NC0040266_application_20230316

North Carolina
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < o.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
6 2023
NCDEQ/DWR/NPDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
h FzaiFly � J
g� �j Modified Appiicabon Form 2A
Modified March 2021
Porn,
NC Departmentof Environmental Quality- Application for NPDES Permit to Discharge Wastewater
NPDES
MINOR SEWAGE FACILITIES (Before completing this form, please read fhe instructions. Failure to follow
the Instructions m result in denial of the plkation.
SECTION
1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.210)(1) and (9))
1.1
1 Facili name,7,S� / d4 to V 14P 1-14W7P
1�S%A7rS
Mailing address (street or P.O. box)
e / 17(4( ;Ad
City bf town
encii�l,
State
�r
ZIPc�dde
vr'�Sq%
Contact name (first and last)
Title
n�u�mb`�ejr
address
)�mail
c
Ia��Y
Iv
nnPhone
1'T'U�P
l.« )
L tion ddre (street, route n�u5nbar, or of er specific identifier) ® Same as mailing address
tL
City or town
UM _ell
State
K)
ZIP code
I
1.2
Is this application f r 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 No + SKIP to Item 1.4.
Applicant name
C
Applicant address (sheet or P.O. box)
0
E
City or town
State
ZIP code
c
Contact name (first and last)
Title
Phone number
Email address
n
1.4
Is the applicant the facilitys owner, operator, or both? (Check only one response.)
Owner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility ❑ Applicant Facility and applicant
X
(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
number for each.
€
Existing Environmental Permit
a
NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
Ew
(e
control)
c
Q
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
C
W
o
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
404)
Page 1

1-1
NPDES Permit Number
�r iN
� ��lodficd AppGgton Form 2A
r
n / G �`l0 0 /„ f„
D�� G� J
Modifi d Mach 2021
1 7
Provide the collection system information
requested below for the treatment works.
Municipality
Population
Collection System Type
Served
indicate percentage)
Ownership Status
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
n❑
Unknown
❑ Own ❑ Maintain
=
me
% separate sanitary sewer
Own Maintain
c
.q
D31+te
1
%combined storm sanitary and sanita sewer
0-Own Maintain
�
{
❑ Unknown
0-10wn 2-'�Maintain
a'
%separate sanitary sewer
❑ Own ❑ Maintain
c
%combined storm and sandary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
m
%separatesanitarysewer
❑ Own ❑ Maintain
a%combined
storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
Total
Population �v
c'i
Served
Separate Banftary Sewer System
Combinetl Storm and
Sanhe Sewer
Total percentage of each type of
sewer line in miles
a7o
as
z'
1.8
Is the treatment works located in Indian Country?
e
'o
U
❑ Yes No
W
1.9
Does the facility discharge to a receiving water that flow thro h Indian Country?
v
❑ Yes No
1.10
Provide design and actual flow rates in the designated tpaces.
Deft n Flow Rate
e 6?,;l '� mgd
a
Annual Average Flow Rates Actual
a ffi
Two Years Ago
Last Year
Tbls Year
c
c 3o
�LL
a li mild
.
mild
e 0 mgd
g
Ill"murn Daily Flow Rates Actual
Tiro Years Ago
Last Year
This Year
t� mild
• bZ L mgd
. C)2.2. mild
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina b
Total Number of Effluent Discharge lntsbyType
a d
Lx
Combined Sewer
Constructed
c
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
Overflows
p
fl
A
,4
Page 2

NPDES Permit Number
Faulity Name
Modified AppGrabon Form 2A
` Z`
1�NC
Modifed March 2021
Outhills Other Than to Waters of the State of North Carol**
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 State of North Carolina?
❑ Yes No 4 SKIP to Item 1.14.
1.13
Provide the location of each surface im oundment and associated dischar a information in the table below.
Surface Impoundment
Location and Discharge
Data
Location
Average Daily Volume
Discharged to Surface
Continuous or Intermittent
im undment
check one)
(
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
gpd
❑ Continuous
S
❑ Intermittent
1.14
Is wastewater applied to land?
❑ Yes No + SKIP to Item 1.16.
c
1.15
Provide the land application site and discharge data requested below.
Land Application Site
and Discharge Data
0
`
LOCatI0r1
ti@B
Average Daily Volume
Continuous or
Intermittent
L"
Applied
check one
n
acres
gpd
❑ Continuous
o
❑ Intermittent
s
acres
9D d
❑ Continuous
❑ Intermittent
A
acres
gpd
❑ Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment nor to discharge?
5
❑ 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 -* SKIP to Item 1.20.
1.19
Provide information on the transporter below.
TransporterData
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
TTitte
Phone number
Email address
Page 3

NPDES Permit Number
Facility' Nama
Modified Application Form 2A
NG Z
,�
Kn, f4"e E,6+Ocr
Modified March 2o21
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Recelvina Facility Data
$
F il' name S P5 - j� l�%
iling ad ess trees P,O. bo) L G C>
dio orIsom'
State /
ZIP code
0
Conte f me/fls and �� r�
Title n
V rl
75
ne mb f `,
-Email address
IY
[NPDE�nu
u M
n
piberof 'vin facile (ffany) ❑None
Average daily flow rate Q/� mgd
C
1,21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
m
not have ou0ets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
s
❑ Yes No 4 SKIP to Item 1.23.
u
c
1.22
Provide information in the table below
on these other disposal
methods.
infommtion on Other
Des osal Methods
Disposal
Memod
location of
Sin of
Annual Average
Daily Discharge
Continuous or Intermittent
A
Description{gleedcane
Disposal Site
Disposal Site
Volume
)
acres
gpd
❑ Continuous
o
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gp d
❑ Continuous
❑ 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.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
❑ Discharges into marine waters (CWA ❑ Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
�$
❑ Not applicable
1.24
Are an4ir one or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the response ility of a contractor?
Yes j9 Q "DNA) ail` ❑ No *SKIP to Section 2.
1,25
Provide location drid contact information for a ch contractor in addition to a description of the contractors operational
and maintenance res onsibilites.
Contractor Information
conbractor l
Contractor 2
Contractor 3
C
Contractor name
I✓1 W
pn '" C A2nd
Ix
(companyname
€
Mailing address
`Qk G2(R
street or P.O. box
Ve
City, state, and ZIP
code
Drti, a
Contact name (first and
e-
c4
last
iY)G5'+e`'>5
Phone number
P-Vil. L DSG
Email address�"`v'�
Operational and
maintenance
responsibilities of
v115;1��1V
contractor
v"' Y
Page
J

NPUESPermit Number FacilityName Modified Application Form 2A
N L s f w�5 I Modified March 2021
SECTION••
• INFORMATION
o
Outfalls to Waters of the Stale of North Carolina
2.1
the treatment works have a design flow greater than or equal to 0.1 mgd?
1Does
❑ Yes No 4 SKIP to Section 3.
`0
2.2
Provide the treatment works' current average daily volume of inflow
Average Dal Volume of Inflow and Infiltration
m
and infiltration.
r
c
gpd
s
Indicate the steps the facility is taking to minimize inflow and infiltration.
a
c
m
3
0
c
—"�
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
m
specific requirements.)
sa
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
u I
(See instructions for specific requirements.)
"
8
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
$
Briefly list and describe the scheduled improvements.
i.
2.
'S
ffi
3.
3
4.
v
6
2.6
Provide scheduled or actual dates of completion for improvements,
Scheduled
or Actual Dates of Completion for Improvements
Scheduled
Affsded
OutwlB
Begin
End
Begin
Attainment of
Operational
Improvement
n� ouCail
Construction
Construction
Discharge
Level
Level
(from above)
number
(MWDD/YYYY)
(MMrDDftWY)
(MWDD/YYYY)
MM
1.
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes 0 No ❑ None required or applicable
Explanation:
Page5

I
NPDES Permd N ont er W n r Gh 4aM 7-e5 Modified Applicalmn Fam 2A
H
D Modified March 2D21
(�
SECTION•' • ON DISCHARGES • 1
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number4�0'
OuffallNumber_
OutfallNumber_
State
CA
County
a K e
City or town
3
Distance from shore
D Q ft.
ft.
ft.
r
Depth below surface
ft.
ft
ft.
Average daily flow rate
mild
mgd
mgd
Latitude
Longitude
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
m
o
❑ Yes No 4 SKIP to Item 3.4.
d
me
3.3
If so, provide the following information for each applicable ouffall.
s
S
OuNall Number_
Outfall Number
Outfall Number
_
'—'
Number of times per year
$
discharge occurs
a
Average duration of each
o
discharge (specify units
`o
Average flow of each
mgd
mgd
mgd
a
discharge
Months in which discharge
occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ yes P( No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser t ve at each applicable outfall.
Outfall Number_
WWI Number—
Outfall Number_
ffi
z�
0
$
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
vi
3.6
one or more discharge points?
Yes p y)( t)1)6 ❑ No 4SKIP to Section 6.
Page 6

NYueS Permd Number
Facility Name Modified Appprafim Form 2A
N y O Z blp
abi"[ S{� Modified March 2021
3.7
Provide the receiving water
and related information if know for each outfall.
Number
Oulfall Number_
Outfell Number_
Receiving water name
,11Outfall
Uet2
Name of watershed, river,
6i.- �//
or stream system
N-3
U.S. Soil Conservation
ql)e h
Servicet4-digit watershed
code
Name of state
3
manaIfingement/river basin
7> 7 D j
O
U.S. Geological Survey
8-digit hydrologic
p
catalo in unit codeb
Critical low flow (acute)
cfs
cis
cfs
Critical low flow (chronic)
cis
of$
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CaCO3
3.8
Provide the following information
describing the treatment provided for dischar es from each outfall.
Outfoll Number DO)
Outfall Number_
Oulfall Number_
Highest Level of
T3 Primary
❑ Primary
❑ Primary
Treatment (check all that
Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outlall)
secondary
secondary
secondary
❑ Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
c
0
Design Removal Rates by
u
a
OuNall
a
BOD5 or CBOD5
%
%
%
TSS
%
%
%
❑ Not applicable
❑ Not applicable
Phosphorus
#=103Notappllcable
%
%
❑ Not applicable
❑ Not applicable
Nitrogen
%
°%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Persil Number
Facility Name
Modified Application Form 2A
Modified March 2021
3.19
Has the PO1W 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 No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority.
❑ Yes No Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES ermabn author and rovide a summa of the results.
�M�p ybymyy �
Summary of Reauka
0
c
0
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
a
❑ Yes No 4 SKIP to Item 3.26.
�
3.23
Describe the cause(s) of the toxicity:
c
m
W
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
Pages

r2
NPDES Permit'Nu(mrher
FaaYity Name
Modified Application Form 2A
Modified March 2021
1
l° 5
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. I� r t �P �� y� {�.11 S)a i : �Je D(2-5 P C JeT5
>'�M) �aa¢� Gib Lh� . 7 -2orn sec k to
� c�air Loa, 9c)
0
`o
Outfell Numbertops
Oulfall Number!
Oulhll Number
Infection typ /
0APO
�Wf e
70
Seaeo s ud-
rnR/1Q�17J s a
V�
E
Dechlorination used.
4f0e �b �r?-(7
❑ Not applicable !)
���1 """ '�v r% t
❑ Not applicable
❑ Not applicable
R' . 1/%RWneft
❑ Yes ����i
❑ No 7d,Y/j
Yes
❑ No
❑ Yes
❑ No
3.10
Have you completed monitoring for all Table A paradirliters and attached the results to the application package?
❑ 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?
❑ Yes I& No + SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted Once the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
OutfallNumber_
OutfailNumber_
OuthllNumber_
Acute
Chronic
Acute
Chronic
Agile
Chronic
Number of tests of discharge
water
r
Number of tests of receiving
water
i d
w
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
re nable potential to discharge chlorine in its effluent?
Yes 4 Complete Table 8, including chlorine. ❑ No + Complete Table 8, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table 8 pollutants and attached the results to this application
package?
❑ Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results to this application package?
❑ No additional sampling required by NPDES
❑ Yes permittingauthority.
Page 8

NPDES Permll Number Facility Name Modified Application Form 2A
K^ Modified March 2021
SECTION1
CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
6.1
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. Basic Application
❑
❑ w/ variance request(s) ❑ w/ additional attachments
Information for All A licants
❑ Section 2: Additional
❑ w/ topographic map ❑ w/ process flow diagram
Information
❑ wl additional attachments
❑ w/ Table A ❑ wl Table D
❑ Section 3: Information on
❑ wt Table B ❑ w/ additional attachments
Effluent Discharges
❑ w/ Table C
Section 4: Not Applicable
0
Section 5: Not Applicable
m
U
❑ Section 6: Checklist and
❑ w/ attachments
m
CeNfiration Statement
62
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 property gather arrd 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.
N not or type first and last name)
Official title
�e Lee, Mofw'5
2 L
Sins -Ka-
Date signed
0(ZL P�40`1& i* q) y - ep _ /osG.
Page 10

NPDESPemdw� Far3q Name Dutlap WnEx *xWuxI Appk® Fp lA
pollutants
NC(�4R2bb k n:Ah+,4cLL- r c 4- waaaum� 01
•—o
TABLE A. EFFLUENT PARAMETERS OR ALL POTWS
MaaYnum D*Dkdtwp
Average Day UkcAarpe
Pdkont
Anatyticel ML or MDL
value III Number Method' (include units)
Sam ke
Value
Unge
Biochemical oxygen demand
a BODs or a CBOD,
❑ Ml
one
❑ MDL
Fecal colikrm
❑ ML
a MDL
Design flow rate
pH (minimum)
PH (maximum)
Temperature (Wnter)
Temperature (summer)
Total suspended solids (TSS)
a ML
'Sampling shall be conducted according to sufficiently sensiGre
test procedures
Lie, methotls)approved
under 40 CFR 736
❑ MD
for the analysis of or pulanl =^^^'^•^^•
required antler 40 CFR chapter I, subchapter N or 0. See instructions arid 40 CFR 12121 (e)(3).
W C
Pape 11

EPAkenMNeewi Number
NPOES Pemil Number
Famly Name
PuaNl Wmber
Modifail APpku Fam 2A
Mo ffi 1lbtlh 2021
a- •• i a
a a- I a
Maximum Del Discharge
Avenge Dually Discharge
Pollutant
Analytlul
MLaMDL
Numberof
Value
Units
Value
Units
Method'
(include units)
Seth lax
Ammonia (as N)
O ML
❑ aOL
Chbnne
O hq
dual residual, TRC 2
❑ b9).
DleedNed oxygen
O M.
OWL
Nitratelnitrle
O
OWL
IGeldahl nihogen
O ME
O rax
Oil and grease
o hall.
NroL
PhosPhonrs
O Nc
o Eex
Total dissolved sleds
O Al
❑EG
' Sampling shall De conducted adducing to sutnciently sensilim test procedures (Le, methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter Nor 0. See Instructions and 40 CFR 122.21(e)(3).
21Facili ies that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chloride in their effluent are not
required to repel data for chbrine.
RECEIVED
EPA Form I510-}A gamNad}19) MAR 16 2o- Pe9e 12

EPA Mmaifion Nulber
MEE Perri[Number Fai Name ooadl Number
I,yifid Atoll Form
MoafieE Mamb 20t1
a. a•a
PollutantMaytlal
Maximum Daily Discharge Average Daily Discharge
ML or MDL
Value
Units Value
Units
Number of
Sample
-
Meth all (include uni
Metals, CyanMe, and Total Phenob
Hardness (as CaCCoi
❑ ss
o 1.mL
Antimony. total recoverable
OML
❑
Arsenic, total recoverable
o ML
❑ MIX
Beryllium, tool recoverable
❑ ML
❑ you
Cadmium, total recoverable
❑
OWL
Chromium, total recoverable
oML
❑ Mo
CoDPe<, total recoverable
OML
❑ma
Lean total recoverable
❑ML
❑ MOL
Mercury, total recoverable
ElML
o MI.
Nickel, food recoverableo
❑ MlA n
Selenium, total recoverable
❑ ME.
❑ MD
Silver, total recoverable
❑ ss
01013
Thallium, total recoverable
❑ ML
L
❑ mL
Zinc, total recoverable
ML
❑MOL
Cyanide
❑ M.
❑ MOL
Total phenolic compounds
❑ ML
❑Mot
VObtNe
Organic Compounds
Aral
❑ Ni
❑ MO
Acrylonildle
❑ML
❑MDL
Benzene
❑Ix
OWL
Bromotorm
0ML
OMbL
EPA Form 35101(Rerma b19) Pape 13

EPA M. fi bin FMm0v NPUES Pemit NumW F.ft, Name 0u 1Nun+ber MWaea A00[. Fw 2A
M 01W Meld, 2021
Mmdmum Daily Discharge
Average Daly Discharge
Pallufanl
Analocal
ML orMDL
Value
Units
Value
Unlb
Humberoi
Method'
(include units)
Samples
Carbon letrachlolide
O ML
❑ MOL
Chlorobenzece
O ML
O MOL
Chbrodibromomethane
O na
o LPL
OML
OWL
Chomathane
2chloroethylvinyl ether
O ML
O MOL
Chbrotorm
o ML
O MOL
Dichlorobromomelhane
O w
O MOL
1,1-dichbroethane
OML
OMO
1,2-dichlorcelhane
OML
❑ WI-
bens-1,2dicMoruethylerie
O ML
0 WL
i,l dbhloroemyiene
OML
O WL
1,24chbmpmpane
O ML
OWL
1,3dichlompropylene
OML
❑MOL
Elhylbenzene
O ML
o WI
Methyl bromide
OML
❑MOL
Melhylchbm7e
ON
O MD
Mathylene chloride
O w
❑ MOL
1,1,2,24trachlowihane
❑ ML
OWL
Tehachbroelhylene
O ML
❑MOl
Toluene
O
❑ hUl
1,1,14bchloroethane
ONL
❑LWL
1,1,2-InchlorcelhaneF-I
aw
❑M0.
EPAFmm3510-M NeviWM0) P tt

EPA MnErratlon Na , NMESPxmH.0 fedwy Name OWNlLmaer M MMApkabm Fw 2A
Mctl,fW WM 2021
a. r
Muimum Daily DischargeAverage
Daily Discharge
Pollutant
MelyliglTin
ML or MDL
Value
Unb
Numbarof
Value Who
Method'dudeunits(
Samalles,
Trichlormthylene
❑ ML
❑ MDL
Vinyl chloride
DML
❑ MDL
Acid -Extractable Compounds
p-ChlolD m-CRa01
D ML
❑NIX
2chlomphenol
DML
D MDL
2,"ichtompheml
aMr.
❑ MD
2,4-dimethYlphenW
D ML
❑ Melt
4,6dindro-ocresol
Cl ML
❑ MD
2,4-diniuopheml
D uL
� MDL
2-nitrophenol
DML
D MDL
4-nilrophenol
D ML
❑ Lail
Pernachlomphenol
DML
❑MDL
Phenol
DML
❑MDL
2,4,6trichlompheml
❑ML
❑ LIDL
Bu►NwbrslC=poWMs
Acenaphthene
DML
D MDL
Amnaphthylene
DML
❑ MD
Anmracene
DML
D MD
Senzidine
DMR.
❑ um
Benzo(a)anthracene
D w
D MDL
Senzo(a)py(em
DUL
D
3,4-benzoamranthene
UL
DML
❑MDL
EPA Form 35WM(e 319) Pp 15

EPA Maabreamp Wa W
NPDES Peme Numeer F.My Name OwbN Nurt
Mbdfee AppkaW Fa 2A
M HWJ � 2021
Pollutant
FLximum Daily Discharge
Average Dally Discharge
Anaytical
Melhodl
ML or MDL
(include units)
Value
Untie
Vadro
UnitsSamples
Numbernt
Benzo(ght)perylene
❑ML
❑Mel
O Ma
❑ MOL
Benzolk)guoranlhene
Bis (2<hloroelhoxy) methane
O ML
❑ um
Bis (Uhloroethyl) ether
0 ML
OWL
Be (2-chloroisOpmpyl) ether
O ML
O um
Bis (2-ethythexyl) phthalate
0 WL
O MD
4-bromophenyi phenyl ether
0 ML
❑ MD
Butyl benzyl phthalate
O ML
❑ MD
Uhloronaphthalene
0 ML
MIX
❑w
4-chlorophenyl phenyl ether
O ML
O MD
Chrysene
OML
❑MO
0
di-n-hutyl phthalate
0 ML
❑ MDL
din-oclyl phthalate
0 ML
OMOL
LNbenzo(a,h)anthracene
O ML
O Mix
1,2-dichlombenzene
❑ML
O MDL
1,3-dichlombenzene
0 ML
❑ MOL
1,4-dichlombenzene
OWL
❑ MOL
13dichlorobenzidine
O ML
OWL
Diethyl phthalate
OML
❑mm
Dimelhyl phthalate
0 to
OMa
2,4-tlinilrot0luene
O ML
❑ MOL
2,Bdinilrotoluene
0 ML
❑ xra
EPA Faun 3510-2A(FIeNseE 3-19) Pegs 15

A MmtlNeeon ft.W
NPDEe Pemil Writer Fwft Nero 0ueelF ndr
W,C APAM F M
Modh M 2Mt
Retort
Maximum Daily Discharp
Avaage Daly Discharge
AnalyUpel
ML or MDL
Veto
Units
Value
Units
Numberof
Method'
(include units)
Sem Ip
ipherrylhydranne
Ors
❑ MOL
ranmene
OMt
am
mne
am
arO
chWrobenzene
OML
O Met.
chlombutadiene
OW
❑ Mot
chbmcydo-pen(adiene
[N-nitrmodiphentilamine
OML
❑ Mo
chloroemane
O ML
❑ Mot
no(1,2,3cd)pyrene
O Mt
❑ Mot
omme
OW
❑M0.
thalene
O
❑MOt
benzens
OMi
OMa
osodi-rvpropylamine
am
❑ Mo
sodimethylamine
O
❑MDL
rosodiphenylamine
OMLOWL
❑a
amhmne
❑WL
Pyrene
O ML
❑Ma
1,2,4-tdchlorobenzensi
OML
OWL
r Sampling shall be conducted according
to sulfiuently sensitive
test procedures (i
e., methods) approved
under 40 CFR 136
for the analysis of oollutents
or ooliulant naramelers
ar
required under 40 CFR Chapter 1, Subchapter N or O. See instmctions and 40 CFR 122.21(e)(3).
EPAFarmWO-Mpa s 1319) P�17

NPDES Pemtil Nurroer Feuliry Neme Outlall BLrrAer Mo6feil PpuN I.2A
M&MM Meth W21
TABLED. ADDITIONAL POLLUTANTS
AS REQUIRED BY NPDES PERMITTING AUTHORITY
■ .e
__._,.._.G_._..____..___................. .a„,,,,,,„,o,,.,r...... .a.„vemesl aPP,uv under WtVK mo norme analysis or pollutants a pollutant parameters or required
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Pa 18