NC0038687_Renewal (Application)_20230420

SiIriIrn
North Carolina
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < m MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
A('k 10 2023
NCDEQ/DWR/NRDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

nurucer
C
�acility,[f�me — Modified Appiketion Form 2A
ya /J4 c Modified March 2021
Form
NC Department of Environmental Quality
- Appli
tion for NPDES Permit to Discharge Wastewater
NPDES
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the nslructions m resukt in dens the
of
iofion.
1.1
Facility name
J l COMO
PlIe5LA VV UUTP
Mailing add s (sir or P.O. box
r►v2
Cl or towr�
State ZIP code
Contact name (first and last)
Title
Phone number Email address
V V In r W
+ Dsts�f�
Location address (street, nu er, or other specific identifier) —� ) ❑ Same as mailing address
City or town
State ZIP��couude
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes + 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 (street or P.O. box)
City or town
State ZIP code
c
Contact name (first and last) Title
Phone number Email address
g
1.4
Is the applicant the facility's owner
operator, or both? (Check only one response.)
Owner ❑ Operator
❑ Both
1.5 To
which entity should the NPDES permitting author ty send co respondence? (Check only one esponse.)
L10 Facility ❑ Applicant ❑ Facility and applicant
(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
a, Exiattng.Environmental Permifs .,
NPDES (discharges to surface ❑ RCRA (hazardous waste
waller ❑ UIC (underground injection
control)
❑ PSD (air emissions) ❑ Nonattainment program (CAA) ❑ NESHAPs (CAA)
c'
w.
w
c
{ ❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section ❑ Other (specify)
404)
cLyn
Page 1

Modified Application Form 2A
r� / rr
1 A a r TP
V\/UU t
Modified March 2021
i"
1.7 Provide the collection s stem intormation re nested below for
he true rent works.
my Population Collection System Type
Stewed
Served indicate can a
ownership sfaltu& _
.�.
1 1,Y111 n6 Prl �/�Q'�'L, L( % separate sanitary sewer
((�
Own ❑ Maintain
. %combined stone and sanitary sewer
❑ Own ❑ Maintain
cT�
�l �r ❑ Unknown
1 ?SG Yn�t31 % separate sanitary sewer
❑ Own ❑ Maintain
❑ Own ❑ Maintain
,•'
Y �TYv %combined storm and sanAa sewer
ry
❑ Own ❑ Maintain
aI
❑ Unknown
❑ Own ❑ Maintain
.a
I %separate sanitary sewer
❑ Own ❑ Maintain
%combined stone and sanitary sewer
❑ Own ❑ Maintain
®
❑ Unknown
❑ Own ❑ Maintain
%separate sanitary sewer
❑ Own ❑ Maintain
_ %combined storm and sanitary sewer
❑ Own ❑ Maintain
Total c I El Unknown
❑Own ❑ Maintain
o
Population 1 V
P
Served 00 1
Separate Sanitary Sewer System
Combined Stain en
Total percentage of each type of
San Sow- ,
sewer line in miles 177
I vv a/
%
1.8 Is the treatment works located in Indian Country?
❑ Yes ./
No
La/
1.9 Does the facility discharge to a receiving water that flows tIndian Country?
hrong
❑ Yes No
1.10 Provide design and actual flow rates in the designated spaces.
Desi Flow
n Rate
�C' mad
ffi
oC
Two Years Apo
Annual Aver a Flow Rates Actual
Last Year
This Year
'
�J , :( L mgd
1
• LLC,.� mgd
rr
11LI--uL mgd
c
Mulmum Daily Row Rates Actual
Two Years A1go
Last Year
This Year
mgd
V mgd
.ffi
•��� mgd
1.11 Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
7aa1 timber of Effluent Disch ar a Points fi
'r
Treated Effluent Untreated Effluent
Combined Sewer
Bypasses
Constructed
Overflows
Emergency .
3
! �
Overflows
Page 2

�( ,, Madified Application Fan 2A
Iy�W Ul 7-3- `-U.11 IFS i Y'IL.a.r ----n Mofted March 2021
erThan t0 Writers of fhe S'�ite d Pbff1 Cardate
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 � SKIP to Item 1.14.
Average Daily Volume
Location Discharged to Surface Continuous or Intermittent
i
Impoundment (checkone}
' El Continuous
gpd ❑ Intermittent
j
I ❑ Continuous gpd
❑ Intermittent
gpd ❑ Continuous
w ❑ Inter $ 1.14 Is wastewater applied to land?
❑ Yes V No + SKIP to Item 1.16.
o. 1,15 Provide the land a lication site and dischar a data requested below.
9L Land lication Site and Discharge Data
0
Location size Average Daily Volume
La
m Applied
p
acres gpd
c
� acres gpd
v
c
acres gpd
1.16 Is effluent transported to another facility for treatment Pri r to discharge?
❑ Yes �/ No 4 SKIP to Item 1.21.
_ 1.17 Describe the means by which the effluent is transported (e.g., tank truck, pipe).
rc`
1.18 1 Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No 4 SKIP to Item 1.20.
1.19 LProvide information on the trancnnrlcr h.1,,,.,
tntity name
C ty or town
Contact name
Title
code
,ononuousor
intermittent'
Page 3

- rauuy name} Modified Applicaton Form 2A
YV IpduIT Modified March 2021
1.20 In the table below, indicate the name, address, contact information, NP S number, and average daily flow rate of the
receivingfacility.
Facility name Receivin F ` .
Mailing address (street or P.O. box)
City or town State
ZIP code
Contact name (first and last) Title
Phone number
_ Email address
NPDES number of receiving facility (if any) ❑None
w Average daily flow rate 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
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
y❑ Yes Una/ No 4 SKIP to Item 1.23,
sa '12 Provide information in the table below on these other disposal methods.
FYsposal Informative on Other D sat Methods
Location of Sze of Annual Average
Dail Discharge Continuous or Mteeinittertt
Disposal She Disposal Site Volume (check one)
10
acres gpd ❑ Continuous
❑ Intermittent
acres g ❑ Continuous
❑ Intermittent
acres gpd ❑ Continuous
❑
€ 1,23 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Chaeck all that apply.
I Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
A ❑ Discharges into marine waters ( CWA
Section 301(h)) ❑ Water quality related effluent limitation (CWA Section
r � 302(b)(2))
qv 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?
V Yes ❑ No +SKIP to Section 2.
1.25 Provide location and contact information for each contractor in addition to a description of the contractor's ol
and maintenance res onsibilities. peratona
Contractor Information
Contractor fi Contractor Cot>tfadPr 3
n Contractor name
com an name
Mailing address street or P.O. box PC)
® City, state, and ZI7153 P
code0 ilk
Contact name (first and
last
Phone number
Email address ��
Operational and
maintenance C rai��15
responsibilities of
contractor rnfl { t l�f L1r P. f D
Page 4

Modified Applinfion Form 2A
.,-7 Modified Mamh 2021
2.1 Does the treatment works have a design Now greater than or equal to 0.1 mgd?
❑ Yes V No + SKIP to Section 3.
2.2 Provide the treatment works' current average daily volume of inflow I Averag
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
2.3 1 Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
❑ Yes ❑ No
2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for specific requirements.)
❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
❑ Yes ❑ No + SKIP to Section 3.
Briefly list and describe the scheduled improvements
1.
2.
3.
4.
26 Prc
or actual dates of
for Imerevnmanta
5cheduted
AReatetl
Outfalls
Begin End
Begin Attammettt of
tm rovament
P
{f om above)
(Iistoufall
Construction Construction
Discharge
number
(AA OONYYY) (MWODNYYY)
{MM/DLevel-
1.
M1DQFlYYY. ,
2.
3.
4.
- -- ate o wi¢xuony umer reaeraustate requirements been obtained? Bdefy explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

Modified Application Form 2A
Modifed March 2021
3.1 f Provide the following information for each outfall. (Attach additional sheets if you have more than three ouffalls.)
Ou0211' NuMb&rtLL_ Oudd Number_. OuffaH Number
State
county
0
City or town
c
a
Distance from shore
ff
ft.
o
Depth below surface
ft•
ft.
Average daily flow rate
, l W ql mgd
mgd
Latitude
Longitude
3.2 Do any of the outalls described under Item 3.1 have seasonal or periodic discharges?
0
❑ Yes
53" No + SKIP to Item 3.4.
R
3,3 If so. provide the following information
for each applicable
outfall.
0
Outial6Number_ OuftlNum6er_
Ott
='
Number of times per year
dischar a occurs
a
Average duration of each
c '
discha e s eci units
c
Average flow of each
dischame
mgd
mgd
H
Months in which dischame
3.4 Are any of the outalls listed under Item 3.1 equipped with a diffuser?
❑ Yes No 4 SKIP to Item 3.6.
mgd
uu udn.
OutfallNumber_
OutfaliNumber_
-
+
of s 36 """ "" 1COWIVIu wurrcs alscnarge or plan to discharge wastewater to waters of the State of North Carolina from I
=, one or more discharge points?
' Yes ❑ No +SKIP to Section 6.
Page 6

nruw remm rvumcer vtaclNtyTlame Modified Appkallon Form 2A
kA t r(i Moped March 2021
3.7
Provide the receivinq water and related information if known for eachAtfall,
Outfall Number
Outfa(INumber_
Ou tNumber
Receiving water name
Name of watershed, river,
L' t t TZYiQSSe
c
or stream system
LP% l '
U.S. Soil Conservation
m `
Service 14-digft watershed
c
code
1
Name of state
Li iti-f TQ 0) C
:
management/riverbasin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cis
cis
of$
Critical low flow (chronic)
cis
cis
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
descrbinq the treatment orovided for discharqes from each outfall.
Outfatt Number.
Wall Number_
Outfag IN
Highest Level of
Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply peroutfall)
secondary
secondary
secondary
❑ Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
a
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
0
FL
Design Removal Rates by
Outfall
BODs or CB00s
TSS
%
%
%
F....'
❑ Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
❑ Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
Other (specify)
❑ Not applicable
❑ Not applicable
❑Not applicable
Page 7

ON
NLOVbUg-4 Q
3.9 Describe the type of disinfection used for the effluent from each
season, describe below.
c
c
0
U
Outfalf Number
Disinfection type I I C, �
m
o �
Seasons used At
m
Modified APPlication Form 2A
n t r V MadiW March 2021
table belowtable below. if disinfection varies byvaries by
Outfall Number_ j Outfatl Number_
Dechionnation used? ❑ Not applicable ❑ Not applicable PP ❑ Not applicable
(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 V 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
dischar as b outfall number or of the receivin water n th d'
ear a
OutFatl Number—
ischar a omts.
0utfalf Number_
Outfalt Number_
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
Number of tests of receiving
water
:i.14 1 Does the POTW use chlorine for dismfechon, use chlonne elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes + Complete Table B, including chlorine. No + 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
RECEIVED
0 1 -3
NCDEQ/DWR/NPDES
Page 8

�e
F
51
Modified Applicallon Form 2A
r'Yl Modified March 2021
mas me ru i vv conducted either (1) minimum of four quarterly WET4Ats for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes No + Complete tests and Table E and SKIP to
Item 3.26.
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,
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Summary of Results
{ 322 Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No + SKIP to Item 3.26.
1 s 23 1 Describe the cause(s) of the toxicity — I
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.
Have you completed Table E for
❑ Yes
hed the results to the application
p Not applicable because I
information to the NPDE
submitted
Page

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I Application Form 2A
Modified March 2021
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 atfarhmenrc
1: Basic AEz�pplication
❑
FInformnationfor All A licants
w/variance request(s)
❑
w/ additional attachments
2: Additional
❑
w/topographic map
❑
w/ process flow diagram
tion
❑
w/ additional attachments
Section 3: Information on
❑
w/ Table A
❑
w/ Table D
Effluent Discharges
w/ Table B
❑
w/additional attachments
❑
w/Table C
Section 4: Not Applicable
Section 5: Not Applicable
Lid Certification Statement � w/ attachments
6.2 Certification Statement
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 property 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 im hsonment for knowin violations.
Name (p>_n`or type first and fast name) Official title
to signed
313o1z3
Page 10