WQ0006075_Application_20230421

State of North Carolina
Department of Environmental Quality
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(bl, if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with.15A
',CAC 02T .0100, i +A NCAC: 21 !, 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 https://edocs.deti.nc.i!ov/Forms/NonDischarQe-Branch-Submittal-Form-Ver2,
or emailed to Non-Discharae.Reports(d)ncdenr.gov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1. Applicant:
2. Permit No.: WQ00 QI
3. Signature authority: Mi '71 WOWMTitle:
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Email: 1 e-19m
4. Mailing address: P�q j q x W9
City: cCJ f�� i' �i
State: Zip: ,
5. Contact person: Y7) , I Y i 6 m Q
Primary phone number: (&V %"-036Select
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Secondary phone number: PW Ybff ftbelect
SECTION R — FACILITY INFORMATION
1. Physical address: ! y County:%�d ( Parcel No.:
City: f 5? rae e. Pin e- State: NC Zip: - W 71/
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: . ° Longitude: - . 0Method: Select
SECTION HI — BILLING INFORMATION
1. Billing address: PO
City: SPWe PiAe State: NC Zip: - &�90-777
2. Verify the Applicant does not have any overdue annual fees:
http s:Hdeq.nc. gov/about/divisions/water-resources/water-resources-permits/wq-epayments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
SECTION IV — OPEN -ATMOSPHERE STRUCTURES
1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type
Parcel No.
Volume (gal)
Liner Type
Freeboard (it)
Latitude
Longitude
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FORM: CLRS-R 02-21 Pagel of 3

SECTION V — RELATED PERMITS
1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type
Permit No.
Relationship Type
Select
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01
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SECTION VI — MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude
I Longitude
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Select
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°
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ATTACHMENT A — SITE MAP
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:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
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.
IV No — Skip Attachment A.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
V1 Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT C — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Do s the Permittee own all of the land associated with the treatment, storage, and recycle system?
Yes — Skip Attachment C.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, 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.
ATTACHMENT D — AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
M Yes — Skip Attachment D.
❑ No — Provide the corrected affiliations and their contact information.
FORM: CLRS-R 02-21 Page 2 of 3

ATTACHMENT E — COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been met.
❑ No — Skip Attachment E.
ATTACHMENT F — CIVIL. PENALTIES AND OUTSTANDING VIOLATIONS
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.
1VNo — Skip Attachment F.
ATTACHMENT G — INDUSTRIAL WASTEWATER
Does the closed -loop recycle system treat and/or store industrial wastewater?
❑ Yes — Proceed to the next question.
VNo — 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.
❑ 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.
ATTACHMENT H — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑ Yes — Pursuant to 15A NCAC 02U .0701(g), 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.
V No — Skip Attachment H.
I,
APPLICANT'S CERTIFICATION I
attest that this application
`Signature authority's name as noted in Section I, 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 .0106(b). An 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, which mqy include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
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Signature: I A, / Date: �/R/
THE COMPLETED AIPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Laserfiche Upload:
Non-Discharge.Reports(a�ncdenr.gov https://edocs.deg.nc.aov/Forms/NonDischarge-Branch-
Submittal-Form-Vert
FORM: CLRS-R 02-21 Page 3 of 3