NC0051322_fact sheet_20230703

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
FACT SHEET
EXPEDITED - PERMIT RENEWAL
NCO051322
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Charles H. Weaver / July 3, 2023
Permit Number - Class
NCO051322 / Class WW-2
Owner
Carolina Water Service, Inc. of NC
Facility Name
Ashley Hills WWTP
Type of Waste
100 % domestic
Basin Name/Sub-basin number
Neuse River Basin / 03-04-02
Receiving Stream
Poplar Creek [segment 27-35
Stream Classification in Permit
C-NSW
Does permit need Daily Max NH3
limits?
No —already present
Does permit need TRC
limits/language?
No —already present
Does permit have toxicity testing?
No
Does permit have Special Conditions?
Neuse River Basin nutrient conditions + radiological
reo ener
Does permit have instream monitoring?
DO & Temperature
Is the stream impaired on 303 d list)?
No
Any obvious compliance concerns?
Nine enforcements during this permit cycle. Facility also
received two NODS and two NOVs.
Any permit MODS since lastpermit?
No
Changes to current permit?
Updated eDMR language
Added Neuse River modeling reo ener
Changes to final permit?
None

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
AFFIDAVIT OF PUBLICATION
Account #
Order Number
Identification
Order PO
Amount
Cols
Depth
19489
422637 i_
Print Legal Ad-IPL01233540 - IPLO123354
$685.65
1
72 L
Attention: Wren Thedford
DEPARTMENT OF WATER RESOURCES - RALEIGH
1617 MAIL SERVICE CENTER
RALEIGH, NC 276991617
[e-mail]
Public Notice
North Carolina Environmental Man-
agement Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a NPDES
Wastewater Permit
The North Carolina Environmental
Management Commission proposes
to issue a NPDES wastewater dis-
charge permit to the person(s) listed
below. Written comments regarding
the proposed permit will be accepted
until 30 days after the publish date of
this notice. The Director of the NC Di-
vision of Water Resources (DWR) may
hold a public hearing should there be
a significant degree of public interest.
Please mail comments and/or infor-
mation requests to DWR at the above
address. Interested persons may visit
the DWR at 512 N. Salisbury Street,
Raleigh, NC 27604 to review the infor-
mation on file. Additional information
on NPDES permits and this notice may
be found on our website: https://deq.
re gov/public-notices-hearings,or by
calling [phone].
Carolina Water Service, Inc. of NC re-
quested renewal of NPDES permit
NC0061638/Amherst WWTP/Wake
County. Facility discharges to Middle
Creek/Neuse River Basin. Currently
BOD, Ammonia Nitrogen, Dissolved
Oxygen, Fecal Coliform, and Total
Residual Chlorine are water quality
limited.
Carolina Water Service, Inc. of NC
requested renewal of NPDES Permit
NC0062219/Kings Grant Subdivision/
Wake County. Facility discharges to an
unnamed tributary to Poplar Creek/
Neuse River Basin. Currently, BOD5,
ammonia, fecal coliform, dissolved
oxygen, and total residual chlorine are
water quality is limited.
Carolina Water Service, Inc. of North
Carolina requested renewal of NPDES
permit NC0064378/Willowbrook
WWTP/Wake County. Facility dis-
charges to an unnamed tributary to
Beddingfield Creek/Neuse River Ba-
sin. Currently, BOD, ammonia -nitro-
gen, dissolved oxygen, fecal coliform,
total residual chlorine, and
4 radioactive substances are water
quality limited.
Carolina Water Service, Inc. of North
Carolina requested renewal of NP-
DES permit NC0051322/Ashley Hills
WWTP/Wake County. Facility dis-
charges to Poplar Creek/Neuse River
Basin. Currently, BOD, ammonia -ni-
trogen, fecal coliform, dissolved oxy-
gen, total phosphorus, and total resid-
ual chlorine are water quality limited.
IPLO123354
May 18 2023
STATE OF NORTH CAROLINA
COUNTY OF WAKE, COUNTY OF DURHAM
Before the undersigned, a Notary Public of Dallas
County, Texas, duly commissioned and authorized to
administer oaths, affirmations, etc., personally
appeared Tara Pennington, who being duly sworn or
affirmed, according to law, cloth depose and say that he
or she is Accounts Receivable Specialist of the News &
Observer Publishing Company, a corporation organized
and doing business under the Laws of the State of North
Carolina, and publishing a newspaper known as The
News & Observer, Wake and State aforesaid, the said
newspaper in which such notice, paper, document, or
legal advertisement was published was, at the time of
each and every such publication, a newspaper meeting
all of the requirements and qualifications of Section 1-
597 of the General Statutes of North Carolina and was a
qualified newspaper within the meaning of Section 1-597
of the General Statutes of North Carolina, and that as
such he or she makes this affidavit; and is familiar with
the books, files and business of said corporation and by
reference to the files of said publication the attached
advertisement for DEPARTMENT OF WATER RESOURCES -
RALEIGH was inserted in the aforesaid newspaper on
dates as follows:
1 insertion(s) published on:
05/18/23
I certify or declare) under penalty of perjury that the
foregoing is true and correct.
Ha"tw
Notary Public in and for the state of Texas, residing in
Dallas County
'�"' '• STEPHANIE HATCHER
x: •- My Notary ID # 1335YAX*
Eorss January 14, 2026
Extra charge for lost or duplicate affidavits.
Legal document please do not destroy!

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Carolina Water Service Inc of North Carolina
Attn: Dana Hill, Director of Operations
4944 Parkway Plaza Blvd, Ste 375
Charlotte, NC 28217
Subject: Permit Renewal
Application No. NCO051322
Ashley Hills WWTP
Wake County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
August 25, 2022
Laserfiehe
The Water Quality Permitting Section acknowledges the August 25, 2022, receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 15OB-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
htt s: d .nc. ov ermits-re ulations ermit- uidance environmental -a lication-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
cc: Brent Milliron-CWSNC
ec: WQPS Laserfiche File w/application
Sincerely
Wren e o d
Administrative Assistant
Water Quality Permitting Section
North Carolina Department ofEnvlronmentai Quality I Division of Water Resources
•%� Raleigh Regional Office 13800 Sarre" Drive I Raleigh, North Carolina 27609
919.7%4200

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO051322
Ashley Hills WWTP
Modified March 2021
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•
INFORMATION •• r
1.1
Facility name
Ashley Hills WWTP
Mailing address (street or P.O. box)
PO Box 240908
City or town
State
ZIP code
Charlotte
NC
28224
€
Contact name (first and last)
Title
Phone number
Email address
Dana Hill
Director of Operations
[phone]
dana.hill@carolinawaterservic
Location address (street, route number, or other specific identifier) ❑ Same as mailing
address
320 Woods Run
City or town State
ZIP code
Knightdale INC
27545
1.2
Is this application for a facility that has yet to commence discharge?
Lase
❑ Yes + See instructions on data submission ❑ No
rfiic
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
0 Yes ❑ No 4 SKIP to Item 1.4.
Applicant name
Carolina Water Service Inc. of North Carolina
=
Applicant address (street or P.O. box)
7a
PO Box 240908
aCity
or town
State
ZIP code
Charlotte
NC
28224
Contact name (first and last)
Title
Phone number
Email address
aDana
Hill
Director of Operations
[phone]
dana.hill@carolinawaterservic
a
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑r Owner ❑ Operator ❑
Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility 0 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.
Existing Environmental Permits
✓❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑
UIC (underground injection
mwater)
control)
£
_
NCO051322
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑
NESHAPs (CAA)
W
co
a
❑ Ocean dumping (MPRSA) ❑ Dredge or fill (CWA Section
404)
❑
Other (specify)
Page 1

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
Modified Application Form 2A
NPDES Permit Number
Facility Name
NCO051322
Ashley Hills WWTP
Modified March 2021
1.7 Provide the collections stem information requested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served_
Served
indicatepercentage)
100 % separate sanitary sewer
EI
Own
❑ Maintain
conn
connections;
sanitary % combined storm and sanita sewer
❑
Own
❑ Maintain
m
�2930 Dooulation
❑ Unknown
❑
Own
❑ Maintain
% separate sanitary sewer
❑
Own
❑ Maintain
°
% combined storm and sanitary sewer
❑
Own
❑ Maintain
❑ Unknown
❑
Own
❑ Maintain
c.
a
% separate sanitary sewer
❑
Own
❑ Maintain
% combined storm and sanitary sewer
❑
Own
❑ Maintain
iO
❑ Unknown
❑
Own
❑ Maintain
% separate sanitary sewer
❑
Own
❑ Maintain
N%
combined storm and sanitary sewer
❑
Own
❑ Maintain
c
❑ Unknown
❑
Own
❑ Maintain
Total
2930
Population
0
Served
Combined
Storm and
Separate Sanitary Sewer System
Sanitary
Sewer
Total percentage of each type of
100 %
%
sewer Ilne In miles
1.8
Is the treatment works located in Indian Country?
c
❑ Yes r❑ No
R
1.9
Does the facility discharge to a receiving water that Flows through Indian Country?
c
❑ Yes El No
1.10
Provide design and actual flow rates in the designated spaces.
a
Annual Average Flow Rates Actual
Two Years Ago
Last Year
c_C
.171 mgd
.203 mgd
m"
Maximum Daily Flow Rates Actual
Two Years Ago
Last Year
.397 mgd
.221 mgd
1.11
Provide the total number of effluent discharge points to waters of the State of North Caroli
c
Total Number of Effluent Discharge ointsbyType
IL Q,
LM .,
Treated Effluent
Untreated Effluent
Combined Sewer
Bypasses
Overflows
G
1 �
ign Flow ate-
. 250 mgd
This Year
.152 mgd
This Year
217 mgd
ape.
Constructed
Emergency
Overflows
Page 2

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 Ashley Hills W WTP Modified March 2021
Outfalls Other Than to Waters of the State of North Carolina
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 0 No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume
Continuous or intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
gpd
❑ Continuous
❑ Intermittent
1.14 Is wastewater applied to land?
❑ Yes ❑✓ No 4 SKIP to Item 1.16.
1.15 Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
1.16
Average Daily Volume
Continuous or
Location
Size
Applied
Intermittent
check one
❑ Continuous
acres
gpd
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
❑ Continuous
acres
gpd
❑ Intermittent
Is effluent transported to another
facilitv for treatment Drior to discharae?
❑ Yes ❑✓ No 4 SKIP to Item 1.21.
1.17 1 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

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 Ashley Hills WWTP Modified March 2021
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facilit .
Receiving Facility Data
m
Facility name
Mailing address (street or P.O. box)
3
City or town
State
ZIP code
0
c�
o
Contact name (first and last)
Title
0
s
m
Phone number
Email address
UNPDES
number of receiving facility (if any) ❑ None Average daily flow rate mgd
W
c
1
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
0
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
LM
❑ Yes ❑✓ No + SKIP to Item 1.23.
o
1.22
Provide information in the table below on these other disposal methods. —
m
Information on Other Dis osal Methods
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
❑ Continuous
acres
gpd ❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
ElContinuous
❑ 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.)
b
❑ Discharges into marine waters (CWA ❑ Water quality related effluent limitation (CWA Section
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 0 No +SKIP 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.
Contractor Information
Contractor 1 I Contractor 2
Contractor 3
0
Contractor name
A
(company name
oMailing
address
c
street or P.O. box
City, state, and ZIP
o
code
Contact name (first and
c
U
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 Ashley Hills WWTP Modified March 2021
SECTIONDD• •' • 1
c Outfalls to Waters of the State of North Carolina
=
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
w
0
0 Yes ❑ No 4 SKIP to Section 3.
c
2.2
Provide the treatment works' current average daily volume of inflow
Average Deify Volume of Inflow and Infiltration
50,000 d
9P
and infiltration.
5
Indicate the steps the facility is taking to minimize inflow and infiltration.
VManholes
are inspected regularly to detect flow changes with suspect areas inspected by CCTV and repairs made
3
accordingly. Several sections of main have been rehabbed in previous years.
0
C
c
r
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
� a
specific requirements.)
o
❑✓ Yes ❑ No
�o
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.)
_o c
o
❑✓ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes 0 No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
0
1.
c
m
E
A?
2.
E
46
3.
„
m
n
4.
-a
a
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
m
Scheduled
Affected
Begin
End Begin
Attainment of
a
o
Q.
Improvement
Outfalls
(list outfall
Construction
Construction Discharge
Operational
Level
E
(from above)
number)
(MM/DD/YYY`)
(MM/DD/YYYY) (MM/DD/YYYY)
MM/DD
m
m
2.
- —
r
co
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

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 I Ashley Hills WWTP I Modified March 2021
3.1 1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001 Outfall Number Outfall Number
State NC
County
Wake
w
City or town Knightdale
0
e
Distance from shore 0 ft. ft. ft.
z
Depth below surface 0 ft. ft. ft.
0
Average daily flow rate .150 mgd mgd mgd
Latitude 35' 48 9.29' N ° '
Longitude 78° 2Y 10.8 W "
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o ❑ Yes 0 No 4 SKIP to Item 3.4.
m
12 3.3 If so, provide the following information for each applicable outfall.
L
Outfall Number
Outfall Number
Outfall Number
c
Number of times per year
discharge occurs
n Average duration of each
`o dischar e (specify units
Average flow of each
mgd
mgd
mgd
discharge
Months in which discharge
occurs
3.4 IAre any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑r No 4 SKIP to Item 3.6.
3.5 Brieflv describe the diffuser tvoe at each aDplicable outfall.
m
Outfall Number
Outfall Number
Outfall Number
vS 3.6 Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
3 0 Yes ❑ No 4SKIP to Section 6.
Page 6

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91 FD3
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO051322
Ashley Hills WWTP
Modified March 2021
3.7 Provide the receiving water and related information if known for each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Receiving water name
Poplar Creek
Name of watershed, river,
Neuse River Basin
g
or stream system
$.
U.S. Soil Conservation
Service 14-digit watershed
030202011103
code
Name of state
3
managementtriver basin
Neuse
U.S. Geological Survey
8-digit hydrologic
03020201
cataloging unit code
Critical low flow (acute)
cis
cfs
cfs
Critical low flow (chronic)
cfs
cfs
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 discharges from each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Highest Level of
❑ Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
0 Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
e
0
g,
Design Removal Rates by
Outfall
m
BOD5 or CBOD5
85 %
%
%
m
TSS
85 %
%
%
f-
® Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
/o o
0
%
%
10 Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
Page 7

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
rn
c
w
4)
m
W
3.9
3.10
3.11
3.12
NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 Ashley Hills WWTP Modified March 2021
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
UV Disinfection
Outfall Number 001 Outfall Number Outfall Number
Disinfection type T UV
Seasons used
All
Dechlorination used? ❑ Not applicable ❑ Not applicable ❑ Not applicable j
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
Have you completed monitoring for all Table A parameters and attached the results to the application package?
E] Yes ❑ No
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 0 No -* SKIP to Item 3.13.
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.
Outfall Number Outfall Number Outfall Number
Acute I Chronic Acute I Chronic Acute I Chronic
Number of tests of discharge
water
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 0 No additional sampling required by NPDES
permitting authority.
Page 8

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-0 1 3776D91 FD3
r --
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO051322
Ashley Hills WWTP
Modified March 2021
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?
❑ Yes 0 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 3 Provide results in Table E and SKIP to
Item 3.26.
3.21 Indicate the dates the data were submitted to our NPDESpermitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
(MMIDDIYYYY)
Page 9

DocuSign Envelope ID: FF7588E3-3B79-4703-955D-013776D91FD3
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NPDES Permit Number Facility Name Modified Application Form 2A
NCO051322 I Ashley Hills WWTP Modified March 2021
6.1 1In 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 aoDlicants are reauired to Drovide attachments.
Column 1
Column 2
ID
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
❑
w/ additional attachments
❑✓
wl Table A
❑
w/ Table D
❑
Section 3: Information on
✓❑
w/ Table B
❑
w/ additional attachments
Effluent Discharges
❑
wl Table C
Section 4: Not Applicable
Section 5: Not Applicable
0 Section 6: Checklist and w/ attachments
Certification Statement
6.2 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 directly responsible
forgathering 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 knowinn violations.
Name (print or type first and last name) Official title
Dana Hill Director of Operations
Signature
Db:—s.o MD.ru xa
Dana Hill
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Date signed
07/19/2022
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