ Yes El No ❑ Yes ❑ No
EPA Form 3510-2A(Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
TABLE F.INDUSTRIAL DISCHARGE INFORMATION
Response space is provided for three SIUs.Copy the table to report information for additional SIUs.
SIU 1 SIU SIU
Under what categories and subcategories is the
SIU subject?
Has the POTW experienced problems(e.g.,
upsets,pass-through interferences)in the past 4.5 ❑ Yes 0 No ❑ Yes El No El Yes CI No
years that are attributable to the SIU?
If yes,describe.
EPA Form 3510-2A(Revised 3-19) Page 30

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City of Hendersont. Facility
Henderson Water Reclamation Facility Location -=•1'
State Grid/goad: B 25 SW/Henderson Latitude: 36.21'01"N (map not to scale)
Receiving Stream:Nutbush Creek Longitude: 78'24'40"W
Drainage Basin: Roanoke Sub-Basin: 03-02-06 NPDES Permit NC0020559
Stream Class: C 8-Digit HUC: 03010102 Vance County