NC0061123_Fact Sheet_20221010

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not
require full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g.,
schools, mobile home parks, etc.) that can be administratively renewed with minor
changes but can include facilities with more complex issues (Special Conditions, 303(d)
listed water, toxicity testing, instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Charles Weaver - 07/19/2022
Permit Number
NC0061123
Facility Name
The Mountain Retreat and Learning
Center WWTP
Basin Name/Sub-basin number
Savannah / 03-13-01
Receiving Stream
Abes Creek
Stream Classification in Permit
C-Trout ORW
Does permit need Daily Maximum NH3
limits?
N/A
Does permit need TRC limits/language?
No - already present
Does permit have toxicity testing?
Yes. Two test failures since 2018.
Does permit have Special Conditions?
Yes. Expansion/Modification; Chronic
Toxicity
Does permit have instream monitoring?
Yes
Is the stream impaired (on 303(d) list)?
No
Any obvious compliance concerns?
No enforcements since 2015. Two NODs
and two NOVs in this permit cycle
Any permit mods since last permit?
No
New expiration date
8/31/2027
Changes to Permit?
• Added monitoring for turbidity as per
15A NCAC 02B.0211 (21).
• eDMR text has been updated
• Added standard TRC footnote with
requirement for dechlorination
added
• Added NH3 limits in place of
effluent WET test Gave
compliance schedule until 2027.

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
Invoice / Affidavit
The Highlander
Post Office Box 249
Highlands, NC 28741
STATE OF NORTH CAROLINA
COUNTY OF MACON
AFFIDAVIT OF PUBLICATION
Personally appeared before the undersigned, Rachel Hoskins, who having been
duly sworn on oath that she is Regional Publisher of The Highlander, and the
following legal advertisement was published in The Highlander newspaper, and
entered as second class mail in the Town of Highlands in said county and state;
and that she is authorized to make this affidavit and sworn statement; that the
notice or other legal advertisement, a true copy of which is attached hereto,
was published in The Highlander newspaper on the following dates:
PUBLIC NOTICE - NOTICE OF
NPDES - PERMIT NC0061123
08/18/2022
And that the said newspaper in which such notice, paper, document or legal
advertisement was published, was at the time of each and every such
publication, a newspaper meeting all the requirements and qualifications of
Section I-597 of the General Statues of North Carolina and was a qualified
newspaper within the meaning of the Section I-597 of the General Statues of
North Carolina.
ach l iichfoD
Signature/F>f person making affidavt
Sworn to and subscribed before me this 18th day of August, 2022.
&A:kJ
Notary Public
My Commission Expires: 7JL2/(S/ p25/ p2Qa24
Total Cost of Advertisement: $57.69
Filed With: NCDENR-DIVISION OF WATER RESOURCES
Address: 1617 MAIL SERVICE CENTER RALEIGH NC 27699-1617
Public Notice
North Carolina Environmental
Management
Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a
NPDES Wastewater Permit
NC0061123 The Mountain
Retreat and Learning Center
The North Carolina
Environmental Management
Commission proposes to issue a
NPDES wastewater discharge
permit to the person(s) listed
below. Written comments
regarding the proposed permit
will be accepted until 30 days
after the publish date of this
notice. The Director of the NC
Division of Water Resources
(DWR) may hold a public hearing
should there be a significant
degree of public interest. Please
mail comments and/or
information requests to DWR at
the above address. Interested
persons may visit the DWR at
512 N. Salisbury Street, Raleigh,
NC 27604 to review information
on file. Additional information on
NPDES permits and this notice
may be found on our website:
http://deq.nc.gov/about/divisions/
water-resources/wate r-resou rces-
perm its/wastewater-
branc h/n pd es-wastewate r/pu bl ic-
notices,or by calling (919) 707-
3601. The Mountain Retreat and
Leaming Center (P.O. Box 1299,
Highlands, NC 28741-1299) has
requested renewal of permit
NC0061123 for their WWTP in
Macon County. This permitted
facility discharges to Abes Creek
in the Savannah River Basin.
Currently dissolved oxygen, total
residual chlorine, and fecal
coliform are water quality limited.
This discharge may affect future
allocations in Abes Creek.
#720243, 8/18/22

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
IWC Calculations
The Mountain Retreat & Learning Center WWTP
NC0061123
Prepared By: Charles Weaver
Enter Design Flow (MGD):
Enter s7Q10(cfs):
Enter w7Q10 (cfs):
0.006
0
0.07
Residual Chlorine Ammonia (NH3 as N)
(summer)
7Q10 (cfs)
DESIGN FLOW (MGD)
DESIGN FLOW (cfs)
STREAM STD (ug/L)
UPS BACKGROUND LEVEL (l
IWC (%)
Allowable Conc. (ug/I)
Fecal Limit
(If DF >331; Monitor)
(If DF <331; Limit)
Dilution Factor (DF)
NPDES Servor/Current Versions/IWC
0 7Q10 (CFS)
0.006 DESIGN FLOW (MGD)
0.0093 DESIGN FLOW (cfs)
17.0 STREAM STD (mg/L)
0 UPS BACKGROUND LEVEL (mg/L)
100.00 IWC (%)
17 Allowable Conc. (mg/I)
Ammonia (NH3 as N)
(winter)
7Q10 (CFS)
200/100m1 DESIGN FLOW (MGD)
DESIGN FLOW (cfs)
STREAM STD (mg/L)
1.00 UPS BACKGROUND LEVEL (mg/L)
IWC (%)
Allowable Conc. (mg/I)
0
0.006
0.0093
1.0
0.22
100.00
1.0
0.07
0.006
0.0093
1.8
0.22
11.73
13.7
10/10/2022

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
July 13, 2022
The Mountain Retreat & Learning Center
Attn: Stephanie Anderson, Executive Director
PO Box 1299
Highlands, NC 28741-1299
Subject: Permit Renewal
Application No. NC0061123
The Mountain Retreat & Learning Center WWTP
Macon County
Dear Applicant:
The Water Quality Permitting Section acknowledges the July 7, 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.
cc: Mark Teague -Environmental Inc.
ec: WQPS Laserfiche File w/application
Sincerely
d
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Asheville Regional Office 12090 US. Highway 70 I Swannanoa, North Carolna 28778
828296.4500

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number Facility Name
u.n Mo-I'a in rekrea-1-t
NCOb lQ l (-3 L.C.Ccrn i hel CPn r— ry IttrrP
Modified Application Form 2A
Modified March 2021
Form
NPDES
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions ma result in denial of the ag. ication.
SECTION
1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1
Facility name
Mew \ .I Y-). +' e-k-rncti- .4- LT.rntn Gam►- v\i wrP
Mailing address (street or P.O. box)
Po Zox 12CP
o
0
City or town
141 obianci5
State
MG
ZIP code
a89. 4 i
EContact
o
name (first old last)
aphariio P cterir1
Title Extort-1 VL
t>t cet -
Phone number
a/is- 52 0-yg3g
Email address
A nonce @-}herr
wLocation
to
u.
address (street, route number, or other specific identifier)
3? 2 -Di llarcl V k
•
Same as mailing
address
City or town
chlarth
State
NC,
ZIP code
an
1.2
Is this
•
applicatio
Yes 4 See
requirements
r a facility that has yet to commence discharge?
instructions on data submission V No
for new dischargers.
Applicant Information
1.3
Is applicant different from entity listed under Item 1.1 above?
❑ Yes V No 4 SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
1.4
Is the applicant the facility's owner, operator.
'Owner
•
or both? (Check only one response.)
Operator ❑ Both
1.5
To
•
which entity should the NPDES permitting
Facility
■
authority send correspondence? (Check only one response.)
Applicant �/ Facility and applicant
(they are one and the same)
Existing Environmental Permits
b)
Indicate
number
below any existing environmental
for each.)
permits.
(Check all that apply and print or type the corresponding permit
Existing Environmental Permits
NPDES (discharges to surface
water)
N
PSD (air emissions)
•
Nonattainment program (CAA)
•
NESHAPs (CAA)
•
Ocean dumping (MPRSA)
•
Dredge or fill (CWA Section
404)
•
Other (specify)
Page 1

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
Collection System and Population Served
1.7
1.8
NPDES Permit Number
Facility Name
I\t DID C21 la 3 MburitiV1 rthre
Provide the collection system information requested below for the treatment works.
Municipality
Served
fete l
d
0
0
a a.
d
01-
.0.a
u
1.9
1.10
Total
Population
Served
Population
Served
Total percentage of each type of
sewer line (in miles)
Is the treatment works located in Indian Country?
❑ Yes
IUD
Collection System Type
(indicate percentage)
separate sanitary sewer
% combined storm and sanitary sewer
Unknown
% separate sanitary sewer
% combined storm and sanitary sewer
Unknown
% separate sanitary sewer
% combined storm and sanitary sewer
Unknown
% separate sanitary sewer
% combined storm and sanitary sewer
Unknown
Separate Sanitary Sewer System
[ ' No
Modified Application Form 2A
t.CQrhl�r�o etrAidvo,, p
Ownership Status
VOwn
❑ Own
❑ Own
❑ Own
❑ Own
O Own
O Own
O Own
O Own
❑ Own
O Own
❑ Own
O Maintain
O Maintain
O Maintain
O Maintain
0 Maintain
O Maintain
O Maintain
O Maintain
O Maintain
❑ Maintain
❑ Maintain
❑ Maintain
Combined Storm and
Sanitary Sewer
O
Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes lam' No
Provide design and actual flow rates in the designated spaces.
Two Years Ago
Annual Average Flow Rates (Actual)
Last Year
Design Flow Rate
D • bd(o
mgd
This Year
0 • C mgd
Two Years Ago
mgd
Maximum Daily Flow Rates (Actual)
Last Year
This Year
mgd
• A mgd
Y1� ki\vv
mgd
V. (Ur mgd
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Treated Effluent
Total Number of Effluent Discharge Points by Type
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
Page 2

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number Facility Name
N C co Li) Mu ariiu ay, P� rec
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods
Outfails Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater
for discharge to waters of the
to basins. ponds, or other surface impoundments that do not have outlets
State of North Carolina?
[�No 4 SKIP to Item 1.14.
■ Yes
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Location
Average Daily Volume
Discharged to Surface
Impoundment
Continuous or Intermittent
(check one}
gpd
❑ Continuous
❑ Intermittent
gpd
❑ Continuous
❑ Intermittent
gpd
0 Continuous
0 Intermittent
1.14
Is wastewater applied to land?
rci No4SKIPtoItem1.16.
• Yes
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Location
Size
Average Daily Volume
Applied
Continuous or
Intermittent
(check one)
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.16
is effluent transported to another
facility for treatment prior to discharge?
I:e No 4 SKIP to Item 1.21.
■ Yes
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 aonUcant?
, _ No 4 SKIP to Item 1.20.
■ Yes
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number Facility Name
i�1Lobi.0l 03 M �b •Ln rQ_'_r_t
Modified Application Form 2A
ModfiedMarch 2021
Outfalls and Other Discharge or Disposal Methods Continued
1.20
In the table below, indicate the name, address, contact information, NPDES number,nurb�r,and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
1.21
Is the
not
•
wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
Yes ®' No 4 SKIP to Item 1.23.
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
Method
Description
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acres
gp d
Continuous
❑ Intermittent
acresgpd
❑ Continuous
❑ Intermittent
acresgpd
0 Continuous
❑ Intermittent
Variance
Requests
1.23
Do
Consult
EZ
you intend to request or renew one or more of the
with your NPDES permitting authority to determine
Discharges into marine waters (CWA
Section 301(h))
Not applicable
variances
•
authorized at 40 CFR 122.21(n)? (Check all that apply.
what information needs to be submitted and when.)
Water quality related effluent limitation (CWA Section
302(b)(2))
Contractor information
(1
Are any operational or maintenance aspects (related
there ponsibility of a contractor?
Yes
to
•
wastewater treatment and effluent quality) of the treatment works
No +SKIP to Section 2.
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)
�f1V i r(, ea*i 1, fr C.
Mailing address
streett or P.O. box)
P�-6bx C15y
City, state, and ZIP
code
C k\ 1u.k hea, Nca�T-a3
Contact name (first and
last
�� 1
Phone number
W _5C66 _ 411t
Email address
L'r1V ►raft i le t►u l
(1C rC- . C1 1, UDE)
Operational and
maintenance
responsibilities of
contractor
c
cape-ratrvr5
'f"
t,D'Y;t.Mcal nfnor
nts
Page 4

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number
Facility Name
in
Modified Application Form 2A
Modified March 2021
w
Design Flow 0
0
N 2. ADDITIONAL INFORMATION (40 CFR 122.21(j)(1) and (2))
Outfaits to Waters of the State of North Carolina
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
• Yes V No 4 SKIP to Section 3.
0
=
c
c
R
3
0
42
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of inflow and infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Topographic
Map
2.3
Have
specific
•
you attached a topographic map to this application
requirements.)
Yes
•
that contains all the required information? (See instructions for
No
Flow
Diagram
2.4
Have
(See
■
you attached a process flow diagram or schematic
instructions for specific requirements.)
Yes
•
to this application that contains all the required information?
No
Scheduled Improvements and Schedules of Implementation
2.5
Are
■
improvements to the facility scheduled?
Yes
■
No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list autfail
number)
Begin
Construction
(MM/DDIYYYY)
End
Construction
(MM/DD/YYYY)
Begin
Discharge
YYYY
(MM/DD/)
Attainment of
Operational
Level
(MM/DD/YYYY)
2.
3.
4.
2.7
Have
response.
•
appropriate permits/clearances
Yes
concerning other federal/state requirements
• No
been obtained? Briefly explain your
• None required or applicable
Explanation:
Page 5

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number
Facility Name
Modified Application Form 2A
Modified March 2021
SECTION 3. INFORMATION
ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Description of Outfalls
3.1
Outfall NumberOOf
Outfall Number
OutfaU Number
StateNcr-thCoxbi
Ira
County
MaLAn
City or town
-k.i(31AlcinctO
Distance from shore
ft.
ft.
ft.
Depth below surface
ft.
ft.
ft.
Average daily flow rate
mgd
mgd
mgd
Latitude
35° (2 1 54 „ Iv
°
0 „
Longitude
83 ° 15 ,Lty " n
"
Seasonal or Periodic Discharge Data
3.2
Do
•
any of the outfalls described under Item 3.1 have seasona
Yes
or periodic discharges?
V No 4 SKIP to Item 3.4.
3.3
If so, provide the following information for each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
mgd
mgd
mgd
Months in which discharge
occurs
Diffuser Type
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.
Outfall Number
Outfall Number
Outfall Number
eh'
w a
cii 3 y
3.6
Does the treatment works discharge or plan to discharge wastewater
one or more discharge points?
D Yes
•
to waters of the State of North Carolina from
No +SKIP to Section 6.
Page 6

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461ED
NPDES Permit Number Facility Name ��y�
IV C. nLe l 1 a3 rY)(iirtittin Y'Q:1 C.�J1
Modified Application Form 2A
► Modified March 2021
Receiving Water Description
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall NumberGb,
Outfall Number
Outfaii Number
Receiving water name
.es C:izetc.
Name of watershed, river,
or stream system
90,��
nvu i n
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
SaVa n .
rig tr basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
mg/L of
CaCO3
mg/L of
CaCO3
mg/L of
CaCO3
Treatment Description
3.8
Provide the following information describing the treatment provided for discharges from each outfall.
Outfall Number Dbt
Outfall Number
Outfall Number
Highest Level of
Treatment (check all that
apply per outfall)
('Primary
0 Equivalent to
secondary
❑ Secondary
❑ Advanced
❑ Other (specify)
❑ Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BODs or CBODs
%
%
%
TSS
%
%
%
Phosphorus
❑ Not applicable
0 Not applicable
0 Not applicable
Nitrogen
❑ Not applicable
%
0 Not applicable
°/u
0 Not applicable
ok
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number Facility Name
a 1 tart
fi
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Treatment Description Continued
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.
Outfall Number
CD(
Outfall Number
Outfall Number
Disinfection type
•
CAlciu pochtartt
Seasons used
Dechlorination used?
■/
Not applicable
Yes
II Not applicable
II Not applicable
LN
■ Yes
■ Yes
■ No
• No
• No
3.10
Have you completed monitoring for all Table A parameters and
Yes
attached the results
to the application package?
IN No
3.11
Have you conducted any WET
discharges or on any receiving
tests during the 4.5 years prior to the date of the application on any of the facility's
water near the discharge points?
Dr. No 4 SKIP to Item 3.13.
■ Yes
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 waver 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
Pr
3.14
Does the PAW :Me chlorine disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
1 (es 4 Complete Table B, including chlorine. V No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants
pack e?
Yes
and attached
the results to this application
• No
3.18
Have you completed monitoring
attached the results to this application
for all applicable Table D pollutants required by your NPDES permitting authority and
package?
/ No additional sampling required by NPDES
® permitting authority.
• Yes
Page 8

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number Facility Name
IV C. CD L 1 l 33 ih Y -F
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Continued
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?
®' Yes J .Jo 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the
VYes
above tests to your NPDES permitting
No 4 Provide
authority?
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
(MM/DD/YYYY)
Summary of Results
'Dec e r tr- ac>i-
-FC, i 1
3.22
Regardless of
toxicity?
how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
No 4 SKIP to Item 3.26.
• Yes
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment
works conducted a toxicity reduction evaluation?
I No 3 SKIP to Item 3.26.
• Yes
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?
Not applicable because previously submitted
information to the NPDES •ermittin• authorit .
IN Yes
Page 9

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
DocuSign Envelope ID: 1C2281DC-3A75-46A7-BC3F-3885D148410C
SECTION
.4,4
, ‘
. ,
't'fx 2
,
,
6. CHECKLIST
6.1
NPDES Perm Number Number
Ni C. Cst) • t G5
AND CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 2A that
each section, specify in Column 2 any attachments
all applicants are required to provide attachments,
Facity Name
0 ... Ali . I I
CFR 122.22(a) and (d()
you have completed and are submitting
that you are enclosing to alert the permitting
Modified Application Form 2A
Mottled March 2021
with your application. For
authority Note that not
''''%::';
Section 1: Basic Application
Information for All Applicants
recuest(s)
• wf variance
• wf additional attachments
Section 2: Additional
Information
• wl topographic map
D w/ additional attachments
III w/ process flow diagram
gr. Section 3: Information on
Effluent Discnarges
wl Table
0 wl Table
A
B
C
0 wi Table D
• w/ additional attachments
• w/ Table
Section 4: Not Applicable
Section 5: Not Applicable
iv/ Section 6: Checklist and
Certification Statement
• wt attachments
.
„
6.2
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. 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)
Stephanie Anderson- Mountain Retreat & Learning Ce
Official title
tWeecutive Director
Signature
SiLfiLltiut. Quatisovu- Itttuutattk, rutvutf 8. (panAititl CuAlt.
Date signed
7/7/2022
Page 10

DocuSign Envelope ID: 2AA20594-3589-4B4E-B9AF-68B95F9461 ED
NPDES Permit Number
Facility Name
(nountio r ct
Outfall Number
coCam./
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS FOR ALL POTWS
Discharge
Average Daily Discharge
Pollutant
Biochemical oxygen demand
❑ BOD5 or ❑ CBOD5
reort one
Maximum Daily
Analytical
Methods
ML or MDL
(include units)
)
❑ ML
1 DL
Value
Units
M .
Value
Units
` L
M. `
Number of
3 . a
1
Fecal coliform
) OD V
❑ ML
la
Design flow rate
+ , -9..
D
O. QQ� T
G
•
-
0 ML
1B.MOL
pH (minimum)
N A
LAhr15
i,Unt t
Ni Pt
pH (maximum)
Is • (
Temperature (winter)
p
0 C
N Ps
° G
Temperature (summer)
i s
0 G
0 G
5
Total suspended solids (TSS)
L. 2 5
NI 1 1.
4 ,5
1
1 Sampling shall be conducted according to sufficiently sensitive test procedures (Le., methods) approved undeMO 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).
Page 11