NC0079740_Renewal (Application)_20230720

ROY COOPER _ A
Governor p�
ELIZABETH S.BISER
Secretary
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
July 20, 2023
City of Kings Mountain
Attn: Rick Duncan, Director
PO Box 429
Kings Mountain, NC 28086-0429
Subject: Permit Renewal
Application No. NC0079740
Ellison WTP
Cleveland County
Dear Applicant:
The Water Quality Permitting Section acknowledges the July 20, 2023, 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. 150B-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:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-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.
Sin re�
i
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
cc: Matt Echols, City Engineer
ec: WQPS Laserfiche File w/application
DE Q,- N Ca of m Q Wa
Mooresvilleorth rolina RegDepartmentional Office 610Environ East Centerental Avenualityur.SuittDivision 301 of MooresviterResourceslk,North Carolina 28115
704.6631699

MAN
KINGS MOUNTAIN
NORTH CAROLINA
fig.ePeuated.
July 17, 2023
Division of Water Resources RECEIVED
/CG D
Water Quality Permitting Section - NPDES
1617 Mail Service Center J U L 2 0 RECO
Raleigh, NC 27699-1617
NCDEQIDWRINPDES
Attn: Andrew Friedman-Herring
Dear Andrew,
Enclosed, please find one original and two copies of the NPDES permit renewal application for
the T.J. Ellison Water Treatment Plant (NC0079740). If you have any questions or require
additional information, please don't hesitate to contact me at 980-396-5807 or
matt.echols(&cityofkm.com.
Sincerely,
Matt Echols, PE
City Engineer
City of Kings Mountain I City Hall 1101 W Gold St. I Kings Mountain, NC 28086
Phone: [phone] [e-mail] ( www.cityofkm.com

•
EPA Identification Number NPDES Permit Number Facility Name \ CEI Olds ll� 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP 2040 0004
U.S.Environmental Protection Agency 2 0 RBA
Form
Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMAIMEUDWRINPDES
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 12
treatment works? 1. . treating domestic sewage?
If yes, STOP. Do NOT complete 0 No If yes. STOP. Do NOT No
Form 1.Complete Form 2A. complete Form 1.Complete
Form 2S.
1.2 Applicants Required to Submit Form 1
1.2.1 Is the facility a concentrated animal feeding 1.2.2 Is the facility an existing manufacturing,
operation or a concentrated aquatic animal commercial, mining,or silvicultural facility that is
a production facility? currently discharging process wastewater?
oYes 4 Complete Form 1 © No 0 Yes 4 Complete Form El No
a. and Form 2B. 1 and Form 2C.
1.2.3 Is the facility a new manufacturing,commercial, 1.2.4 Is the facility a new or existing manufacturing,
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 0 No Yes 4 Complete Form 0 No
re and Form 2D. 1 and Form 2E.
F.
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose •
discharge is composed of both stormwater and
non-stormwater?
0 Yes 4 Complete Form 1 0 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x)or
b 15 .
SECTION 2.NAME, MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2))
2.1 Facility Name
T.J.Ellison Water Treatment Plant(WTP)
2.2 EPA Identification Number
v
1000-0005-8929
-a
2.3 Facility Contact
Name(first and last) Title Phone number
-a Rick Duncan Public Infrastructure Director [phone]
rn Email address
[e-mail]
co
2.4 Facility Mailing Address
Street or P.O.box
PO Box 429
City or town State ZIP code
Kings Mountain NC 28086
EPA Form 3510-1(revised 3-19) Page 1

•
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
Ica 2.5 Facility Location
= Street,route number,or other specific identifier
Q o 1432 Oak Grove Road
V
c o County name County code(if known)
Cleveland
o
City or town State ZIP code
z R Kings Mountain NC 28086
SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3))
3,1 SIC Code(s) Description(optional)
to
-13
0
U
y
3.2 NAICS Code(s) Description(optional)
221310 Water Treatment Plant
U
U)
SECTION 4.OPERATOR INFORMATION(40 CFR 122.21(f)(4))
4.1 Name of Operator
City of Kings Mountain
4.2 Is the name you listed in Item 4.1 also the owner?
_ ❑✓ Yes ❑ No
4.3 Operator Status
❑ Public—federal ❑ Public—state ❑✓ Other public(specify)Municipal
o ❑ Private 0 Other(specify)
4.4 Phone Number of Operator
[phone]
4.5 Operator Address
Street or P.O. Box
E �i PO Box 429
`o
c ._ City or town State ZIP code
o o Kings Mountain NC 28086
a Email address of operator
O [e-mail]
SECTION 5.INDIAN LAND(40 CFR 122.21(f)(5))
R c 5.1 Is the facility located on Indian Land?
c ❑ Yes ❑✓ No
EPA Form 3510-1(revised 3-19) Page 2

•
EPA Identification Number NPDES Permit Number Facility Approved Form A roved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each)
d m NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
c w water) fluids)
- NC0079740
W a ❑ PSD(air emissions) ElNonattainment program(CAA) ElNESHAPs(CM)
❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑ Other(specify)
SECTION 7.MAP(40 CFR 122.21(f)(7))
7.1 Have you attached a topographic map containing all required information to this application?(See instructions for
0 specific requirements.)
2
❑✓ Yes ❑ No ❑ CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8.NATURE OF BUSINESS(40 CFR 122.21(f)(8))
8.1 Describe the nature of your business.
Conventional Water Treatment Plant treating raw water from John H.Moss Lake and serving the City of Kings
Mountain. The NPDES Permit NC0079740 is for discharge of backwash water to Buffalo Creek in the Broad River
Nl
to Basin.
c
.N
CO
0
d
a
is
z
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does your facility use cooling water?
d ❑ Yes © No 4 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
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.)
o R
U
SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
N 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
cc Section 301(n)) 302(b)(2))
❑ Non-conventional pollutants(CWA ❑ Thermal discharges(CWA Section 316(a))
Section 301(c)and(g))
❑✓ Not applicable
EPA Form 3510-1(revised 3-19) Page 3

•
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
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 Column 2
❑✓ Section 1:Activities Requiring an NPDES Permit 0 wl attachments
❑✓ Section 2:Name, Mailing Address,and Location ❑ w/attachments
❑✓ Section 3: SIC Codes ❑ w/attachments
❑✓ Section 4:Operator Information ❑ wl attachments
❑✓ Section 5:Indian Land 0 w/attachments
❑✓ Section 6:Existing Environmental Permits ❑ w/attachments
w/topographic
Section 7:Map ❑✓ ❑
❑✓ w/additional attachments
map
cn
o ❑✓ Section 8:Nature of Business ❑ w/attachments
2 Section 9:Cooling Water Intake Structures ❑ w/attachments
V ✓ Section 10:Variance Requests ❑ w/attachments
❑✓ 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
directly responsible for gathering the information,the information submitted is,to the best of my knowledge and
belief,true,accurate,and complete. lam 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
Rick Duncan Public Infrastructure Director
Signature Date signed
7h.2 )adV3
EPA Form 3510-1(revised 3-19) Page 4

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EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2C "EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTIOIII 1.OUTFALL LOCATION(40 CFR 122.21(g)(1))
1.1 Provide information on each of the facility's outfalls in the table below.
Outfal
.7
Numberl Receiving Water Name Latitude Longitude
001 Buffalo Creek 35° 16' 32" N 81° 27' 21' WE
Ta i
O
SECTION 2.LINE DRAWING(40 CFR 122.21(g)(2))
a, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
c •3 balance?(See instructions for drawing requirements.See Exhibit 2C-1 at end of instructions for example.)
J
0 Yes ❑ No
SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(g)(3))
3.1 For each outfall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
**Outfall Number** 001
Operations Contributing to Flow
Operation Average Flow
Decant from gravity thickened backwash wastewater 0.120 mgd
mgd
mgd
co
mgd
0
LL
Description Final Disposal of Solid or
Cod112 (include size,flow rate through each treatment unit, Tabl from Liquid Wastes Other Than
retention time,etc.) Table 2G•1 by Discharge
Slow Sand Filtration 1-V
Gravity Thickening 5-L
Belt Filtration 5-C Landfill Disposal of sludge
EPA Form 3510-2C(Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
3.1 **Outfall Number**
cont. Operations Contributing to Flow
Operation Average
a Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C 1 Liquid Wastes Other Than
retention time,etc.) by Discharge
d
0
� I
iv
m ,
**Outfall Number**
N Operations Contributing to Flow
o Operation Average Flow
a, mgd
Q mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Table 2C 1 Liquid Wastes Other Than
retention time,etc.) by Discharge
3.2 Are you applying for an NPDES permit to operate a privately owned treatment works?
❑ Yes ❑� No 4 SKIP to Section 4.
N n 3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C(Revised 3-19) Page 2

Approved 1
EPA Identification Number NPDES Permit Number Facility Name Form 031051 9
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 4.INT RMITTENT FLOWS(40 CFR 122.21(g)(4))
4.1 Except for storm runoff, leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑✓ Yes ❑ No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages.if necessary.
Outfall Operation Frecuency Flow Rate
Number (list) Average Average Long-Term Maximum Duration
Days/Week Months/Year Average Daily
Filter backwash decant 4 days/week 12 months/year 0.12 mgd 0.12 mgd 1 days
m
c 001 days/week months/year mgd mgd days
ET-
days/week months/year mgd mgd days
ar
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5.PRODUCTION(40 CFR 122.21(g)(5))
5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes ❑✓ No 4 SKIP to Section 6.
5.2 Provide the following information on applicable ELGs.
LaELG Category ELG Subcategory Regulatory Citation
5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
❑ Yes © No 4 SKIP to Section 6.
0
co 5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall Operation,Product,or Material Quantity per Day Unit of
Number Measure
CO
0
O
L
a
EPA Form 3510-2C(Revised 3-19) Page 3

•
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 6.IMPROVEMENTS(40 CFR 122.21(g)(6))
6.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing,
upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑✓ No 4 SKIP to Item 6.3.
6.2 Briefly identify each applicable project in the table below.
Affected Final Compliance Dates
E Brief Identification and Description of Outfalls Source(s)of
Project (list outfall Discharge
o Required Projected
q J
`o number)
E
U)
c
CL
6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental projects
that may affect your discharges)that you now have underway or planned?(optional item)
❑ Yes ❑ No ✓❑ Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and,in turn,the tables you must
complete. Not all applicants need to complete each table.
Table A.Conventional and Non-Conventional Pollutants
7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your ouffalls?
j ❑ Yes ❑✓ No 4 SKIP to Item 7.3.
7.2 If yes,indicate the applicable outfalls below.Attach waiver request and other required information to the application.
Outfall Number Outfall Number Outfall Number
tfl
7.3 Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
rn requested and attached the results to this application package?
No;a waiver has been requested from my NPDES
❑✓ Yes ❑ permitting authority for all pollutants at all outfalls.
v Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
c F listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes ❑✓ No 4 SKIP to Item 7.8.
7.5 Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B?
w ❑ Yes ❑ No
7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified
in Exhibit 2C-3.
Primary Industry Category Required GC/MS Fraction(s)
(Check applicable boxes.)
❑Volatile 0 Acid ❑ Base/Neutral ❑ Pesticide
❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide
❑Volatile ❑Acid ❑Base/Neutral ❑ Pesticide
EPA Form 3510-2C(Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
7.7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑ No
7.8 Have you checked"Believed Present"or"Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required'?
ElYes ❑ No
7.9 Have you provided(1)quantitative data for those Section 1,Table B,pollutants for which you have indicated testing is
required or(2)quantitative data or other required information for those Section 1,Table B,pollutants that you have
indicated are"Believed Present"in your discharge?
❑✓ Yes ❑ No
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑✓ No
then SKIP to Item 7.12.
= 7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have
o determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B,
pollutants you have indicated are"Believed Present"in your discharge?
.N
✓❑ Yes El No
d Table C.Certain Conventional and Non-Conventional Pollutants
12 7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C
for all outfalls?
El Yes El No
c 1 7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated
"Believed Present"?
d ElYes ElNo
Table D.Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for
all outfalls?
❑✓ Yes ❑ No
7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)by providing quantitative data,if available?
❑✓ Yes ❑ No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ElNo 4 SKIP to Section 8.
7.17 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑ No
SECTION 8.USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9))
8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
❑ Yes ❑✓ No 4 SKIP to Section 9.
8.2 List the pollutants below.
F0 1. 4. 7.
0
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Approved Form A roved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 9.BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(g)(11))
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge?
❑✓ Yes ❑ No 4 SKIP to Section 10.
9.2 Identify the tests and their Durposes below.
Test(s) Purpose of Test(s) Submitted to NPDES Date Submitted
Permitting Authority?
0
Effluent Toxicity Permit Requirement ✓❑ Yes ❑ NO 04/26/2023
U
O
m ❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑✓ Yes ❑ No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of laboratory/firm Watertech labs
;, Laboratory address PO Box 1056
#5 Pinewood Plaza Dr.
Granite Falls,NC 28630
Co
c
0 Phone number
[phone]
Pollutant(s)analyzed Turbidity,TSS,Aluminum,
Copper,Manganese,NO2
+NO3,TKN,TN,TP,
Hardness,Fluoride
SECTION 11.ADDITIONAL INFORMATION(40 CFR 122.21(g)(13))
11.1 Has the NPDES permitting authority requested additional information?
❑ Yes ❑✓ No 4 SKIP to Section 12.
0
MS 11.2 List the information requested and attach it to this application.
1. 4.
0
2. 5.
3. 6.
EPA Form 3510-2C(Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
12.1 In Column 1 below, mark the sections of Form 2C 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 complete all sections or provide attachments.
Column 1 Column 2
✓❑ Section 1:Outfall Location ❑ w/attachments
❑✓ Section 2:Line Drawing w/line drawing ❑ w/additional attachments
im Section 3:Average Flows and w/list of each user of
Treatment ❑ w/attachments Elprivately owned treatment
works
O Section 4: Intermittent Flows ❑ w/attachments
❑✓ Section 5:Production ❑ w/attachments
w/optional additional
0Section 6:Improvements Elw/attachments ❑ sheets describing any
additional pollution control
plans
❑ w/request for a waiver and ❑ w/explanation for identical
supporting information outfalls
w/small business exemption request w/other attachments
d ❑ ❑
N ❑ Section 7:Effluent and Intake ❑ w/Table A ❑ w/Table B
a Characteristics
0
❑ w/Table C ❑ w/Table D
w/Table E w/analytical results as an
c� ❑ ❑ attachment
Section 8:Used or Manufactured
11) ❑ Toxics ❑ w/attachments
Section 9:Biological Toxicity
d ❑✓ Tests ❑ w/attachments
V
❑✓ Section 10:Contract Analyses ❑ w/attachments
O Section 11:Additional Information ❑ w/attachments
Section 12:Checklist and
❑ Certification Statement ❑ w/attachments
12.2 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 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
Rick Duncan Public Infrastructure Director
Signature Date signed
7-12- 20 z3
EPA Form 3510-2C(Revised 3-19) Page 7

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EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))1
Effluent Intake
Waiver (Optional)
Units Maximum Maximum Long-Term
Pollutant Requested
(if applicable) (specify) Daily Monthly Average Daily Number of Long-Term Number of
Discharge Discharge Discharge Analyses Average Value Analyses
(required) (if available) (if available)
❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
Biochemical oxygen demand Concentration
1. (BOD5) ❑ Mass
Chemical oxygen demand Concentration
2' (COD) ❑ Mass
Concentration
3. Total organic carbon(TOC) ❑
Mass
Concentration mg/L <2.5
4. Total suspended solids(TSS) ❑
Mass
Concentration
5. Ammonia(as N) ❑
Mass
6. Flow ❑ Rate
Temperature(winter) ❑ °C °C
7.
Temperature(summer) ❑ °C °C
pH(minimum) ❑ Standard units s.u.
8.
pH(maximum) ❑ Standard units s.u.
1 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 Form 3510-2C(Revised 3-19) Page 9

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EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one) Effluent Intake
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge D Discharge Analyses A Analyses
(required) (if available) Value(if available)
❑ Check here if you qualify as a small business per the instructions to Form 2C and,therefore,do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note,however,that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1.Toxic Metals,Cyanide,and Total Phenols
Antimony,total Concentration
1.1 (7440-36-0) Mass
Arsenic,total Concentration
1.2 El El El
(7440-38-2) Mass
Beryllium,total Concentration
1.3 0 El
(7440-41-7) Mass
1.4 Cadmium,total ❑ Concentration
(7440-43-9) Mass
1.5 Chromium,total ElConcentration
0 El
(7440-47-3) Mass
1.6 Copper,total ❑ 0 © Concentration mg/L <.002 1
(7440-50-8) Mass
1.7 Lead,total Concentration
El El 0
(7439-92-1) Mass
1.8 Mercury,total 0 Concentration
El El(7439-97-6) Mass
1.9 Nickel,total Concentration
El 0 El
(7440-02-0) Mass
1.10 Selenium,total 0 Concentration
(7782-49-2) Mass
Silver,total1=1 Concentration
1.11 (7440-22-4) Mass
EPA Form 3510-2C(Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge ifavalablle) Diischarge scharge Analyses AValuee Analyses
(if available)
1.12 Thallium,total El 0
❑ Concentration
(7440-28-0) Mass
1.13 Zinc,total El ❑ 0 Concentration
(7440-66-6) Mass
1.14 Cyanide,total ❑ ❑ ❑ Concentration
(57-12-5) Mass
1.15 Phenols,total 0 0 ❑✓
Concentration
Mass
Section 2.Organic Toxic Pollutants(GC/MS Fraction—Volatile Compounds)
2.1 Acrolein ❑ ❑ ❑ Concentration
(107-02-8) Mass
2.2 .Acrylonitrile ❑ ❑ ❑ Concentration
(107-13-1) Mass
2.3 Benzene ❑ ❑ ❑ Concentration
(71-43-2) Mass
2.4 Bromoform El ❑ 0 Concentration
(75-25-2) Mass
2.5 Carbon tetrachloride El ❑ 0 Concentration
(56-23-5) Mass
2.6 Chlorobenzene 0
0
❑ Concentration
(108-90-7) Mass
2.7 Chlorodibromomethane 0
❑ 0 Concentration
(124-48-1) Mass
Chloroethane ci Concentration
2.8 (75-00-3) El ❑ Mass
EPA Form 3510-2C(Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
CAS Number,if available) Required Believed Believed Maximum Maximum Long-
(and q (specify) Average Number Number
Present Absent Daily Monthly Daily of Term of
Discharge
a De) Value
De ischarge Analyses Average Analyses
(required) (i f ava lab (if available)
2 9 2-chloroethylvinyl ether El ❑ 0Concentration
(110-75-8) Mass
2.10 Chloroform(67-66-3) 0 0 0Concentration
Mass
2.11 Dichlorobromomethane El 0 0Concentration
(75-27-4) Mass
1,1-dichloroethane ❑ ❑ ❑ Concentration
2.12 (75-34-3) Mass
1,2-dichloroethane ❑ ❑ 0 Concentration
2.13 (107-06-2) Mass
11-dichloroethylene ❑ ❑ Concentration
2.14 (75-35-4) Mass
1,2-dichloropropane 0 0
❑ Concentration
2.15 (78 87 5) Mass
1,3-dichloropropylene 0 ❑ ❑ Concentration
2.16 (542-75-6) Mass
2.17 Ethylbenzene El El ❑✓ Concentration
(100-41-4) Mass
•
2.18 Methyl bromide ❑ ❑ O Concentration
(74-83-9) Mass
Methyl chloride ❑ ❑ ❑ Concentration
2.19 (74-87-3) Mass
Methylene chloride 0 El Concentration
2.20 (75-09-2) Mass
1,1,2 2-tetrachloroethane 0 0 ❑ Concentration
2.21 (79-34-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent
(optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Df d) (iavailable) Discharge scharge Analyses AValuee Analyses
(if available)
Tetrachloroethylene � Concentration
2.22 (127-18-4) Mass
2.23 Toluene Concentration
(108-88-3) Mass
12-trans-dichloroethylene � 0 Concentration
2.24 (156-60-5) Mass
1,1,1-trichloroethane Concentration
2.25 El 0 El
(71-55-6) Mass
2.26 1,1,2-trichloroethane ElConcentration
0 0(79-00-5) Mass
2.27 Trichloroethylene 0 El Concentration
(79-01-6) Mass
Vinyl chloride Concentration
2.28 (75-01-4) Mass
Section 3.Organic Toxic Pollutants(GC/MS Fraction—Acid Compounds)
3.1 2-chlorophenol Concentration
(95-57-8)
Mass
2,4-dichlorophenol � � 0 Concentration
3.2 (120-83-2) Mass
3.3 2,4-dimethylphenol 0 0 0 Concentration
(105-67-9) Mass
3.4 4,6-dinitro-o-cresol 0 Concentration
El 0
(534-52-1) Mass
3.5 2,4-dinitrophenol 0 Concentration
0 El
(51-28-5) Mass
EPA Form 3510-2C(Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
2-nitrophenol o Concentration
3.6 0 El
(88-75-5) Mass
3.7 4-nitrophenol 0 0 Concentration
El
(100-02-7) Mass
3.8 p chloro m cresolEl El 0 Concentration
(59-50-7) Mass
Pentachlorophenol 0 Concentration
3'9 0 El
(87-86-5) Mass
Phenol 0 Concentration
3.10 (108-95-2) 0 El
3.11 2,4,6-trichlorophenol 0 0 Concentration
(88-05-2) Mass
Section 4.Organic Toxic Pollutants(GC/MS Fraction-Base/Neutral Compounds)
4.1 Acenaphthene 0 0 Concentration
El
(83-32-9) Mass
4.2 Acenaphthylene 0 Concentration
El 0
(208-96-8) Mass
4.3 Anthracene © Concentration
El El
(120-12-7) Mass
4.4 Benzidine © Concentration
0 0
(92-87-5) Mass
4.5 Benzo(a)anthracene 0 El 0 Concentration
(56-55-3) Mass
4.6 Benzo(a)pyrene 0 Concentration
El 0
(50-32-8) Mass
EPA Form 3510-2C(Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term _
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long Number
Present Absent Daily Monthly Daily of Term of
Discharge (id) favalabllee) Discharge Analyses Average
Analyses
(r (if available)
4.7 3 4-benzofluoranthene El El a Concentration
(205-99-2) Mass
4.8 Benzo(ghi)perylene 0 El Concentration
(191-24-2) Mass
4.9 Benzo(k)fluoranthene 0 El ❑ Concentration
(207-08-9) Mass
4.10 Bis(2-chloroethoxy)methane El Concentration
(111-91-1) Mass
4.11 Bis(2-chloroethyl)ether 0 ❑ Concentration
(111-44-4) Mass
4.12 Bis(2-chloroisopropyl)ether ❑ Concentration
(102-80-1) Mass
4.13 Bis(2-ethylhexyl)phthalate ❑ Concentration
(117-81-7) Mass
4-bromophenyl phenyl ether Concentration
4.14 0 0
(101-55-3) © Mass
4.15 Butyl benzyl phthalate 0 0 ElConcentration
(85-68-7) Mass
4.16 2-chloronaphthalene © Concentration
(91-58-7) Mass
4-chlorophenyl phenyl ether 1:1Concentration
4.17 0 El
(7005-72-3) Mass
Chrysene 1:1Concentration
4.18 0 El
(218-01-9) Mass
4.19 Dibenzo(a,h)anthracene El El
(53-70-3) Mass
EPA Form 3510-2C(Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
4.20 1,2-dichlorobenzene ❑ ElConcentration
El
(95-50-1) Mass
4.21 1,3-dichlorobenzene ElConcentration
El 0
(541-73-1) Mass
4.22 1,4-dichlorobenzene Concentration
(106-46-7) Mass
4.23 3,3-dichlorobenzidine ❑ ElConcentration
(91-94-1) Mass
4.24 Diethyl phthalate El © Concentration
(84-66-2) Mass
4.25 Dimethyl phthalate ElConcentration
El 0
(131-11-3) Mass
4.26 Di-n-butyl phthalate © Concentration
(84-74-2) Mass
4.27 2 4-dinitrotoluene ❑ Concentration
(121-14-2) Mass
4.28 2,6-dinitrotoluene ElConcentration
El El
(606-20-2) Mass
4.29 Di-n-octyl phthalate 0 Concentration
(117-84-0) Mass
4.30 1,2-Diphenylhydrazine ❑ ❑ Concentration
(as azobenzene)(122-66-7) Mass
4.31 Fluoranthene Concentration
(206-44-0) Mass
4.32 Fluorene Concentration
(86-73-7) Mass
EPA Form 3510-2C(Revised 3-19) Page 17

EPA Identification Number NPDES Permit Number Faality Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number
Present Absent Daily Monthly Daily of Term of
Discharge Dfavailablle) Discharge Analyses ischarge AValuee Analyses
( ui (if available)
Hexachlorobenzene 0 Concentration
4.33 (118-74-1) 0 0 Mass
4.34 Hexachlorobutadiene Concentration
(87-68-3) Mass
4.35 Hexachlorocyclopentadiene ElConcentration
(77-47-4) Mass
4.36 Hexachloroethane 0 Concentration
0 0
(67-72-1) Mass
4.37 Indeno(1,2,3-cd)pyrene 0 Concentration
(193-39-5) Mass
4.38 Isophorone Concentration
(78-59-1) Mass
4.39 Naphthalene Concentration
El El El
(91-20-3) Mass
4.40 Nitrobenzene 0 Concentration
El El
(98-95-3) Mass
4.41 N-nitrosodimethylamine 0 Concentration
0 El
(62-75-9) Mass
4.42 N-nitrosodi-n-propylamine 0 0 Concentration
(621-64-7) Mass
4.43 N-nitrosodiphenylamine El0 Concentration
(86-30-6) Mass
4.44 Phenanthrene 0 Concentration
El El
(85-01-8) Mass
-
Pyrene Concentration
4.45 El 0(129-00-0) El
Mass
EPA Form 3510-2C(Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term Long
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) (if available) Value
1,2,4-trichlorobenzene Concentration
4.46 (120-82-1) El ❑ ❑ Mass
Section 5.Organic Toxic Pollutants(GC/MS Fraction—Pesticides)
5.1 Aldrin ❑ ❑ ❑ Concentration
(309-00-2) Mass
a-BHC 0 Concentration
5.2 (319-84-6) ❑ ❑ Mass
R-BHC 0 Concentration
5.3 (319-85-7) ❑ 0 Mass
y-BHC Concentration
5.4 (58 89 9) ❑ ❑ Mass
i-BHC El Concentration
5.5 (319-86-8) El El
5.6 Chlordane ❑ 0 © Concentration
(57-74-9) Mass
5.7 4 4'-DDT El 0
❑ Concentration
(50-29-3) Mass
4 4'-DDE Concentration
5.8 (72-55-9) ❑ 0 ❑ Mass
5.9 4 4'-DDD ❑ 0
ElConcentration
(72-54-8) Mass
5.10 Dieldrin ❑ ❑ 0 Concentration
(60-57-1) Mass
5.11 a-endosulfan 0
❑ ❑ Concentration
(115-29-7) Mass
EPA Form 3510-2C(Revised 3-19) Page 19

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long-
Number
Present Absent Daily Monthly Daily of Term of
D(req i edge Df available) Diischarge scharge Analyses AValuee Analyses
(if available)
p-endosulfan Concentration
5.12 (115 29 7) 0 0 0
Mass
Endosulfan sulfate Concentration
5.13 (1031-07-8) Mass
5.14 Endrin Concentration
(72-20-8) Mass
Endrin aldehyde Concentration
5.15 El El 0
(7421-93-4) Mass
5.16 Heptachlor Concentration
(76-44-8) Mass
Heptachlor epoxide Concentration
5.17 (1024-57-3) 0 0 C✓ Mass
PCB-1242 Concentration
5.18 (53469-21-9) 0 ❑ ❑✓ Mass
PCB-1254 Concentration
5.19 (11097-69-1) 0 0 0 Mass
PCB-1221 Concentration
5.20 (11104-28-2) 0 0 0 Mass
PCB-1232 Concentration
5.21 (11141-16-5) 0 0 ❑✓ Mass
PCB-1248 Concentration
5.22 (12672-29-6) ❑ 0 ❑� Mass
PCB-1260 Concentration
5.23 (11096-82-5) 0 0 ❑✓ Mass
PCB-1016 Concentration
5.24 (12674-11-2) 0 0 0 Mass
EPA Form 3510-2C(Revised 3-19) Page 20

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1
Presence or Absence Intake
(check one) Effluent (optional)
Pollutant/Parameter Testing Units Long-Term
(and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long-
Number
Present Absent Daily Monthly Daily of Term of
Discharge Discharge Discharge Analyses Average Analyses
(required) (if available) Value
(if available)
Toxaphene Concentration
5.25 (8001-35-2) 0 0 0 Mass
1 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 Form 3510-2C(Revised 3-19) Page 21

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EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004 -
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1
Presence or Absence Intake
(check one) Effluent (Optional)
Pollutant Units Maximum Long-Term
Believed Believed (specify) Maximum Daily Long-Term
Present Absent Discharge Monthly Average Daily Number of Average Number of
Discharge Discharge Analyses Analyses
(required) Value
(if available) (if available)
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for
each pollutant.
1 Bromide ❑ ❑ Concentration
(24959-67-9) Mass
2 Chlorine,total 0 ❑ Concentration ug/L <20
residual Mass
3. Color 0 ElConcentration
Mass
Concentration
4. Fecal coliform ❑ 0 Mass
5 Fluoride ❑ ❑ Concentration mg/L <.1
(16984-48-8) Mass
Concentration mg/L 0.4
6 Nitrate-nitrite El ❑ Mass
Nitrogen,total Concentration mg/L 1.5
7' organic(as N) ❑ Mass
Concentration
8. Oil and grease 0 0 Mass
9 Phosphorus(as)
El 0
Concentration mg/L 0.22
P),total(7723-14-0) Mass
10. Sulfate(as SO4) ❑ ❑ Concentration
(14808-79-8) Mass
Concentration
11. Sulfide(as S) ❑ 0 Mass
EPA Form 3510-2C(Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 Ti.. Ellison WTP OMB No.2040-0004 -
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one) Effluent Intake
(Optional)
Pollutant Units Maximum Long-Term
Believed Believed (specify) Maximum Daily Long-Term
Present Absent Discharge Monthly Average Daily Number of I Average Number of
Discharge Discharge Analyses Analyses
(required) Value
(if available) (if available)
12. Sulfite(as SO3) ❑ ❑ Concentration
(14265-45-3) Mass
Concentration
13. Surfactants ❑ ❑ Mass
14. Aluminum,total ❑ ❑ Concentration mg/L .049 1
(7429-90-5) Mass
15. Barium,total ❑ ❑ Concentration
(7440-39-3) Mass
16. Boron,total El ❑ Concentration
(7440-42-8) Mass
17. Cobalt,total ❑ 0 Concentration
(7440-48-4) Mass
18 Iron,total El ElConcentration
(7439-89-6) Mass
19 Magnesium,total ❑ ❑ Concentration
(7439-95-4) Mass
Molybdenum, Concentration
20. total ❑ ❑ Mass
(7439-98-7)
21. Manganese,total ❑✓ ❑ Concentration mg/L .653 1
(7439-96-5) Mass
Tin,total Concentration
22. (7440-31-5) El 0
Mass
23. Titanium,total 0 0 Concentration
(7440-32-6) Mass
EPA Form 3510-2C(Revised 3-19) Page 24

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1
Presence or Absence Intake
(check one) Effluent (Optional)
Pollutant Units Maximum Long-Term
Believed Believed (specify) Maximum DailyLong-Term
f
Present Absent Discharge Monthly Average Daily Number of Average Number
Discharge Discharge Analyses Analyses
(required) Value
(if available) (if available)
24. Radioactivity
Concentration
Alpha,total El El � _--
Mass
Concentration
Beta,total ❑ 0 Mass
Concentration
Radium,total ❑ 0 Mass
Concentration
Radium 226,total 0 ❑ Mass
1 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 Form 3510-2C(Revised 3-19) Page 25

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EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
•
1000-0005-8929 NC0079740 T.J.Ellison WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))'
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
1. Asbestos ❑ ❑
2. Acetaldehyde ❑ ❑
3. Allyl alcohol ❑ ❑
4. Allyl chloride 0 ❑
5. Amyl acetate ❑ 0
6. Aniline ❑ ❑
7. Benzonitrile ❑ ❑
8. Benzyl chloride ❑ ❑
9. Butyl acetate 0 ❑
10. Butylamine ❑ ❑
11. Captan 0 ❑
12. Carbaryl 0 0
13. Carbofuran 0 ❑
14. Carbon disulfide ❑ ❑
15. Chlorpyrifos 0 ❑
16. Coumaphos 0 ❑
17. Cresol 0 ❑
18. Crotonaldehyde ❑ ❑
19. Cyclohexane ❑ ❑
EPA Form 3510-2C(Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP 001 OMB No.2040-0004 •
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
20. 2,4-D(2,4-dichlorophenoxyacetic acid) ❑ ❑
21. Diazinon 0 ❑
22. Dicamba 0 0
23. Dichlobenil 0 ❑
24. Dichlone 0 0
25. 2,2-dichloropropionic acid ❑ 0
26. Dichlorvos 0 ❑
27. Diethyl amine 0 ❑
28. Dimethyl amine 0 0
29. Dintrobenzene 0 0
30. Diquat ❑ ❑
31. Disulfoton 0 ❑
32. Diuron ❑ ❑
33. Epichlorohydrin 0 0
34. Ethion ❑ 0
35. Ethylene diamine ❑ ❑
36. Ethylene dibromide 0 ❑
37. Formaldehyde ❑ ❑
38. Furfural ❑ ❑
EPA Form 3510-2C(Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03105/19
1000-0005-8929 NC0079740 T.J.Ellison WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
39. Guthion ❑ ❑
40. Isoprene 0 0
41. lsopropanolamine 0 ❑
42. Kelthane ❑ 0
43. Kepone ❑ ❑
44. Malathion 0 0
45. Mercaptodimethur 0 ❑
46. Methoxychlor 0 0
47. Methyl mercaptan 0 0
48. Methyl methacrylate ❑ 0
49. Methyl parathion ❑ ❑
50. Mevinphos 0 ❑
51. Mexacarbate 0 0
52. Monoethyl amine ❑ 0
53. Monomethyl amine 0 0
54. Naled 0 0
55. Naphthenic acid 0 ❑
56. Nitrotoluene 0 ❑
57. Parathion 0 ❑
EPA Form 3510-2C(Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP 001 OMB No.2040-0004
TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data
Believed Believed (specify units)
Present Absent
58. Phenolsulfonate ❑ ❑
59. Phosgene 0 ❑
60. Propargite ❑ ❑
61. Propylene oxide 0 0
62. Pyrethrins 0 ❑
63. Quinoline 0 ❑
64. Resorcinol ❑ ❑
65. Strontium 0 ❑
66. Strychnine ❑ ❑
67. Styrene ❑ ❑
68 2,4,5-T(2,4,5-trichlorophenoxyacetic ❑ ❑
acid)
69. TDE(tetrachlorodiphenyl ethane) 0 0
70 2,4,5-TP[2-(2,4,5-trichlorophenoxy) ❑ ❑
propanoic acid]
71. Trichlorofon ❑ ❑
72. Triethanolamine ❑ ❑
73. Triethylamine ❑ ❑
74. Trimethylamine ❑ ❑
75. Uranium ❑ ❑
76. Vanadium ❑ ❑
EPA Form 3510-2C(Revised 3-19) Page 30

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
•
1000-0005-8929 NC0079740 T.J.Ellison WTP 001 OMB No.2040-0004
TABLED.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))1
Presence or Absence
Pollutant (check one) Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
77. Vinyl acetate ❑ ❑
78. Xylene ❑ ❑
79. Xylenol 0 ❑
80. Zirconium ❑ ❑
1 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 Form 3510-2C(Revised 3-19) Page 31

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EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
1000-0005-8929 NC0079740 T.J.Ellison WTP OMB No.2040-0004
TABLE E.2,3,7,8 TETRACHLORODIBENZO P DIOXIN(2,3,7,8 TCDD)(40 CFR 122.21(g)(7)(viii))
TCDD Presence or
Congeners Absence
Pollutant Used or (check one) Results of Screening Procedure
Manufactured Believed Believed
Present Absent
2,3,7,8-TCDD ❑ ❑ �
EPA Form 3510-2C(Revised 3-19) Page 33