NC0032174_fact sheet_20230815

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not
require full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g.,
schools, mobile home parks, etc.) that can be administratively renewed with minor changes
but can include facilities with more complex issues (Special Conditions, 303(d) listed water,
toxicity testing, instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Charles H. Weaver — 8/15/2023
Permit Number
NCO032174
Facility Name
United World Mission WWTP
Basin Name/Sub-basin number
Broad 03-08-02
Receiving Stream
UT to Cherry Creek
Stream Classification in Permit
WS-V
Does permit need Daily Max NH3 limits?
NH3 limits are at BAT for Class WW-1
facilities.
Does permit need TRC limits/language?
Already resent, if TRC is used.
Does permit have toxicity testing?
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
Dissolved Oxygen and Temperature
Is the stream impaired (on 303(d) list)? For
whatparameter?
No
Any obvious compliance concerns?
Three enforcements, six NOVs and one NOD
during this permit cycle.
Any permit mods since lastpermit?
No
New expiration date
7/31/2028
Changes in Draft Permit?
Updated eDMR text
Changes to finalpermit?
None

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C Public Notice
AFFP North Carolina
Public Notice North Carolina Environmental Management
Commission/NPDES Unit
1617 Mail Service Center
Affidavit of Publication Raleigh, NC 27699-1617
Notice of Intent to Issue a NP-
DES Wastewater Permit
STATE OF NC } SS
NCO032174 United World Mis-
COUNTY OF RUTHERFORD
sion WWTP The North Caro-
lina Environmental Manage-
ment Commission proposes to
LORI SPURLING, being duly sworn, says:
issue a NPDES wastewater dis-
charge permit to the person(s)
That she is PUBLISHER of the THE DAILY COURIER, a
listed below. Written comments
daily newspaper of general circulation, printed and
regarding the proposed permit
published in FOREST CITY, Rutherford County, NC; that
will be accepted until 30 days
the publication, a copy of which is attached hereto, was
after the publish date of this no -
published in the said newspaper on the following dates:
tice. The Director of the NC Di -
June 29, 2023
vision of Water Resources
(DWR) may hold a public hear-
ing should there be a signific-
ant degree of public interest.
Please mail comments and/or
information requests to DWR at
the above address. Interested
That said newspaper was regularly issued and circulated
persons may visit the DWR at
512 N. Salisbury Street,
on those dates.
SIGN :
Raleigh, NC to review informa-
tion on file. Additional informa-
tion on NPDES permits and this
PU SHER Lj
notice may be found on our
website:
Subscribed to and sworn to me this 29th day of June
http://deq.nc.gov/abouti
2023.
divisions/water-resources/
water-resources-
permits/wastewater-branch/
npdes-wastewater/public-
1
Denise'N.
notices, or by calling (919) 707-
Downs, NOTARY', Rutherford County, NC
3601, United World Mission ap-
plied to renew NPDES permit
My commission expires: July 16, 2027
NCO032174 for their facility at
6494 Hudlow Road. Union
Mills, Rutherford County, This
facility discharges treated
wastewater to Cherry Creek in
00013047 70710662
the Broad River Basin. Cur -
rently. Ammonia, Dissolved
WREN THEDFORD (FC)
Oxygen (DO). Fecal Coliform,
DEO-DIVISION OF WATER RESOURCES (FC)
and Total Residual Chlorine
1617 MAIL SERVICE CENTER
(TRC) are water -quality limited.
RALEIGH, NC 27699 1617
This discharge may affect fu-
ture wasteload allocations in
this portion of Cherry Creek,
June 29, 2023

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
United World Mission
Attn: Andrew LaBreche, Operations Supervisor
PO Box 250
Union Mills, NC 28167-0250
Subject: Permit Renewal
Application No. NCO032174
United World Mission
Rutherford County
Dear Applicant:
NORTH CAROLINA
Environmental Quality
January 31, 2023
The Water Quality Permitting Section acknowledges the January 30, 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. 150E-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://deg.nc.govlpermits-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.
ec: WQPS Laserfiche File w/application
Sincerely,
3:�
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Asheville Regional Office 1 2090 US, Highway 70 1 Swannanoa. North Carolina 28778
828.296.4500

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
CIT
center for intercultural training
January 26, 2023
NC DENR / DWR / NPDES Unit
ATTN: Charles Weaver
1617 Mail Service Center
` I Raleigh, North Carolina 27699-1617 g
Dear Charles:
Regarding our Sludge Management Plan, we currently have sludge removed from
our system two times a year (usually in January and July). HST, Inc. is who we
normally use to handle this for us. Their address is:
Harris Septic Tank Service
1103 E. US 74 Hwy Business
Ellenboro, North Carolina 28040
Phone: [phone] or 704-434-0350
If you need additional information, please contact Andy LaBreche at 828-287-8996
Sincerely yours,
Dr. George Schultz
Senior Residential Director
Center for Intercultural Training
P.O. Box 250 1 Union Mills, NC 281671 800-887-17861 www.cit-online.org

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
North Carolina
Department of Environmental Quality
Division of Water Resources
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
REuEIVED
JAN 3 0 2023
NODE / WR/NP®ES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
CIT
center for intercultural training
January 26, 2023
RECEIVED
JAN 3 0 2023
NC DENR / DWR / NPDES Unit
ATTN: Charles weaver NCDEQ/DlNR/NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Dear Charles:
We are requesting a renewal of our wastewater permit for: Center for Intercultural
Training, located at 6494 Hudlow Rd. Union Mills, North Carolina.
Could you please see if there is any relief you can offer with ammonia limits?
We have had no changes at the facility since the issuance of the last permit.
Sincerely yours,
Dr. George Schultz
Senior Residential Director
Center for Intercultural Training
P.O. Box 250 1 Union Mills, NC 281671800-887-17861 www.cit-online.org

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
Modified March 2021
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
Form
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))
Facility name
1.1
Center for Intercultural Training
Mailing address (street or P.O. box)
PO Box 250
City or town
State
ZIP code
o
w
Union Mills
INC
28167
Contact name (first and last)
Title
Phone number
Email address
0
Andy LaBreche
Operations Supervisor
[phone]
[e-mail]
c
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
6494 Hudlow Road
u_
City or town
State
ZIP code
Union Mills
NC
28167
1.2
Is this application for a facility that has yet to commence discharge?
❑ 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?
0 Yes ❑ No 4 SKIP to Item 1.4.
Applicant name
United World Mission, Inc
Applicant address (street or P.O. box)
cc
6494 Hudlow Rd
m
oCity
or town
State
ZIP code
w
Union Mills
NC
28167
Contact name (first and last)
Title
Phone number
Email address
a
Andy LaBreche
Operations Supervisor
[phone]
[e-mail]
a
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 authority send correspondence? (Check only one response.)
❑ Facility ❑ Applicant ID 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
a
✓❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
c
water )
control)
a)
E
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
W
N
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
w
404)
Page 1

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
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
indicate percentage)
Residential
100
% separate sanitary sewer
❑ Own ❑ Maintain
Z
% combined storm and sanitary sewer
ElOwn ElMaintain
d
School
❑ Unknown
0 Own El Maintain
co
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
CL
0
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
d%
separate sanitary sewer
❑ Own ❑ Maintain
y%
combined storm and sanitary sewer
❑ Own ❑ Maintain
_
❑ Unknown
❑ Own ❑ Maintain
Total
100
Population
c�
Served
Combined Storm and
Separate Sanitary Sewer System
Sanitary Sewer
Total percentage of each type of
unknown %
unknown %
sewer line in miles
1.8
Is the treatment works located in Indian Country?
o
❑ Yes 0 No
c�
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
20
c
❑ Yes 0 No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
0.020 mgd
Annual Average Flow Rates Actual
N
Two Years Ago
Last Year
This Year
c
.004 mgd
.004 mgd
.004 mgd
o
Ua:Maximum
Dail Flow Rates Actual
Two Years Ago
Last Year
This Year
.005 mgd
.004 mgd
.004 mgd
H
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Dischar a Points by Type
a CL
a
Combined Sewer
Constructed
) �
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
U
Overflows
4i
G
1
1
Page 2

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
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 ❑✓ 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 Im oundment Location and Dischar a Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
Y
1.14
Is wastewater applied to land?
❑ Yes 0 No + SKIP to Item 1.16.
0
1.15
Provide the land application site and discharge data requested below.
C
Land Application Site and Discharge Data
c
Average Daily Volume
Continuous or
cm
Location
Size
Applied
Intermittent
check one
y
acres
gp d
❑ Continuous
o
❑ Intermittent
=
acres
gpd
❑ Continuous
a
❑ Intermittent
0
acres
9p d
El Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
El Yes ❑✓ No 4 SKIP to Item 1.21.
0
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.
Trans orter 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: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modred Application Form 2A
NCO1331
NCO032174
CIT
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 facility.
Receiving IF cility Data
a
Facility name
Mailing address (street or P.O. box)
d
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
s
d
Phone number
Email address
c
NPDES number of receiving facility (if any) ❑ None
r Avea a daily flow rate m g
g y d
a
N1
0
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)?
rn
s
❑✓ Yes ❑ No -* SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
d
Information on Other Dis osal Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Descriltion
Volume
Outfall into
UT to Cherry Creek
1/2 acres
.004 gpd
❑ Continuous
rtraam
21 Intermittent
❑ 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.
y
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
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 +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
Contractor 2
Contractor 3
0
Contractor name
(company name
Earth Environmental Services
Mailing address
c
street or P.O. box
75 Bison Lane
`o
City, state, and ZIP
code
Murphy, NC 28906
L
c
Contact name (first and
0
last
Wanda Ladd
Phone number
[phone]
Email address
[e-mail]
Operational and
Bacteriological Analysis
maintenance
responsibilities of
contractor
Page 4

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number Facility Name Modified Application Form 2A
NCO1331 NCO032174 CIT Modified March 2021
SECTIONI1 • •' • I
c Outfalls to Waters of the State of North Carolina
U.
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
rn
o
❑ Yes ❑✓ No 4 SKIP to Section 3.
c
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
'2
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
a
c
m
3
0
c
s
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
o �
CL
0
© Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
c M
_ CM
(See instructions for specific requirements.)
U-T
o
❑ Yes © No
2.5
Are improvements to the facility scheduled?
❑ Yes © No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
=
0
:s
1.
c
d
E
c.
2.
E
Z
0
�+
d
3.
-0
d
U
4.
0
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Com letion for Im rovements
d
Scheduled
Affected
Begin
End
Begin
Attainment of
' o
CL
Improvement
Outfalls
(list o
Construction
Construction
Discharge
Operational
Level
E
(from above)
number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MMIDD/YYYY
a
41
1.
d
s
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

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number Facility Name Modified Application Form 2A
NC01331 NC0032174 CIT Modified March 2021
SECTION•' • ON 1 I
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 1
Outfall Number NSA
Outfall Number N/A
State
NC
County
Rutherford
O
w
0
City or town
Union Mills
c
Distance from shore
0 ft.
ft.
ft.
a
Depth below surface
0 ft.
ft.
ft.
a
Average daily flow rate
.004 mgd
mgd
mgd
Latitude
35' 21 24" No
°
Longitude
81° 59 09, vE]
"
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o
✓❑ Yes ❑ No -+ SKIP to Item 3.4.
d
3.3
If so, provide the following information for each applicable outfall.
y
Outfall Number 1
Outfall Number NSA
Outfall Number N/A
0
Number of times per year
discharge occurs
365
a
Average duration of each
on amount of flow
o
discharge S eCl units)Dependant
c
Average flow of each
.0047263 mgd
mgd
mgd
0
discharge
Months in which discharge
Jan -Dec
Occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑ No SKIP to Item 3.6.
CD
3.5
Briefly describe the diffuser type at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
d
N
G
ui
3 6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
a �
one or more discharge points?
9 y
❑✓ Yes ❑ No -*SKIP to Section 6.
Page 6

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
Modified March 2021
3.7
Provide the receiving water and related information if known for each outfall.
Outfall Number I
Outfall Number NSA
Outfall Number NSA
Receiving water name
UT to Cherry Creek
Name of watershed, river,
Catheys Creek
0
or stream system
U.S. Soil Conservation
L
y
Service 14-digit watershed
03050105070020
o
code
L
ai
Name of state
management/river basin
Broad River Basin
U.S. Geological Survey
8-digit hydrologic
03050105
W
cataloging unit code
Critical low flow (acute)
N/A cfs
cfs
cfs
Critical low flow (chronic)
N/A cfs
cfs
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
N/A CaCO3
CaCO3
CaCO3
3.8
Provide the following information
describing the treatment pr vided for discharges from each outfall.
Outfall Number
Outfall Number NSA
Outfall Number N/A
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)
c
0
a.
Design Removal Rates by
Outfall
f/!
H
BOD5 or CBOD5
N/A %
%
%
d
E
d
TSS
N/A %
%
%
r
0 Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen le4 o„ �
Other (specify)
0 Not applicable
❑ Not applicable
❑ Not applicable
Fecal Coliform PH
%
%
%
Page 7

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
Modified March 2021
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.
v
d
_
w
_
0
=
Outfall Number 1
Outfall Number N/A
Outfall Number N/A
0
a
Disinfection type
uv
U
H
W
G
Seasons used
All Seasons
d
E
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
© Yes rjee,,
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
0 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.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
cc
R
Number of tests of discharge
as
=
w
water
Number of tests of receiving
water
d
LU
W
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?
2 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 El No additional sampling required by NPDES
permitting authority.
Page 8

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO1331
NCO032174
CIT
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 + 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 4 Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MM/DD/YYYY
m
c
0
w3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
c
toxicity?
CO
❑ Yes No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
d
W
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.
3.26
Have you completed Table E for all applicable outfalls and attached the results to the application package?
❑ Yes Not applicable because previously submitted
information to the NPDES permitting authority.
Page 9

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number Facility Name Modified Application Form 2A
NCO1331 NCO032174 CIT Modred March 2021
SECTION.
CHECKLIST
AND CERTIFICATION STATEMENT (40
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
Informationforfor All A licants
Section 2: Additional
El w/ topographic map ❑ w/ process flow diagram
Information
❑ w/ additional attachments
0 w/ Table A ❑ w/ Table D
❑ Section 3: Information on
✓❑ w/ Table B ❑ w/ additional attachments
Effluent Discharges
E
❑ wl Table C
::
R
'
Section 4: Not Applicable
c
0
Section 5: Not Applicable
U
Section 6: Checklist and
❑
0 w/attachments
cc
Certification Statement
Y
6.2
Certification Statement
U
67
i
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
Andrew LaBreche
Operations Supervisor
Signature
Date signed
z6z3
LIM
Page 10

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number
Facility Name
Outfall Number
NCO1331
NCO032174
CIT
Modified Application Form 2A
Modified March 2021
•• •0
Maximum Daily Discharge
Pollutant
Value Units
Average Daily Discharge
Analytical
Methods
ML or MDL
(Include units)
Value
Units
Number
Samples
Biochemical oxygen demand
❑ BOD5 or ❑ CBOD5
(report one
8.4
mg/L
2.72
mg/L
52
SM5210B
OML
mg/L ❑ MDL
Fecal conform
5.78
ml
1.42
ml
52
SM9222D
pan100 ml ❑MDL
Design flow rate
0.020
MGD
0.004
MGD
52
pH (minimum)
pH (maximum)
Temperature (winter)
7.6
8.0
19
Su
su
C
13.044
C
21.3
Temperature (summer)
31
C
25.428
C
30.3
Total suspended solids (TSS)
10
mg/L
1.908
mg/L
52
SM2540D
mg/L ❑ MDL
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).
Page 11

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number
NCO1331 NCO032174
Facility Name
CIT
Outfall Number
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical
MIL or MDL
Value
Units
Value
Units
Number
Pollutant
Methods
(Include units)
Samples
Ammonia (as N)
17.2
mg/L
3.883
mg/L
52
SM4500NH3F
❑ MIL
❑ MDL
Chlorine
N/A
ElMIL
residual, TRC 2
❑ MDL
Dissolved oxygen
13.4
mg/L
7.635
mg/L
52
❑ ML
❑ MDL
Nitrate/nitrite
N/A
❑ ML
❑ MDL
Kjeldahl nitrogen
N/A
❑ MIL
❑ MDL
Oil and grease
N/A
❑ MIL
❑ MDL
Phosphorus
N/A
❑ ML❑MDL
Total dissolved solids
N/A
❑ MIL
❑ MIDI
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).
Z 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

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NC01331 NCO032174 CIT 1
Modred March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant
Analytical ML or MDL
Number of
Value Units Value Units
Method' (include units)
Samples
Metals, Cyanide, and Total Phenols
Hardness (as CaCO3)
N/A
❑ ML
❑ MDL
Antimony, total recoverable
N/A
❑ ML
❑ MDL
Arsenic, total recoverable
N/A
❑ ML❑
MDL
Beryllium, total recoverable
N/A
❑ ML
❑ MDL
Cadmium, total recoverable
N/A
❑ ML
❑ MDL
Chromium, total recoverable
N/A
❑ ML
❑ MDL
Copper, total recoverable
N/A
❑ ML
❑ MDL
Lead, total recoverable
N/A
❑ ML
❑ MDL
Mercury, total recoverable
N/A
❑ ML❑
MDL
Nickel, total recoverable
N/A
❑ ML❑
MDL
Selenium, total recoverable
N/A
El ML
❑ MDL
Silver, total recoverable
N/A
❑ ML❑
MDL
Thallium, total recoverable
N/A
❑ ML❑
MDL
Zinc, total recoverable
N/A
❑ ML
❑ MDL
Cyanide
N/A
❑ ML
❑ MDL
Total phenolic compounds
N/A
❑ ML
❑ MDL
Volatile Organic Compounds
Acrolein
N/A
❑ ML❑
MDL
Acrylonitrile
N/A
❑ ML
❑ MDL
Benzene
N/A
❑ ML
❑ MDL
Bromoform
N/A
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO1331 NC0O32174 CIT 1
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant
Analytical ML or MDL
Number of
Value Units Value Units
Method' (include units)
Samples
Carbon tetrachloride
N/A
❑ ML
❑ MDL
Chlorobenzene
N/A
❑ ML❑
MDL
Chlorodibromomethane
N/A
❑ ML❑
MDL
Chloroethane
N/A
❑ ML
❑ MDL
2 chloroethylvinyl ether
N/A
❑ ML❑
MDL
Chloroform
N/A
❑ ML❑
MDL
Dichlorobromomethane
N/A
❑ ML
❑ MDL
1,1 dichloroethane
N/A
❑ ML❑MDL
1,2-dichloroethane
N/A
❑ ML❑
MDL
trans-1,2-dichloroethylene
N/A
❑ ML
❑ MDL
1,1 dichloroethylene
N/A
❑ ML
❑ MDL
1,2-dichloropropane
N/A
❑ ML
❑ MDL
1,3 dichloropropylene
N/A
❑ ML❑
MDL
Ethylbenzene
N/A
❑ ML❑
MDL
Methyl bromide
N/A
❑ ML
❑ MDL
Methyl chloride
N/A
❑ ML
❑ MDL
Methylene chloride :
N/A
El ML
❑ MDL
1,1,2,2-tetrachloroethane
N/A
❑ ML❑
MDL
Tetrachloroethylene
N/A
❑ ML
❑ MDL
Toluene
N/A
❑ ML
❑ MDL
1,1,1 trichloroethane
N/A
❑ ML❑
MDL
1,1,2-trichloroethane
N/A
❑ ML❑
MDL
EPA Form 3510-2A (Revised 3-19) Page 14

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO1331 NC0032174 CIT 1
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant --- —
Analytical ML or MDL
Value Units Value Units Number of
Method' (include units)
Samples
Trichloroethylene
N/A
❑ ML
❑ MDL
Vinyl chloride
N/A
❑ ML
❑ MDL
Acid -Extractable Compounds
p-chloro-m-cresol
N/A
❑ ML
❑ MDL
❑ ML
2-chlorophenol
N/A
❑ MDL
2,4 dichlorophenol
N/A
❑ ML
❑ MDL
2,4-dimethylphenol
N/A
❑ ML
❑ MDL
4,6-dlnitrO-o-cresol
N/A
❑ ML
❑ MDL
2,4 dinitrophenol
N/A
❑ ML
❑ MDL
2-nitrophenol
N/A
❑ ML
❑ MDL
4-nitrophenol
N/A
❑ ML
❑ MDL
Pentachlorophenol
N/A
❑ ML
❑ MDL
Phenol
N/A
❑ ML
❑ MDL
2,4,6-trichlorophenol
N/A
❑ ML
❑ MDL
e-Neutral Compounds
Acenaphthene
N/A
❑ ML
❑ MDL
Acenaphthylene
N/A
❑ ML
El MDL
Anthracene
N/A
❑ ML
❑ MDL
Benzidine
I
N/A
❑ ML
❑ MDL
Benzo(a)anthracene
N/A
❑ ML
El MDL
Benzo(a)pyrene
N/A
❑ ML
❑ MDL
3,4-benzofluoranthene
N/A
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO1331 NC0032174 CIT 1
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units
Samples
Benzo(ghi)perylene
N/A
❑ ML
❑ MDL
Benzo(k)fluoranthene
N/A
❑ MI
❑ MDL
Bis (2-chloroethoxy) methane
N/A
❑ ML
❑ MDL
Bis (2-chloroethyl) ether
N/A
❑ ML
❑ MDL
Bis (2-chloroisopropyl) ether
N/A
❑ ML
❑ MDL
Bis (2-ethylhexyl) phthalate
N/A
❑ ML
❑ MDL
4-bromophenyl phenyl ether
N/A
❑ ML
❑ MDL
Butyl benzyl phthalate
N/A
❑ ML
❑ MDL
2-chloronaphthalene
N/A
❑ ML
❑ MDL
4-chlorophenyl phenyl ether
N/A
❑ ML
❑ MDL
Chrysene
N/A
❑ ML
❑ MDL
di-n-butyl phthalate
N/A
❑ ML
❑ MDL
di-n-octyl phthalate
N/A
❑ ML
❑ MDL
Dibenzo(a,h)anthracene
N/A
❑ ML
❑ MDL
1,2-dichlorobenzene
N/A
❑ ML
❑ MDL
1,3-dichlorobenzene
N/A
❑ ML
❑ MDL
1,4-dichlorobenzene
N/A
❑ ML
❑ MDL
3,3-dichlorobenzidine
N/A
❑ ML
❑ MDL
Diethyl phthalate
N/A
❑ ML
❑ MDL
Dimethyl phthalate
N/A
❑ ML
❑ MDL
2,4-dinitrotoluene
N/A
❑ ML
❑ MDL
2,6-dinitrotoluene
N/A
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 16

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO1331 NCO032174 CIT 1
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant _
Analytical ML or MDL
Number of
Value Units Value Units
Method' (include units)
Samples
1,2 diphenylhydrazine
N/A
El ML
❑ MDL
Fluoranthene
N/A
❑ ML
❑ MDL
Fluorene
N/A
❑ ML
❑ MDL
Hexachlorobenzene
N/A
❑ ML
❑ MDL
Hexachlorobutadiene
N/A
❑ ML
❑ MDL
Hexachlorocyclo-pentad
N/A
❑ MLiene
❑ MDL
Hexachloroethane
N/A
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
N/A
❑ ML
❑ MDL
Isophorone
N/A
❑ ML
❑ MDL
Naphthalene
N/A
❑ ML
❑ MDL
Nitrobenzene
N/A
❑ ML
❑ MDL
N-nitrosodi-n-propylamine
N/A
❑ ML
❑ MDL
N nitrosodimethylamine
N/A
❑ ML
❑ MDL
N nitrosodiphenylamine
N/A
❑ ML
❑ MDL
Phenanthrene
N/A
❑ ML
❑ MDL
Pyrene
N/A
❑ ML
❑ MDL
1,2,4-trichlorobenzene
N/A
❑ ML
❑ MDL
5ampling snail 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 3510-2A (Revised 3-19) Page 17

DocuSign Envelope ID: 3D07EC2E-A2E4-4BOB-B9D4-766730B5986C
NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO1331 NCO032174 CIT
Modified March 2021
1 11 • ••a •� ••
Maximum Dail Discharge Average Dail Discharge
Pollutant
Analytical ML or MDL
Number
(list) Value Units Value Units
Methods (include units)
Samples
s
No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
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).
Page 18