NC0038300_Application_20210403

United States Office of Water EPA Form 3510-1
Environmental Protection Agency Washington, D.C. Revised March 2019
Water Permits Division
."10
EPA Application Form 1
General Information
NPDES Permitting Program
11/CDo MO
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 213, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
SS Mobile Home Park
OMB No. 2040-0004
NCO038300
U.S. Environmental Protection Agency
Farm
t
\=OEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION
1. ACTIVITIES REQUIRING AN NPDES PERMIT (40 CFR 122.21(f) and (f)(1))
1 r 'Applicants Hot'Rqulred:to Submit Form
1.1.1
Is the facility a new or existing publicly owned
1 12
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
•
-
App'licantsRequired to Submit Form 1 ',
rf
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
x` ;
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
production facility?
currently discharging process wastewater?
Yes -3� Complete Form 1 No
Yes 4 Complete Form No
and Form 2B.
1 and Form 2C.
z
�
12.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
y g g
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
'
Yes 4 Complete Form 1 No
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
1.2.5
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 0 No
and Form 2F
unless exempted by
40 CFR
12226(b)(14)(x) or
SECTION
2. NAME,
MAILING ADDRESS, 40 CFR
2.1
,Faclli Name
"
SS Mobile Home Park
2.2
EPA Identification Number. .
oY
J.
"D
2.3
Facility Contact
..
N,
Name (first and last)
Title
Phone number
lames R. Edwards
Owner
13362603396
Email address
[e-mail]
2.4
Facility Mailing�Address _ ...
Street or P.O. box
1808 PINECREST ST
City or town
State
ZIP code
Burlington
NC
27215-5639
EPA Form 3510-1(revised 3-19) Page 1

EPA Identification Number
NPOES Permit Number
Facility Name
Form Approved 03/05119
SS Mobile Home Park
OMB No. 2040-0004
NCO038300
2.5
Faoy Location
Street, route number, or other specific identifier
241 Graham Moore Rd
County name
County code (if known)
�. c :
�.
Chatham
w:
City or town
State ZIP code
Z4'. ccv
Staley I
NC 27355
SECTIONr
NAICS CODES41 CFR
3.1
SIC Codes}
D'escriptionr1;(opflonal)
yC%
3.2
NAICS Code(s)
De scriptton_(optional)
4.1
``Name of'0 Ora
James R. Edwards
4.2
Is the name you listed in Item 4.1 also the owner?
❑ Yes ❑ No
4.3
0 erator- Status
'"
❑ Public —federal ❑ Public —state ❑ Other public (specify)
-o
❑✓ Private El Other (specify)
4.4
Phone. Number of Operator
3362603396
4.5
Operator, Address
•�
Street or P.O. Box
`
1808 PIN ECREST ST
o a
City or town
State
ZIP code
�c
Burlington
NC
27215-5639
Email address of operator
Q:
[e-mail]
SECTIONr
+ r 41 CFR
5.1
Is the facility located on Indian Land?
❑ Yes ❑ No
EPA Form 3510-1(revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105119
SS Mobile Home Park OMB No. 2040-0004
NCO038300
SECTION••
, ,1
6.1 A Existing Environmental Permits (check;all that apply; and print or,type the corres on ing,permtt nV ffi_ t- for, each)r
w _
❑✓ NPDES (discharges to surface ❑ RCRA (hazardous wastes) ❑ UIC (underground injection of
..= -
water) fluids)
NCO038300
u °
❑ PSD (air emissions) ❑ Nonattainment program (CAA) ❑ NESHAPs (CAA)
c
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section 404) ❑ Other (specify)
SECTIONA•
4I CFR
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
CL _ `
specific requirements.)
0 Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 213.)
SECTIONOF
41
8.1
Describe the nature of your business.
<F
Mobile Home Park serving 32 mh spaces
UY
.y
m
O,
L .
r+
cc
SECTION••
9.1
41
Does your facility use cooling water?
e� _,
❑ Yes 0 No > SKIP to Item 10.1.
.-
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
2` :
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
SECTION
I VARIANCE
REQUESTS41 1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
r
10.1
y;-
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
=
when.)
a•
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
.M
Section 301(c) and (g))
0 Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
SS Mobile Home Park OMB No. 2040-0004
NCO038300
SECTION
11. CHECKLIST
AND CERTIFICATION STATEMENT ,0
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For 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 ' `
Golump.2
Section 1: Activities Requiring an NPDES Permit
❑ wl attachments
❑✓ Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑ Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
❑ Section 5: Indian Land
❑ wl attachments
❑ Section 6: Existing Environmental Permits
❑ w/ attachments
w
✓ Section 7: Ma
❑ p
wl topographic
❑ El w/ additional attachments
' "r � .:,_
map
�I
o,
❑✓ Section 8: Nature of Business
❑ w/ attachments
❑ Section 9: Cooling Water Intake Structures
❑ w/ attachments
d-
`
❑ Section 10: Variance Requests
❑ w/ attachments
N
❑✓ Section 11: Checklist and Certification Statement
❑ w/ attachments
11.2
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
Y '
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete.) 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)
Official title
James R. Edwards
Owner
S' ature
Date signed
_
4/3/21
LJ
EPA Form 3510-1(revised 3-19) Page 4

-1Z JU
USGS Quad: Coleridge, N.C.
Latitude: 3544?18"
Longitude: 7932'08"
Stream Class: C
Subbasin; 03-06-09
Receiving Stream UT Brush Creek
1 840 000 FEET
NCO038300 Facility
S.S. Mobile Home Park Location
Chatham County
Map not to scale

North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < o.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.

NPDES Permit Number
Facility Name
Modified Application Form 2A
SS Mobile Home Park
Modified March 2021
NCO038300
Form
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
NPDES
the instructions may result in denial of the application.
SECTION 1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.210)(1) and (9))
1.1
Facility name
_ =
SS Mobile Home Park
Mailing address (street or P.O. box)
1808 Pinecrest St
f.
City or town
State
ZIP code
o `
Burlington
NC
27215-5639
Contact name (first and last)
Title
Phone number
Email address
James R. Edwards
3362603396
tri le
[e-mail].
P J
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
241 Graham Moore Road
City or town
State
ZIP code
Staley
NC
27355
.'
1.2
Is this application for a facility that has yet to commence discharge?
f`
❑ 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 4 SKIP to Item 1.4.
t
Applicant name
<,a
SS Construction & Rental Inc.
Applicant address (street or P.O. box)
1808 Pinecrest St
.
City or town
State
ZIP code
1- .,
c. =
Burlington
NC
27215
Contact name (first and last)
Title
Phone number
Email address
- Q-'
James R. Edwards
Manager
g
3362603396
tri le [e-mail]
A 1
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
_r;
-
El owner ❑ Operator ❑✓ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility ❑ Applicant Facility and applicant
(they are one and the same)
N : +
1.6
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.
d.
: ; existing Environmental Permits
✓❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
water)
control)
:E4
NCO038300
-': _
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c.
�`
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
.X..
404)
Page 1

NPDES Permit Number
Facility Name
Modified Application Form 2A
SS Mobile Home Park
Modified March 2021
NCO038300
1.7
Provide the collections stem information
requested below for the treatment works.
Municipality
Population
Collection System Type:
Ownersus,
-.Served-
Served..:
� indicate percenta e
_
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
% separate sanitary sewer
❑ Own ❑ Maintain
: `
% combined storm and sanitary sewer
❑ Own ❑ Maintain
v;
❑ Unknown
❑ Own ❑ Maintain
=o :: r'
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
%separate sanitary sewer
❑Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
Total
m'-
Population
Served
Combine_ Stone=and
$eparate:Sanitary,Sewer System
Sonita .Sewe r.
Total percentage of each type of
sewer line in miles
z'
1.8
Is the treatment works located in Indian Country?
o.
❑ Yes 0 No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes El No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow. Rate
.01 mgd
Annual Avera `e: Flow Rates Actual
a
Two Years Ago .
Last Year
Thi§Year
.002832 m
9 d
.00276 mgd
AOS76 mgd
Maximum.Dail FIow:Rates Actual - , -
w.
TwaYears Ago
.
Last Year
- This Year
.004 mgd
.00S76 mgd
.00S76 mgd
y.
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type..
mDsrP'
oins :T Total:Nuberof,Efuen:be
Z.
� �•
�-
Treated Effluent
.
Untreated; Effluent
Combined. Sewer
Bypasses
Constructed V
-
Emergency .
Overflows
Overflows
.;o
1
Page 2

NPDES Permit Number
Facility Name
SS Mobile Home Park
Modified Application Form 2A
Modified March 2021
N/A
NCO038300
:O.utfalls-Otiar Than to -Waters of the State of* -Camlina. -
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
' in the table below
Provide. the location of each surface impoundment and associated di schar a information .,
Surface_Im oundmenfLocation and Dischar
a Data
Y
Average Daily Volume
,
Continuous oranterm�ttent
Location
Discharged'to.Surface
(check onej
.Im ' oundment�
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
1.14 1
Is wastewater applied to land?
`
Yes ❑ ❑ No 4 SKIP to Item 1.16.
H
1.15
Provide the land application site and discharge data requested below.
:Land=A lication.Site:;and
Discharge Data _
_ :c
- - -
Continuous or
Location :
Size
Average,Daily Volume
A lied
Inferrriitent, _
o,
check one
acres
gpd
❑ Continuous
❑ Intermittent
❑ Continuous
acres
gpd
❑ Intermittent
C,
acres
gpd
❑ Continuous
❑ Intermittent
N
1.16
Is effluent transported to another facility for treatment prior to discharge?
_
El Yes No 4 SKIP to Item 1.21.
o
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 4 SKIP to Item 1.20.
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

NPDES Permit Number
Facility Name
Modified Application Form 2A
SS Mobile Home Park
Modified March 2021
N/A
NCO038300
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
-
receiving facility.
_. Receivirt :Facil
pata. -
Facility name
Mailing address (street or P.O. box)
.o a
City or town
State
ZIP code
Contact name (first and last)
Title
a ;
Phone number
Email address
y
NPDES number of receiving facility (if any) O None
Average daily flow rate mgd
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
`
❑ Yes 0 No 4 SKIP to Item 1.23.
1.22
Provide information in the table below on
these other disposal methods.
R o,
Information On'Other. Dis osal Methods
a�
Disposal
Location of
.'
Sie of
Annual,Average
Daily
Continuous;or Intermittent
r .� .
c-0
Descri tioh
Disposal Site
��Disposai Site 1
Discharge
Volume
(checkone}
acres
gpd
O Continuous
O Intermittent
-
O Continuous
acres
gpd
❑ Intermittent
acres
gpd
❑ 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.
d
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
�R -Cr
Section 301(h)) 302(b)(2))
❑✓ Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes ❑✓ No 4SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
.. Contracto00#ormation.
,
=' Contractor 1
Contractor:2 :
Contractor 3
Contractor name
'
(company name
Mailing address
` c ;
street or P.O. box
City, state, and ZIP
c .
code
Contact name (first and
.9' .'
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
SS Mobile Home Park Modified March 2021
NCO038300
o ; r .of the State of . olth~Carona: u -
.t,��itfaiis/to.Waters
u.
:
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
o
❑ Yes ❑ No 4 SKIP to Section 3.
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow o'infi tration
,.,.
and infiltration.
gp d
Indicate the steps the facility is taking to minimize inflow and infiltration.
o.
_Z `
:�,
2.3
Have you attached a topographic ma to this application that contains all the required information. See instructions for
Yp pP � q �(
;.-
specific requirements.)
•O :ilf .
❑ Yes ❑ No
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
;o
(See instructions for specific requirements.)
u
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
cc2.
1.
o.".
E
3.
�.
d
t
4.
N
cc
2.6
Provide scheduled or actual dates of completion
for improvements.
"Scheduled,*-"
Ac#ual Dates: of Com teton for lm rovements
-
Scheduied
Affected
0utfalls
Begin .. -
End `
Begin
Attainment of t:
operational .'
e
.� �
improvement
(list butfall
Construction
Construction
Discharge
� Level -
E.
(from above)
number
(MM/DDIYY.YY)
(MMIDDIYYYY)
(MMIDDIYYYY)
Mfg/,DDNYYY
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number
Facility Name Modified Application Form 2A
SS Mobile Home park Modified March 2021
NCO038300
SECTION
3. INFORMATION
ON EFFLUENT DISCHARGES (40 CFR 122.210)(3) to (5))
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
3.1
0u'tFall N�lniber s : i z
Outfail Number - :-� � `
�u�fall�Nu�n.�er� -
State
001
r,
.: kt... .:.
�.N s
County
Chatham
.n
City or town
Staley
Distance from shore
0 ft•
ft.
ft.
Depth below surface
0
Average daily flow rate
.ao3sz mgd
mgd
mgd
Latitude
35° 44' 18 N
°
-
Longitude
79 3Y 08"
s =
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
..::.
`- -
✓ No 4SKIP to Item 3.4.
Yes ❑
3.3
If so, provide the following information for each applicable outfall.
S �
�Qutfall,ll�um�eY; � ;
O�tfal��N"umber �-;
� Outfa��l�u�nber
a
Number of times per year
E Y
` 10 4,
discharge occurs
Average duration of each
' o
discharge (specify units
Average flow of each
mgd
mgd
mgd
_.;
_�
discharge
Months in which discharge
occurs
-7,
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
�`;F. z."
❑ Yes ❑✓ No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser
a at each applicable outfall
'��
°'0, lumber
0` fall Number -
-
w Oaff l`� rber'
.0alli
.!
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
3.6
one or more discharge points?
t°
❑ No 4SKIP to Section 6.
Yes
Page 6

NPDES Permit Number
Facility Name
Modified Application Forth 2A
SS Mobile Home Park
Modified March 2021
NC0038300
3.7
Provide the receiving water and related information if known for each outfall.
Outfall Number _
Outfall Number
Outfall Number
Receiving water name
Unnamed tributary
Name of watershed, river,
0
or stream system
UT Brush Creek
a
U.S. Soil Conservation
Service 14-digit watershed
o
code
N/A
Name of state
management/river basin
Cape Fear
m
U.S. Geological Survey
d
8-digit hydrologic
cataloging unit code
N/A
Critical low flow (acute)
N/A cis
cfs
cfs
Critical low flow (chronic)
N/A cfs
cfs
cis
Total hardness at critical
mglL of
mglL of
mglL of
low flow
N/A CaCO3
CaCO3
CaCO3
3.8
Provide the following information describing the treatment provided for dischar es from each outfall.
OutfallNumber_
Outfall Number
Outfall Number
Highest Level of
O Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
❑ Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
c
0
'Q
Design Removal Rates by
Outfall
N
BODs or CBODs
N/A %
%
%
E
E
d
TSS
N/A %
%
%
® Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
® Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Permit Number
Facility Name
Modred Application Form 2A
SS Mobile Home Park
Modified March 2021
NCO038300
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.
o-
0 b er N ��
utf Number
0 ap
Oiu l,N r
tial robe
v
-
�u
Disinfection type
Chlorine
Seasons used
All
a "
E-
t
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
0 Yes
❑ Yes
❑ Yes
- -_
❑ No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters 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 ❑ No 4 SKIP to Item 3.13.
-- ;.
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 water near the discharge points.
4utfall Number
ao1
Outfall Number
Outfall Number
o`
Acute
hronic.
Acute
Chronic
Acute
;c
Number of tests of discharge
water
17
a
Number of tests of receiving
water
-
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑✓ Yes 4 Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B 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?
❑ Yes � No additional sampling required by NPDES
permittingauthority.
Page 8

NPDES Permit Number
Facility Name
SS Mobile Home Park
Modified Application Form ZA
Modified March 2021
NCO038300
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?
No Complete tests and Table E and SKIP to
❑
✓❑ Yes Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
No > Provide results in Table E and SKIP to
❑
0 Yes Item 3.26.
3.21
Indicate the dates the data were submitted toour NPDES ermittin authorityand provide a summaryof the results.
Dates) Submitted
:Summary of Results' `
MMIDDNM .
Pass
3/31/2021
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
o
toxicity?
c
El Yes [✓] No SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment works conducted a toxicity reduction evaluation?
El Yes 0 No SKIP to Item 3.26.
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?
0 Not applicable because previously submitted
Yes
rl information to the NPDES permitting authority.
Page 9

NPDES Permit Number Facility Name Modified Application Form 2A
55 Mobile Home Park Modified March 2021
NC0038300
6.1 In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
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) ❑ wl additional attachments
Information for All Applicants
Section 2: Additional 0 w/ topographic map ❑ wl process flow diagram
❑ Information
❑ wl additional attachments
0 Section 3: Information on
Effluent Discharges
Section 4: Not Applicable
Section 5: Not Applicable
❑ Section 6: Checklist and
Certification Statement
6.2 Certification Statement
wl Table A
w/ Table B
❑
wl Table C
❑
w/ attachments
U wl Table D
❑ wl additional attachments
I 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) Official title
James R Edwards Owner
Sign re Date signed
4/3/21
Page 10

NPDES Permit Number
Facility Name
Outfall Number
55 Mobile Home Park
NCO038300
001
Modified Application Form 2A
Modified March 2021
rr• •�
Maximum Daily Discharge
Average Daily Discharge
Analytical M MDL
Value
Units
Value
Units
Number ofMILor
Pollutant
Method (include units)
Sam les
Biochemical oxygen demand
❑ BODe or ci CBODs
o ML
2.5 0 MDL
(report one
45.2
mg/I
19.46
mg/I
52
SM521OB-2011
Fecal coliform
160
mg/I
1.21
mg/I
52
o MIL
Colilert-18 1'0 ❑ MDL
Design flow rate
0.00576
mgd
0.0028
mgd
52
pH (minimum)
7.3
su
pH (maximum)
7.5
su
Temperature (winter)
0.00408
Celsius
0.00214
Celsius
52
Temperature (summer)
0.0024
Celsius
0.0037
Celsius
52
Total suspended solids (TSS)
103
mg/I
5.05
mg/l
52
SM 2540D-2011 2.5 O MDL
f Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 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).

EPA Identification Number NPDES Permit Number Facility Name Outfall Number I Modified Application Form 2A
55 Mobile Home Park Modified March 2021
NCO038300
001
.; ••.
e • e•
- e- a •e 11 v a.. a:
Avers e:':Da�C :Dischar e.
Maximum Dail Dischar e. 9��. ,
..9 � a� 9 Y_.
tic
Ar�aiy al �
�
L�so DL;
. , ....
; .,
Value:
--
.-
V ltae
a
Units;
Number of
.. _.
Pollutant;
Metnaa
r
the ude. t , its ;
{ _ :: (_:..h...n.�,. a
r
"Units-
z Sa"in
Ammonia (as N)
2.7
mg/I
0.499
mg/I
52
.PA 350. Rev 2.0 199
El NIL
0.10 ❑ MDL
Chlorine
❑ ML
17
total residual, TRC 2
40
ug/I
12
ug/I
104
4500-CI G-201120
p MDL
0 ML
>5
Dissolved oxygen
10
mg/I
7.4
mg/I
52
SM 4500-OG-2011
El MDL
❑ ML
Nitrate/nitrite
❑ MDL
❑ ML
Kjeldahl nitrogen
❑ MDL
❑ ML
Oil and grease
❑ MDL
❑ ML
Phosphorus
❑ MDL
❑ ML
Total dissolved solids
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approves under 4U U-K 13b Tor me analysis or pollutants or pollutant parameters ur
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A (Revised 3-19) Page 12

Hardness (as CaCO3)
Antimony, total recoverable
Arsenic, total recoverable
Beryllium, total recoverable
Cadmium, total recoverable
Chromium, total recoverable
Copper, total recoverable
Lead, total recoverable
Mercury, total recoverable
Nickel, total recoverable
Selenium, total recoverable
Silver, total recoverable
Thallium, total recoverable
Zinc, total recoverable
Cyanide
Total phenolic compounds
olatfle Q'rgamcCompounds
Acrolein
Acrylonitrile
Benzene
Bromoform
EPA Form 3510-2A (Revised 3-19)

EPA Identification Number
N,
,
zPollutant
c
NPDES Permit Number Facility Name Outfall Number
..
Maximum Daily,°Discharge . Average Daily, Discfialrge T
Value
Uinits
Value
Units
ANum eF41D
NO -
Amp
Carbon tetrachloride
Chlorobenzene
Chlorodibromomethane
Chloroethane
2-chloroethyivinyl ether
Chloroform
Dichlorobromomethane
1,1-dichloroethane
1,2-dichloroethane
trans-1,2-dichloroethylene
1,1-dichloroethylene
1,2-dichloropropane
1,3-dichloropropylene
Ethylbenzene
Methyl bromide
Methyl chloride
Methylene chloride
1,1,2,2-tetrachloroetha ne
Tetrachloroethylene
Toluene
1,1,1-tdchloroetha ne
1,1,2-tdchloroethane
EPA Form 3510-2A (Revised 3-19)

Acid=Extractable Compounds
p-chloro-m-cresol
2-chlorophenol
2,4-dichlorophenol
2,4-dimethylphenol
4,6-dinitro-o-cresol
2,4-dinitrophenol
2-nitrophenol
4-nitrophenol
Pentachlorophenol
Phenol
2,4,6-tdchlorophenol
I Base -Neutral Compounds _
Acenaphthene
Acenaphthylene
Anthracene
Benzidine
Benzo(a)anthracene
Benzo(a)pyrene
3,4-benzotjuoranthene
EPA Form 3510-2A (Revised 3-19)

EPA Identification Number
`
Pollutant
NPDES Permit Number Facility Name Outfall Number
Maximum Daiiy,,Disct 'arge= Average Da fy;Discharge
A
Value
:Units
KValue
Units
N4timberoff i
Benzo(ghi)perylene
Benzo(k)fluoranthene
Bis (2-chloroethoxy) methane
Bis (2-chloroethyl) ether
Bis (2-chloroisopropyl) ether
Bis (2-ethylhexyl) phthalate
4-bromophenyl phenyl ether
Butyl benzyl phthalate
2-chloronaphthalene
4-chlorophenyl phenyl ether
Chrysene
di-n-butyl phthalate
di-n-octyl phthalate
Dibenzo(a,h)anthracene
1,2-dichlorobenzene
1,3-dichlorobenzene
1,4-dichlorobenzene
3,3-dichlorobenzid i ne
Diethyl phthalate
Dimethyl phthalate
2,4-dinitrotoluene
2,6-dinitrotoluene
EPA Form 3510-2A (Revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Outfail Number
KIM AT
MaximumDailyaDfscharge - Average Daily'Dscharge
�oliuiarrt-lum,elrf
- m �i �S
i
1,2-diphenylhydrazine
Fluoranthene
Fluorene
Hexachlorobenzene
Hexachlorobutadiene
Hexachlorocyclo-pentadiene
Hexachloroethane
Indeno(1,2,3-cd)pyrene
Isophorone
Naphthalene
Nitrobenzene
N-nitrosodi-n-propylamine
N-nitrosodimethylamine
N-nitrosodiphenylamine
Phenanthrene
Pyrene
1,2,4-trichlorobenzene
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutan
required under 40 CFR Chapter I, Subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A (Revised 3-19)

NPDES Permit Number Facility Name Outfall Number
chi e A
MaXEm umDaiiDis ar vera" gDaf�Disc ,� ,
-�Pollutants r -.�
Nu"rnber.�of�
Value Units 'Value
_ Sam
`
❑ No additional sampling is required by NPDES permitting authority.
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutan-
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).