NC0085979_Renewal Application_20100301

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NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated with groundwater treatment facilities.
Mail the complete application to:
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit Number INCO085979
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name NCDOT Equipment Unit
Facility Name NCDOT-Rosman Maintenance Facility
Mailing Address 4809 Beryl Road
City Raleigh
State / Zip Code NC 27606
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same as above ❑
Street Address or State Road 100 Old Calvert Landfill Road
City Brevard
State / Zip Code NC 28716
County Transylvania
3. Operator Information:
Name of the firm, consultant or other entity that operates the facility. (Note that this is not referring to the
Operator in Responsible Charge or ORC)
Name NCDOT Rosman Maintenance
Mailing Address 100 Old Calvert Landfill Road
City Brevard
State / Zip Code NC 28716
Telephone Number [phone]
Fax Number [phone]
4. Ownership Status:
Federal ❑ State ® Private ❑ Public ❑
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NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated with groundwater treatment facilities.
S. Products recovered:
Gasoline ❑ Diesel fuel ❑ Solvents ❑ Other chloride
6. Number of separate discharge points: 1
Outfall Identification number(s) 001
7. Frequency of discharge: Continuous ® Intermittent ❑
If intermittent:
Days per week discharge occurs: Duration:
S. Treatment System Design flow 0.0288 MGD
9. Name of receiving stream(s) (Provide a map showing the exact location of each outfall, including
latitude and longitudes
French Broad River
10. Please list all additives to the treatment system, including chemicals or nutrients, that have
the potential to be discharged.
No Additives
11. Is this facility located on Indian country? (check one)
Yes ❑ No
12. Additional Information
All applicants (including renewalss
• A USGS topographical map (or copy of the relevant portion) which shows all outfalls
• A summary of the most recent analytical results (effluent data, if available) containing the
maximum values for each chemical detected
NEW Applicants only:
Engineering Alternative Analysis
Description of remediation treatment system components, capacities, and removal efficiency
for detected compounds.
If the treatment system will discharge to a storm sewer,written approval from the
municipality responsible for the sewer.
A list of any chemicals found in detectable amounts at the site, with the maximum observed
concentration reported for each chemical (the most recent sample must be collected less
than one year prior to the date of this application)
For petroleum-contaminated sites-Analyses for Volatile Organic Compounds (VOC) should
be performed. Analyses for any fuel additives likely to be present at the site and for phenol
and lead should also be performed.
For sites contaminated with solvents or other contaminants - EPA Method 624/625
analysis should be performed.
Page 2 of 3 C-GW 03/05

NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated
with groundwater treatment facilities.
13. Applicant Certification
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Eric Motzno Environmental Engineer
Printed name of Person Signing Title
l' , o�010
Signature of Applicant Date
North Carolina General Statute 143-215.6 (b)(2) provides that: Any person who knowingly makes any false
statement representation, or certification in any application, record, report, plan, or other document files or
required to be maintained under Article 21 or regulations of the Environmental Management Commission
implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or
monitoring device or method required to be operated or maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section
1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both,
for a similar offense.)
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