WQ0003442_Application_20230328

State of North Carolina
Department of Environmental Quality
DW. R
Division of Water Resources
Division of Water Resources 15A NCAC 02U —CLOSED-LOOP RECYCLE SYSTEM RENEWAL
FORM: CLRS-R 02-21
Pursuant to 15A NCAC 02T .0107 b , if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. Ti►e application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02U, and Division Policies. For more information, visit the Water Quality Permitting Section's
Non -Discharge Branch website, The Applicant shall submit an electronic copy of the application and attachments uploaded as
a single Portable Document Format (PDF) file to litt s:lledocs.de .nc. ov/FormsMonDiscliar e-Branch-Submittal-Form-Vert,
or emailed to NOR- Dischar e.Re orts il dent-.1joy, if less than 20 megabytes (MB).
I List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessarv.
Type
Parcel No. Volume (gal) Liner Type
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Freeboard (ft) Latitude Longitude
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FORM; CLRS-R 02-21
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1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing pert -nit.
Attach additional sheets if necessary.
Permit Type Permit No. Relationship Type
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1 List all groundwater monitoring wells associated with the renewing
permit. Attach additional sheets if necessary.
Well Name
Parcel No. Status Gradient
Location
Latitude Longitude
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Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes -� Pursuant to 15A NCAC 02T .0105 d , submit a site map pursuant to the requirements in 15A NCAC 02U .0201 d .These
requirements are:
s not exceeding 10 Feet o► 25 percent of total site relief and showing
El A scaled map of the site with topographic contour interval
all facility -related structures and fences within 500 feet of the treatment, storage, and recycle areas.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108.
❑ Setbacks as required by 15A NCAC 02U .0701.
❑ Site property boundaries within 500 feet of all treatment, storage, and recycle sites.
®/No — Skip Attachment A.
KDoesignature authority in Section 1, Item 3 meet the requirements pursuantto 15A NCAC 02T.0106 b ?
Skip Attachment B.
ubmit a dele anon Letter pursuant to 15A NCAC 02T .0106 c authorizing the signature authority to sign.
Does he Perrnittee own all of the land associated with the treatment, storage, and recycle system?
[Yes — Skip Attachment C.
No — Pursuant to 15A NCAC 02T .0116c), provide a copy of all easem cuts, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the treatment, storage, and recycle system on property not owned by the Permittee.
Are lie Perniittee's affiliations of record correct? Check affiliations.
WYes — Skip Attachment D.
❑ No — Provide the corrected affiliations and their contact information.
FORM: CLRS-R 02-21 Page 2 of 3

Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ es — Submit documentation that the compliance schedules have been met.
V-N-NNo — Skip Attachment E.
Does the Permittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request,
❑ Yes (violations) -- Submit a copy of your response to the Notice of Violation.
�No — Skip Attachment F.
Does the closed -loop recycle system treat and/or store industrial wastewater?
❑ Yes — Proceed to the next question.
[V'No -- Skip Attachment G.
Has the nature of the industrial wastewater changed since the last permit issuance (i.e,, changes in industrial process, introduction of
new materials or chemicals, etc.)?
❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02U .0201(g). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing process;
and an overview of the cleaning and treatment methodology.
[E(No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology.
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02U .0701 , provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds, waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
❑ No -- Skip Attachment H.
1, 1�� �Vd
that this application
(Signature authority's name as noted in Section 1, item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I further certify pursuant to 15A NCAC 02T .0120(b), that the applicant, or any
parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .010An alternate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106 c . Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, )yhich spay include a �i% not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature:
Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload:
litt s://edoes.de .nc. ov/Forms/NonDiseliat, e-Bra
lloii-Disebar e.Re orts ircdenr, ov Submittal -Form -Vert
FORM: CLRS-R 02-21
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