NC0020290_Renewal (Application)_20230825

United States Office of Water EPA Form 3510-2A
Environmental Protection Agency Washington,D.C. Revised March 2019
Water Permits Division
:,EPA Application Form 2A
New and Existing Publicly
Owned Treatment Works
NPDES Permitting Program
Note: Complete this form if your facility is a new or existing publicly owned treatment works.

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to collect information and
complete Form 2A to average between 4.7 and 24.7 hours, depending on the number of sections the
applicant must complete. The estimate includes time for reviewing instructions, searching existing data
sources, gathering and maintaining the needed data, and completing and reviewing the collection of
information. Send comments about the burden estimate or any other aspect of this collection of
information to the Chief, Information Policy Branch(PM-223), U.S. Environmental Protection Agency,
1200 Pennsylvania Avenue,NW,Washington, DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 171h Street,NW, Washington, DC 20503,
marked"Attention: Desk Officer for EPA."

FORM 2A—GENERAL INSTRUCTIONS
Who Must Complete Form 2A? Form 2A.If you do not assert a claim of confidentiality at the time
All new and existing publicly owned treatment works(POTWs)and you submit your information to the NPDES permitting authority,
other dischargers designated by the National Pollutant Discharge EPA may make the information available to the public without
Elimination System(NPDES)permitting authority must complete further notice to you.EPA will handle claims of confidentiality in
Form 2A.Note that you may wish to consult the"Genera[ accordance with the Agency's business confidentiality regulations
Instructions"of NPDES Application Form 1 to determine if your at Part 2 of Title 4 of the Code of Federal Regulations(CFR).
treatment works is required to submit any additional NPDES Completion of Forms
application forms.
Form 2A is divided into six major sections. It also contains five
At the state level,either the U.S.Environmental Protection Agency effluent monitoring tables(Tables A through E)and an industrial
(EPA)or an approved state agency administers the NPDES permit discharge information table(Table F),all located at the end of the
program.if you are located in a jurisdiction in which an EPA form.Note that not all applicants are required to complete each
regional office administers the NPDES permit program,you should section of the form or all of the tables.The questions on the form
use Form 2A and all other applicable forms described in these will direct you to the items and tables you must complete.
instructions.If you are located in a jurisdiction where a state Print or type in the specified areas only.If you do not have enough
administers the NPDES permit program,contact the state to
determine the forms you should complete.States often develop space on the form to answer a question,you may continue on
their own application forms rather than use the federal forms.See additional sheets,as necessary,using a format consistent with the
htt :llwww.e a. ovin desln des-state- ro ram-information for a form.
list of states that have approved NPDES permit programs and Provide your EPA Identification Number from the Facility Registry
those that do not. Service,NPDES permit number,and facility name at the top of
Exhibit 2A-1 (see end of this section)provides contact information each page of Form 2A and any attachments.If your facility is new
for each of EPA's 10 regional offices.Since the exhibit's content is (i.e.,not yet constructed),write or type"New Facility"in the space
subject to change,consult EPA's website for the latest information: Provided for the EPA Identification Number and NPDES permit
htt alwww.e a. ov/aboute a#re ional. number.If you do not know your EPA Identification Number,
contact your NPDES permitting authority.See Exhibit 2A-1 for
Where to File Your Completed Form contact information.Additionally,for Tables A through E,provide
• If you are in a jurisdiction with an approved state NPDES the applicable outfall number at the top of each page.
permit program,file according to the instructions on the state Do not leave any response areas blank unless the form directs you
forms. to skip them.If the form directs you to respond to an item that does
• If you are in a jurisdiction where EPA is the NPDES permitting not apply to your facility or activity,enter"NA"for"not applicable"to
authority(Le.,the state is not an NPDES-authorized state), show that you considered the item and determined a response was
mail the completed application forms to the EPA regional office not necessary for your facility.
that covers the state in which your facility is located(see If you have previously submitted information that answers a specific
Exhibit 2A-1). question to EPA or an approved state NPDES agency,you may
When to File Your Completed Form either repeat the information in the space provided or attach a copy
of the previous submission.
Form 2A must be submitted at least 180 days before your present
NPDES permit expires or,if you are a new discharger,at least Note for New Dischargers
180 days before the date on which the discharge is to commence, Provide all information available to you at the time you
unless the NPDES permitting authority has granted permission for a complete Form 2A.If you do not have information to respond
later date. to an item because your facility has yet to discharge,write or
Fees type"data are not available"next to the item on the form.Note
EPA does not require applicants to pay a fee for applying for that you are required to submit actual data no later than
NPDES permits.However,states that administer the NPDES permit 24 months after your facility commences to discharge.
program may charge fees.Consult with state officials for further The NPDES permitting authority will consider your application
information. complete when It and any supplementary material are received and
Public Availability of Submitted Information completed according to the authority's satisfaction.The NPDES
permitting authority will judge the completeness of any application
EPA will make information from NPDES permit application forms independently of the status of any other permit application or permit
available to the public for inspection and copying upon request.You for the same facility or activity.
may not claim any information on Form 2A(or related attachments) Definitions
as confidential.
You may make a claim of confidentiality for any information that you The legal definitions of all key terms used in the various NPDES
application forms are included in the"Glossary"at the end of these
submit to EPA that goes beyond the information required by instructions.
2A-1

FORM 2A—GENERAL INSTRUCTIONS CONTINUED
Exhibit 2A-1.Addresses of EPA Regional Contacts and Covered States
REGION 1 REGION 6
U.S.Environmental Protection Agency,Region 1 U.S.Environmental Protection Agency,Region 6
5 Post Office Square,Suite 100,Boston,MA 02109-3912 1445 Ross Avenue,Suite 1200,Dallas,TX 75202-2733
Phone:[phone];toll free:[phone] Phone:[phone];toll free:[phone]
Fax:[phone] Fax:[phone]
Website:httpllwww.epa.govlaboutepaleoa-region-l-new-england Website:hffr):Ilwww.eva.gov/aboulepa/epa-region-6-south-central
Covered states:Connecticut,Maine,Massachusetts,New Hampshire,Rhode Covered states:Arkansas,Louisiana,New Mexico,Oklahoma,and Texas
Island,and Vermont
REGION 2 REGION 7
U.S.Environmental Protection Agency,Region 2 U.S.Environmental Protection Agency,Region 7
290 Broadway,New York,NY 10007-1866 11201 Renner Boulevard,Lenexa,KS 66219
Phone:[phone];toll free:(877)2514575 Phone:[phone];toll free:[phone]
Fax:[phone] Website:http:l/www,epa.govlabouter)a/ena-region-7-midwest
Website:http://www.epa.goviaboutepaiepa-region-2 Covered states:Iowa,Kansas,Missouri,and Nebraska
Covered states:New Jersey,New York,Virgin Islands,and Puerto Rico
REGION 3 REGION 8
U.S.Environmental Protection Agency,Region 3 U.S.Environmental Protection Agency,Region 8
1650 Arch Street,Philadelphia,PA 19103-2029 1595 Wynkoop Street,Denver,CO 80202-1129
Phone:(215)B14-5000;toll free:[phone] Phone:[phone];tell free:[phone]
Fax:[phone] Fax:[phone]
Website:http:llwww.epa.govlaboutepa/epa-region-3-mid-atlantic Website:hUp:llwww.epa.govlaboutepalepa-region-8-mountains-and-plains
Covered states:Delaware,District of Columbia,Maryland,Pennsylvania,Virginia, Covered states:Colorado,Montana,North Dakota,South Dakota,Utah,and
and West Virginia Wyoming
REGION 4 REGION 9
U.S.Environmental Protection Agency,Region 4 U.S.Environmental Protection Agency,Region 9
Sam Nunn Atlanta Federal Center 75 Hawthorne Street,San Francisco,CA 94105
61 Forsyth Street,SW,Atlanta,GA 30303-8960 Phone:[phone];toll free:(866)EPA-WEST
Phone:[phone];toll free:[phone] Fax:[phone]
Fax:[phone] Website:http://www.epa.govlaboutei)alepa-region-9-pacific-southwest
Website:httoalwww.epa,novlaboutepalabout-epa-region-4-southeast Covered states:Arizona,California,Hawaii,Nevada,Guam,American Samoa,
Covered states:Alabama,Florida,Georgia,Kentucky,Mlssissippi,North Carolina, and Trust Territories
South Carolina,and Tennessee
REGION 5 REGION 10
U.S.Environmental Protection Agency,Region 5 U.S.Environmental Protection Agency,Region 10
77 West Jackson Boulevard,Chicago,IL 60604-3507 1200 Sixth Avenue,Suite 900,Seattle,WA 98101
Phone:[phone];toll free:[phone] Phone:[phone];toll free:[phone]
Fax:[phone] Fax:[phone]
Website:http:tlwww.epa.gov/aboutepalepa-region-5 Website:http:llwww.epa.govlaboutepalepa-region-10-pacific-northwest
Covered states:Illinois,Indiana,Michigan,Minnesota,Ohio,and Wisconsin Covered states:Alaska,Idaho,Oregon,and Washington
2A-2

FORM 2A—LINE-BY-LINE INSTRUCTIONS
Section 1.Basic Application Information for All Applicants Discharge Points by Type
Facility Information Item 1.11.Provide the facility's total number of effluent discharge
Item 1.1.Enter the facility's official or legal name.Do not use a points to waters of the United States by type(e.g.,treated effluent,
colloquial name.Provide the mailing address of the facility.Next, untreated effluent,combined sewer overflows,bypasses,and
give the name(first and last),title,work telephone number,and constructed emergency overflows)r
email address of the person who is thoroughly familiar with the
operation of the facility and with the facts reported in this Outfalls and Other Discharge or Disposal Methods
application. Outfalls Other Than to Waters of the United States
Include a complete location address for the facility if different from Item 1.12.Indicate whether the POTW discharges wastewater to
basins,ponds,or other surface impoundments that do not have
the mailing address. If the facility lacks a street name or route
outlets for discharge to waters of the United States. If yes,continue
number,give the most accurate,alternative geographic information
e to Item 1.13.If no,skip to Item 1.14.
( g.,section number or quarter section number from county
records or"at intersection of Routes 425 and 22"). Item 1.13.Specify the location of each surface impoundment,the
Item 1,2. Indicate whether the application is for a facility that has average daily volume discharged to each surface impoundment in
not yet commenced discharge.If yes,be advised that you are gallons per day(gpd),and whether the discharge is continuous or
required to submit actual data no later than 24 months after your intermittent,
facility commences to discharge. Item 1.14.indicate if the facility applies wastewater to land. If yes,
Applicant Information continue to Item 1.15.If no,skip to Item 1.16.
Item 1.3.Indicate if the applicant is different from the entity listed Item 1.15.Provide the location of each land application site;the
under Item 1.1.If so,specify the applicant name and address. size of each land application site(in acres);the average daily
Provide the name(first and last)of a contact,including his/her title, volume applied to each land application site(in gpd),and whether
telephone number,and email address. the land application is continuous or intermittent.
Item 1.4.Indicate if the applicant is the facility's owner,operator,or Item 1.16,Note whether the facility's effluent is transported to
both. another facility for treatment prior to discharge,If yes,continue to
Item 1.5.Specify whether the NPDES permitting authority should Item 1.17.If no,skip to Item 1.21.
send correspondence to the facility or the applicant. Item 1.17.Describe the means by which the effluent is transported,
Existing Environmental Permits such as by tank truck or pipe.
Item 1.6.Indicate all environmental permits or construction Item 1.18.Specify whether the facility's effluent is transported by a
approvals received or applied for(including dates)under the noted party other than the applicant.If yes,continue to Item 1.19.If no,
Print or skip to item 1.20,
programs. type the corresponding permit number for each.
Collection System and Population Served Item 1,19.Provide the name,mailing address,contact person,
phone number,and email address of the entity that transports the
Item 1.7.Specify the municipalities served by the treatment works, discharge.
including unincorporated connector districts.For each municipality,
Indicate the population served,the percentage of each collection Item 1.20.Provide the name,mailing address,contact person,
system type if known(e.g.,separate sanitary or combined storm phone number,email address,and NPDES permit number{if any)
of the receiving facility.Also specify the average daily flow rate from
and sanitary),and collection system ownership status. Finally,
indicate the total percentage of sewer line each type comprises. the facility into the receiving facility in mgd.
Do not report privately owned collection systems discharging Item 1.21.Indicate if wastewater is disposed of in a manner other
industrial waste to the treatment works in Item 1.7.Those facilities than those already mentioned in Items 1.14 through 1.21 that do
must be reported on Table F. not have outlets to waters of the United States,such as
underground percolation and underground injections.If yes,
Indian Country continue to Item 1.22. If no,skip to Item 1.23.
Item 1.8.Indicate if the POTW is located in Indian Country. Item 1.22.Provide a description of the disposal method,including
Item 1.9.Note whether the treatment works discharges to a the location and size of each disposal site;the annual average daily
receiving stream that flows through Indian Country. discharge volume(in gpd),and whether disposal through this
Design and Actual Flow Rates method is continuous or intermittent.
Item 1.10.Provide the facility's design flow rate in million gallons Variance Requests
per day(mgd).Next,specify the facility's actual annual average Item 1.23.If known at the time of application,check all of the
daily flow rate and maximum daily flow rate for each of the previous authorized variances that you plan to request or renew.Note that
three years(in mgd). you are not being asked to submit any other information at this
time.Contact your NPDES permitting authority to determine the
2A-3

FORM 2A--LINE-BY-LINE INSTRUCTIONS CONTINUED
specifics of what you should provide and when.The ability to website at http:llnationalmaimovl.(For a map from this site,use
request a variance is not limited to the time of application,and an the traditional 7.5-minute quadrangle format.If none is available,
applicant may request a variance consistent with statutory and use a USGS 15-minute series map.)You may also use a plat or
regulatory requirements. other appropriate map.Briefly describe land uses in the map area
Contractor Information (e.g.,residential,commercial).An example of an acceptable
location map is shown as Exhibit 2A-2 at the end of these
Item 1.24.Indicate if any of the operational or maintenance instructions.Note:Exhibit 2A-2 is provided for illustration only;it
activities associated with wastewater treatment and effluent quality does not show an actual facility.Note that you have completed your
of the POTW are the responsibility of a contractor.If yes,continue topographic map and attached it to the application.
to Item 1.25.If no,skip to Section 2.
Flow Diagram
Item 1.25.Provide a listing of all contractors(by company name).
For each,specify the mailing address,a contact name,telephone Item 2.4.Provide a process flow diagram or schematic showing the
number,and email address.Also summarize the operational and processes of the treatment plant,including all bypass piping and all
maintenance responsibilities of each contractor. backup power sources or redundancy in the system.This includes
a water balance showing all treatment units,including disinfection
Section 2.Additional Information (e.g.,chlorination and dechlorination),and showing daily average
Outfaiis to Waters of the United States flow rates at influent and discharge points,and approximate daily
Design Flow flow rates between treatment units.Also provide a narrative
description of the diagramischematic.Rnswer"Yes"to Item 2.4
Item 2.1.Indicate whether the treatment works has a design flow once you have completed and attached your diagram to the
greater than or equal to 0.1 mgd.if yes,continue to Item 2.2.If no, application.
skip to Section 3.
Scheduled improvements and Schedules of Implementation
Inflow and Infiltration Item 2.5.Indicate whether any improvements to the facility are
Item 2.2.Specify the POTW's current average daily volume of scheduled.If yes,list and briefly describe each scheduled
inflow and infiltration(in gpd)and steps the facility is taking to improvement and continue to Item 2.6.If no,skip to Section 3.
minimize inflow and infiltration.
Item 2.6.For each scheduled improvement,indicate the outfall
Topographic Map number of each outfall affected and the scheduled or actual dates
Item 2.3.Prepare a topographic map(or other map if a topographic of completion for the following:(1)commencement of construction,
map is unavailable)extending at least one mile beyond property (2)completion of construction,(3)commencement of discharge,
boundaries of the treatment plant,including all unit processes and and(4)attainment of operational level.
showing the following:(1)treatment plant area and unit processes; Item 2.7.Note whether the appropriate permits/clearances
(2)major pipes or other structures through which wastewater enters concerning other federallstate requirements have been obtained
the treatment plant and the pipes or other structures through which and briefly explain your response.
treated wastewater is discharged from the treatment plant(include
outfalls from bypass piping,if applicable);(3)each well where fluids Section 3.Information on Effluent Discharges
from the treatment plant are injected underground;(4)wells, Description of Outfalls
springs,and other surface water bodies listed in public records or
otherwise known to the applicant within'/o mile of the treatment Item 3.1.Provide a description of each of the POTW's wastewater
discharge outfalls.The application form provides reporting space
works'property boundaries;(5)sewage sludge management
for three outfalls.If your facility has more than this number,attach
facilities(including onsite treatment,storage,and disposal sites);
and(6)location at which waste classified as hazardous under the additional sheets as necessary.
Resource Conservation and Recovery Act(RCRA)enters the For each outfall,provide the outfall number.Indicate the state,
treatment plant by truck,rail,or dedicated pipe. county,and city or town where each outfall is located.Note the
On each map,include the map scale,a meridian arrow showing distance from shore in feet and the depth below the surface in feet.
north,and latitude and longitude to the nearest second.Latitude Specify the average daily flow rate through the outfall in mgd.Also
and longitude coordinates may be obtained in a variety of ways, specify the latitude and longitude of each outfall to the nearest
including use of hand held devices(e.g.,a GPS enabled second.Latitude and longitude coordinates may be obtained in a
smartphone),internet mapping tools(e.g., variety of ways,including use of hand held devices(e.g.,a GPS
httgs:ilmvnasadata.iarc.nasa.gov/iatitudelongitude-finder/ , enabled smartphone),internet mapping tools(e.g.,
geographic information systems(e.g.,ArcView),or paper maps htt s:llm nasadata.larc.nasa. ovliatitudelon itude-finder),
from trusted sources(e.g.,U.S.Geological Survey or USGS). geographic information systems(e.g.,ArcView),or paper maps
from trusted sources(e.g.,USGS).The location of each outfall(i.e.,
On all maps of rivers,show the direction of the current.In tidal where the coordinates are collected)shall be the point where the
waters,show the directions of ebb and flow tides. discharge is released into a water of the United States.For further
You may develop your map by going to USGS's National Map guidance,refer to httpllwww epa.qov/geosDatial/latitudelon is tude-
data-standard.
2A-4

FORM 2A--LINE-BY-LINE INSTRUCTIONS CONTINUED
Seasonal or Periodic Discharge Data completing Items 3.10 to 3.26 and Tables A through E.
Item 3.2.Indicate whether any of the outfalls described under Item 3.10 and Table A.All applicants that discharge wastewater to
Item 3.1 have seasonal or periodic discharges,If yes, continue to waters of the United States must provide effluent data for Table A
Item 33. If no,skip to Item 3.4. parameters.Respond"Yes"to Item 3.10 when you have completed
Item 3.3.Specify the following for each applicable outfall: Table A and attached it to your application.
(1)number of times per year discharge occurs,(2)average duration item 3.11.Answer whether the POTW has conducted any whole
of each discharge,(3)average flaw of each discharge in mgd,and effluent toxicity(WET)tests during the 4.5 years prior to the date of
(4)months in which discharge occurs. the application on any of the facility's discharges or on any
Diffuser Type receiving water near the discharge points. If yes,continue to Item
Item 3.4.Note whether any of the outfalls listed under Item 3.1 are 3.12.If no,skip to Item 3.13.
equipped with a diffuser. If yes,continue to Item 3.5.If no,skip to Item 3.12.For each applicable outfall,note the number of acute
Item 3.6. and chronic WET tests conducted since the last permit reissuance
Item 3.5.Briefly describe the diffuser type at each applicable of the facility's discharges or of the receiving water near the
outfall. discharge points.
Waters of the United States Item 3.13.Note whether the POTW has a design flow greater than
Item 3.6.Note whether the POTW discharges or plans to discharge or equal to 0.1 mgd.If yes,continue to Item 3.14. If no,skip to Item
wastewater to waters of the United States from one or more 3.16.
discharge points.If yes,continue to Item 3.7.If no,skip to Item 3.14 and Table B.Answer whether the treatment works uses
Section 6. chlorine for disinfection,uses it elsewhere in the treatment process,
Receiving Water Description or otherwise has reasonable potential to discharge chlorine in its
Item 3.7.Provide receiving water and related information in the effluent. If yes,complete Table B including chlorine.If no,complete
table provided on the form(if known):(1)name of receiving water, Table B,omitting chlorine.
(2)name of watershed/river/stream system and U.S.Soil Item 3.15.Answer"Yes"when you have completed monitoring for
Conservation Service 14-digit watershed code,(3)name of state all applicable Table B parameters and attached the results to your
management/river basin and U.S.Geological Survey(USGS)8-digit application.
hydrologic unit code,(4)acute and chronic critical low flow in cubic
feet per second(cfs)and total hardness of receiving stream at Item 3.16 and Screen for Tables C through E.Indicate whether
critical low flow,in milligrams per liter(mg/L)of calcium carbonate, one or more of the conditions apply to your POTW. If yes,continue
if applicable. to item 3.17.If no,skip to Section 4.
Treatment Description Item 3.17 and Table C.Answer"Yes"to indicate you have
completed monitoring for all applicable Table C pollutants and
Item 3.8.Specify the highest level of treatment provided for attached the results to your application package.
discharges from each outfall(e.g.,primary,equivalent to
secondary,secondary,or advanced).Also indicate the following Item 3.18 and Table D.Answer"Yes"to indicate you have
design removals(in percent)for the following parameters for each completed monitoring for applicable Table D pollutants required by
outfall:(1)biochemical oxygen demand(BODs or CBODs),(2)total your NPDES.permitting authority and attached the results to your
suspended solids(TSS),(3)phosphorus(if applicable),(4)nitrogen application package,or"No"if the NPDES permitting authority has
(if applicable),and(5)any other removals that an advanced not required additional sampling for the pollutants in Table D.
treatment system is designed to achieve. Item 3.19 and Additional Screen for Table E.Answer whether the
Item 3.9.Provide a description of the type(s)of disinfection used for POTW conducted either(1)a minimum of four quarterly WET tests
wastewater discharged through each outfalL Indicate the seasons for one year preceding this permit application or(2)at least four
the disinfection type is used.Note whether the POTW dechlorinates annual WET tests in the past 4.5 years.If yes,continue to Item
if disinfection is accomplished through chlorination.Otherwise, 3.20,If no,complete tests and Table E and then skip to Item 3.26.
check"Not Applicable." Item 3.20 and Additional Screen for Table E. Report whether you
Effluent Testing Data and Tables A through E have previously submitted the results of the WET tests indicated in
Items 3.10 to 3.26.These items require you to collect and report Item 3.19 to your NPDES permitting authority. If yes,continue to
data for the parameters and pollutants listed in Tables A through E, Item 3.21.If no,provide the results in Table E and skip to Item 3.26.
located at the end of Form 2A.The instructions for completing the Item 3.21.Report the dates the testing data were submitted to your
tables are table-specific,as are the criteria for determining who NPDES permitting authority and provide a summary of the results.
should complete them.
Item 3.22.Regardless of how you may have provided the results of
Important note:Read the"General Instructions for Reporting, previously conducted WET analyses to your NPDES permitting
Sampling,and Analysis"later in these instructions before authority, indicate if any of the tests resulted in toxicity. If yes,
2A-5

FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED
continue to Item 3.23.If no,skip to Item 3.26. pretreatment program,which is defined at 40 CFR 403.3 as a
Item 3.23.Describe the cause(s)of toxicity, program administered by a POTW that meets the criteria
established in 40 CFR 403.8 and 403.9 and that has been
Item 3.24.Indicate if the POTW has conducted a toxicity reduction approved by the NPDES permitting authority.
evaluation.If yes,continue to Item 3.25.if no,skip to Item 3.26. Item 4.4.Answer whether you have submitted either of the
Item 3.25.Provide details of any toxicity reduction evaluations following to the NPDES permitting authority that contains
performed. information substantially identical to that required in Table F:(1)a
Item 3.26.Answer"Yes"when you have completed Table E for all pretreatment program annual report submitted within one year of
applicable outfalls and attached the results to the application the application or(2)a pretreatment program.If yes,continue to
package,or answer"No"if the item is not applicable because you Item 4.5.If no,skip to Item 4.6.
previously submitted WET data to your NPDES permitting authority. Item 4.5,Identify the title and date of the pretreatment program
Section 4.Industrial Discharges,Table F,and Hazardous annual report or pretreatment program referenced in Item 4.4 and
Wastes skip to Item 4.7.
Item 4.1.Indicate if the POTW receives discharges from significant Item 4.6 and Table F.Complete Table F by providing the following
industrial users(SIUs)or non-significant categorical industrial users information for each SIU that discharges to the POTW:(1)name
(NSCIUs),including SIUs and NSCIUs that truck or haul waste.If and mailing address;(2)description of all industrial processes that
yes,continue to Item 4.2.If no,skip to Item 4.7. affect or contribute to each SIU's discharge;(3)a list of the principal
products and raw materials that affect or contribute to the SIU's
1. SIUs are defined as: discharge;(4)average daily volume of wastewater discharged by
a. All industrial users subject to categorical pretreatment each SIU,indicating the amount attributable to process flow and
standards under 40 CFR 403.6 and 40 CFR Chapter I, non-process flow;(5)whether the SIU is subject to local limits;
Subchapter N(CIUs);and (6)whether the SIU is subject to categorical standards and the
b. Any other industrial user per 40 CFR 403.3 that: categoriestsubcategories under which the SIU is subject;and
(7)whether any problems(e.g.,upsets,pass-through interference)
i. Discharges an average of 25,000 gpd or more of have occurred at the POTW that can be attributed to the SIU in the
process wastewater to the treatment works(with past 4.5 years.Answer"Yes"to Item 4.6 when you have completed
certain exclusions);or and attached Table F to the application package.
ii. Contributes a process wastestream that makes up Note:SIUs include users that truck or haul industrial waste to the
5 percent or more of the average dry weather POTW Information for these users must be provided in Table F.
hydraulic or organic capacity of the treatment plant;
or Item 4.7.Indicate if the POTW receives or has been notified that it
iii. Is designated as an SIU by the control authority. will receive by truck, rail,or dedicated pipe any wastes that are
regulated as RCRA hazardous wastes pursuant to 40 CFR 261.If
2. The control authority may determine that an Industrial User yes,continue to Item 4.8.If no,skip to Item 4.9.
subject to categorical Pretreatment Standards under 40 CFR
403.6 and 40 CFR Chapter I,Subchapter N is a NSCIU rather Item 4.8.For each hazardous waste received,provide the
than a SIU on a finding that the Industrial User never hazardous waste number,the method by which the waste is
discharges more than 100 gpd of total categorical wastewater received(e.g.,by truck,dedicated pipe,rail,etc.),and the amount
(excluding sanitary,non-contact cooling and boiler blowdown of waste received annually(specify units).
wastewater,unless specifically included in the Pretreatment Item 4.9.Answer whether the POTW receives,or has been notified
Standard)and the following conditions are met: that it will receive,wastewaters that originate from remedial
a. The Industrial User,prior to the control authority's finding, activities,including those undertaken pursuant to Comprehensive
has consistently complied with all applicable categorical Environmental Response,Compensation,and Liability Act
Pretreatment Standards and Requirements; (CERCLA)and Sections 3004(u)or 3008(h)of RCRA.If yes,
b. The Industrial User annually submits the certification
continue to Item 4.10.If no,skip to Section 5.
statement required in 40 CFR 403.12(q)together with any Item 4.10.Answer whether the POTW receives(or expects to
additional information necessary to support the receive)less than 15 kilograms per month of non-acute hazardous
certification statement;and wastes as specified at 40 CFR 261,30(d)and 261.33(e).If yes,skip
c. The Industrial User never discharges any untreated to Section 5.If no,continue to Item 4.11.
concentrated wastewater. Item 4.11.In an attachment to the application,provide an
identification and description of the site(s)orfacility(ies)at which
Item 4.2.Indicate the number of SIUs and NSCIUs that discharge the wastewater originates;the identities of the wastewater's
to the POTW. hazardous constituents,as listed in Appendix VII of 40 CFR 261,if
Item 4.3.Answer whether the POTW has an approved known;and the extent of treatment,if any,the wastewater receives
2A-6

General Instructions for Reporting,Sampling,and Analysis
Important note:Read these instructions before completing The method ML is above the water quality criterion,but the
Tables A through E and Section 3 of Form 2A. amount of the pollutant or pollutant parameter in the facility's
General Items discharge is high enough that the method detects and
quantifies the level of the pollutant or pollutant parameter in
Complete the applicable tables for each outfall at your facility. Be the discharge.
sure to note the EPA Identification Number, NPDES permit
number,facility name,and applicable outfall number at the top of : ' The method has the lowest ML of the analytical methods
each page of the tables and any associated attachments. approved under 40 CFR 136 or required under 40 CFR
chapter 1,subchapter N or 0,for the measured pollutant or
You may report some or all of the required data by attaching pollutant parameter.
separate sheets of paper instead of completing Tables A through
E for each of your outfalls,so long as the sheets contain all of the Consistent with 40 CFR 136,you may provide matrix-or sample-
required information and are similar in format to Tables A through specific MLs rather than the published levels.Further,where you
E.For example,you may be able to print a report in a compatible ran demonstrate that,despite a good faith effort to use a method
format from the data system used in your analysis of metals that would otherwise meet the definition of"sufficiently sensitive,"
completed under Table C. the analytical results are not consistent with the quality assurance
(QA)/quality control(QC)specifications for that method,then the
Note for new dischargers.Provide all information available to NPDES permitting authority may determine that the method is not
you at the time you complete Form 2A.If you do not have performing adequately and the NPDES permitting authority should
information to respond to an item because your facility has yet to select a different method from the remaining EPA-approved
discharge,write or type"data are not available"next to the item methods that is sufficiently sensitive consistent with 40 CFR
on the form.Note that you are required to submit actual data no 122.21(e)(3)(i).Where no other EPA-approved methods exist,you
later than 24 months after your facility commences discharge. must select a method consistent with 40 CFR 122.21(e)(3)(ii).
Reporting of Effluent Data When there is no analytical method that has been approved under
Where effluent data are requested,do not provide information on 40 CFR 136;required under 40 CFR chapter I,subchapter N or 0,
CSQs.The latter information is requested instead under Section 5 and is not otherwise required by the NPDES permitting authority,
of Form 2A. you may use any suitable method but shall provide a description
Provide data for each outfall through which effluent is discharged. of the method.When selecting a suitable method,other factors
When an applicant has two or more outfalls with substantially such as a method's precision,accuracy,or resolution,may be
identical effluents,the NPDES permitting authority may allow the considered when assessing the performance of the method.
applicant to test only one outfall and report that quantitative data Effluent monitoring data must comply with the QAIQC
as applying to the substantially identical outfall.If the permitting requirements of 40 CFR 136(and other appropriate QA/QC
authority grants your request,attach a separate sheet to the requirements for standard methods for analytes not addressed by
application form identifying the outfall tested and describing why 40 CFR 136).
the other outfall(s)are substantially identical. Clearly specify the units of measure on Tables A through E for
At a minimum,effluent testing data must be based on at least each para mete rlpollutant analyzed.Values should be reported as
three samples taken within 4.5 years prior to the date of the concentration or mass,except for flow,temperature,pH,color,
permit application.Samples must be representative of the and fecal coliform organisms,unless otherwise requested or
seasonal variation in the discharge from each outfall.Existing required by the NPDES permitting authority.Flow,temperature,
data may be used,if available,in lieu of sampling done solely for pH,color,and fecal coliform organisms must be reported as mgd,
the purpose of this application. degrees Celsius(°C),standard units,color units,and most
All existing data for pollutants specified in Tables A through D that probable number per 100 milliliters(MPN1100 mL),respectively.
is collected within 4.5 years of the application must be included in Use the following abbreviations in the columns requiring"units"in
the pollutant data summary that you submit.If,however,you Tables A through D.
sampled for a specific pollutant on a monthly or more frequent Concentration Mass
basis,it is only necessary,for such pollutant,to summarize all ppm=parts per million Ibs=pounds
data collected within 1 year of the application. mglL=milligrams per liter ton=tons(English tons)
Except as specified below,all required quantitative data shall be ppb=parts per billion mg=milligrams
collected in accordance with sufficiently sensitive analytical pglL=micrograms per liter g=grams
methods approved under 40 CFR 136 or required under 40 CFR
chapter I,subchapter N or 0.A method is"sufficiently sensitive" MPN=most probable number kg=kilograms
when: per 100 milliliters T=tonnes(metric tons)
• The method minimum level(ML)is at or below the level of
the applicable water quality criterion for the measured
pollutant or pollutant parameter.
2A-7

General Instructions for Reporting,Sampling,and Analysis Continued
Grab samples must be used for pH,temperature,cyanide,total times,and the collection of duplicate samples—must be followed.
phenols,residual chlorine,oil and grease,fecal coliform(including The time when you sample should be representative of your normal
E.coh),and volatile organic compounds.For all other pollutants, operation,to the extent feasible,with your treatment system
24-hour composite samples must be used.For a composite operating properly with no system upsets.Collect samples from the
sample,only one analysis of the composite of aliquots is required. center of the flow channel,where turbulence is at a maximum,at a
The effluent monitoring data provided must include at least the site specified in your present NPDES permit,or at any site
following for each parameter:(1)the maximum daily discharge adequate for the collection of a representative sample.
based upon actual sample values,(2)average daily discharge for Further Requirements for Table E,Whole Effluent Toxicity
all samples,expressed as concentration or mass,and the number Testing
of samples used to obtain this value,(3)the analytical method Each applicant required to perform WET testing must provide
used,and(4)the threshold level(i.e.,method detection limit, results of a minimum of four quarterly tests for a year,from the year
minimum level,or other designated method endpoints)for the preceding the permit application,or the results from four tests
analytical method used. performed at least annually in the 4.5-year period prior to the
Metals must be reported as"total recoverable metal,"unless all application,provided the results show no appreciable toxicity using
approved analytical methods for the metal inherently measure only a safety factor determined by the NPDES permitting authority.
its dissolved form(e.g.,hexavalent chromium)or otherwise directed Applicants must conduct tests with multiple species(no less than
by the NPDES permitting authority. two species;e.g.,fish,invertebrate,plant)and test for acute or
Sampling chronic toxicity,depending on the range of receiving water dilution.
The collection of samples for the reported analyses should be See 40 CFR 122.210)(5)(v)for further details.
supervised by a person experienced in performing sampling of WET testing must be conducted using methods approved under
domestic wastewater.You may contact your NPDES permitting 40 CFR 136.West coast facilities in Washington,Oregon,
authority for detailed guidance on sampling techniques and for California,Alaska,Hawaii,and the Pacific Territories are exempted
answers to specific questions.See Exhibit 2A-1 for contact from 40 CFR 136 chronic methods and must use alternative
information.Any specific requirements in the analytical methods— guidance as directed by the NPDES permitting authority.
for example,for sample containers,sample preservation,holding
2A-8

FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED
or will receive before entering the POTW.Answer"Yes"to Item watershed(14-digit)code,if known;(3)name of the state
4.11 when you have completed and attached the information to the management/river basin and the USGS 8-digit hydrologic
application package. cataloging unit code,if known;and(4)a description of any known
Section 5.Combined Sewer Overflows water quality impacts on the receiving water caused by the CSO
CSO Map and Diagram (e.g.,permanent or intermittent beach closings,permanent or
intermittent shellfish bed closings,fish kills,fish advisories,other
Item 5.1. Indicate if the treatment works has a combined sewer recreational loss,or exceedance of any applicable state water
system.If yes,continue to Item 5.2.If no,skip to Section 6. quality standard).
Item 5.2.Attach a CSO system map to the application.The map Section 6.Checklist and Certification Statement
should indicate:(1)all CSO discharge points,(2)sensitive use
areas potentially affected by CSOs(e.g.,beaches,drinking wafer Item 6.1.Review the checklist provided. In Column 1,mark the
supplies,shellfish beds,sensitive aquatic ecosystems,and sections of Form 2A that you have completed and are submitting
with your application.In
outstanding national resource waters),and(3)waters supporting t Column 2, indicate for each section
threatened and endangered species potentially affected by CSOs, whether you are submitting attachments.
Answer"Yes"to Item 5.2 when you have completed the map and Item 6.2.The Clean Water Act provides for severe penalties for
attached it to the application package. submitting false information on this application form.CWA Section
Item 5.3.Prepare a diagram of the CSO collection system.The 309(c)(2)provides that"Any person who knowingly makes any false
diagram should show the following:(1)the location of major sewer statement,representation,or certification in any application, ...shall
trunk lines,both combined and separate sanitary;(2)the locations upon conviction,be punished by a fine of no more than$10,000 or
of paints where separate sanitary sewers feed into the combined by imprisonment for not more than six months,or both."
sewer system;(3)in-line and off-line storage structures;(4)the FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
locations of flow-regulating devices;and(5)the locations of pump APPLICATION TO BE SIGNED AS FOLLOWS:
stations.Answer"Yes"to Item 5.3 when you have completed the A. For a corporation,by a responsible corporate officer.For the
diagram and attached it to the application package. purpose of this section,a responsible corporate officer means:
CSO Outfall Description (1)a president,secretary,treasurer,or vice-president of the
Item 5.4.Provide the following information for each CSO ouffall: corporation in charge of a principal business function,or any
(1)outfall number;(2)state,county,city or town and ZIP code in other person who performs similar policy-or decision-making
which the outfall is located;(3)latitude and longitude of the outfall, functions for the corporation,or(2)the manager of one or
to the nearest second,(4)distance of the outfall from shore and more manufacturing,production,or operating facilities,
depth of the outfall below water surface.Latitude and longitude provided the manager is authorized to make management
coordinates may be obtained in a variety of ways,including use of decisions which govern the operation of the regulated facility
hand held devices(e.g.,a GPS enabled smartphone), internet including having the explicit or implicit duty of making major
mapping tools(e.g., capital investment recommendations,and initiating and
https://mynasadata.larc.nasa.govilatitudelongitude-finder/), directing other comprehensive measures to assure long term
geographic information systems(e.g.,ArcView),or paper maps environmental compliance with environmental laws and
from trusted sources(e.g.,USGS).The location of each CSO regulations;the manager can ensure that the necessary
outfall(i.e.,where the coordinates are collected)shall be the point systems are established or actions taken to gather complete
where the discharge is released into a water of the United States. and accurate information for permit application requirements;
CSO Monitoring and where authority to sign documents has been assigned or
delegated to the manager in accordance with corporate
Item 5.5.Indicate whether the POTW has monitored any of the procedures.
following items in the past year for each of its CSO outfalls: B. For a partnership or sole proprietorship,by a general partner
(1)rainfall,(2)CSO flow volume,(3)CSO pollutant concentrations; or the proprietor,respectively.
(4)receiving water quality,(5)CSO frequency,and(6)number of
storm events. C. For a municipality,state,federal,or other public facility,by
either a principal executive officer or ranking elected official.
CSO Events in Past Year For purposes of this section,a principal executive officer of a
Item 5.6.For each CSO outfall,record(1)the number of CSO federal agency includes:(1)The chief executive officer of the
events in the past year,(2)the average duration in hours per event, agency,or(2)a senior executive officer having responsibility
(3)the average volume per CSO event in million gallons,and for the overall operations of a principal geographic unit of the
(4)the minimum rainfall that caused a CSO event in inches of agency(e.g.,Regional Administrators of EPA).
rainfall in the past year.Note whether your responses for sub-items END
(2)through(4)above are based on actual or estimated data.
Submit your completed Form 2A and
CSO Receiving Waters all associated attachments
Item 5.7.For each CSO outfall,record the following receiving water (and any other required NPDES application forms)
information:(1)name of receiving water;(2)name of to your NPDES permitting authority.
watershed/stream system and the U.S.Soil Conservation Service
2A-9

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2A-10

FORM 2A—GLOSSARY
Note:This glossary includes terms used in the various NPDES application forms,including Form 2A.The definitions are from the NPDES
regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms,contact
your NPDES permitting authority,
ANIMAL FEEDING OPERATION(defined at§122.23)means a lot or facility(other than an aquatic animal production facility)where the
following conditions are met;
• Animals(other than aquatic animals)have been,are,or will be stabled or confined and fed or maintained for a total of 45 days or
more in any 12-month period;and
• Crops,vegetation,forage growth,or post-harvest residues are not sustained In the normal growing season over any portion of the lot
or facility.
APPLICATION means the EPA standard national forms for applying for a permit,including any additions,revisions,or modifications to the
forms;or forms approved by EPA for use in approved states, including any approved modifications or revisions.
APPROVED PROGRAM or APPROVED STATE means a State or interstate program which has been approved or authorized by EPA
under part 123.
AQUACULTURE PROJECT(defined at§122.25)means a defined managed water area which uses discharges of pollutants into that
designated area for the maintenance or production of harvestable,freshwater,estuarine,or marine plants or animals.DESIGNATED
PROJECT AREA means the portions of the waters of the United States within which the permittee or permit applicant plans to confine the
cultivated species,using a method or plan or operation(including,but not limited to,physical confinement)which,on the basis of reliable
scientific evidence,is expected to ensure that specific individual organisms comprising an aquaculture crop will enjoy increased growth
attributable to the discharge of pollutants,and be harvested within a defined geographic area.
AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month,
calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured during that
month.
AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week,
calculated as the sum of all daily discharges measured during a calendar week divided by the number of daily discharges measured during
that week.
BEST MANAGEMENT PRACTICES(BMPs)means schedules of activities,prohibitions of practices,maintenance procedures,and other
management practices to prevent or reduce the pollution of waters of the United States.BMPs include treatment requirements,operation
procedures,and practices to control plant site runoff,spillage or leaks,sludge or waste disposal,or drainage from raw material storage.
BIOSOLIDS(see sewage sludge).
BYPASS(defined at§122.41(m))means the intentional diversion of waste streams from any portion of a treatment facility.
COMBINED SEWER OVERFLOW(CSO)means a discharge from a combined sewer system(CSS)at a point prior to the Publicly Owned
Treatment Works(POTW)Treatment Plant(defined at§403.3(r)).
COMBINED SEWER SYSTEM(CSS)means a wastewater collection system owned by a State or municipality(as defined by section
502(4)of the CWA)which conveys sanitary wastewaters(domestic,commercial and industrial wastewaters)and storm water through a
single-pipe system to a Publicly Owned Treatment Works(POTW)Treatment Plant(as defined at§403.3(r)).
CONCENTRATED ANIMAL FEEDING OPERATION(defined at§ 122.23)means an animal feeding operation that is defined as a Large
CAFO or as a Medium CAFO by the terms of(A)or(B)below,or that is designated as a CAFO in accordance with 40 CFR 122.23(c).Two
or more AFOs under common ownership are considered to be a single AFO for the purposes of determining the number of animals at an
operation,if they adjoin each other or if they use a common area or system for the disposal of wastes.
A. LARGE CONCENTRATED ANIMAL FEEDING OPERATION(LARGE CAFO)means an AFO that stables or confines as many as or
more than the numbers of animals specified in any of the following categories:
1. 700 mature dairy cows,whether milked or dry;
2. 1,000 veal calves;
3. 1,000 cattle other than mature dairy cows or veal calves.Cattle includes but is not limited to heifers,steers,bulls and cow/calf
pairs;
4. 2,500 swine each weighing 55 pounds or more;
5. 10,000 swine each weighing less than 55 pounds;
6. 500 horses;
7. 10,000 sheep or Iambs;
2A-11

FORM 2A—GLOSSARY CONTINUED
8. 55,000 turkeys;
9. 30,000 laying hens or broilers,if the AFO uses a liquid manure handling system;
10. 125,000 chickens(other than laying hens),if the AFO uses other than a liquid manure handling system;
11. 82,000 laying hens,if the AFO uses other than a liquid manure handling system;
12. 30,000 ducks(if the AFO uses other than a liquid manure handling system);or
13. 5,000 ducks(if the AFO uses a liquid manure handling system).
B. MEDIUM CONCENTRATED ANIMAL FEEDING OPERATION(MEDIUM CAFO)means any AFO with the type and number of
animals that fall within any of the ranges listed below and which has been defined or designated as a CAFO.An AFO is defined as a
Medium CAFO if:
1. The type and number of animals that it stables and confines falls within any of the following ranges:
a. 200 to 699 mature dairy cows,whether milked or dry;
b. 300 to 999 veal calves;
c. 300 to 999 cattle other than mature dairy cows or veal calves.Cattle includes but is not limited to heifers,steers,bulls and
cow/calf pairs;
d. 750 to 2,499 swine each weighing 55 pounds or more;
e. 3,000 to 9,999 swine each weighing less than 55 pounds;
f. 150 to 499 horses;
g. 3,000 to 9,999 sheep or lambs;
h. 16,500 to 54,999 turkeys;
i. 9,000 to 29,999 laying hens or broilers,if the AFO uses a liquid manure handling system;
j. 37,500 to 124,999 chickens(other than laying hens),if the AFO uses other than a liquid manure handling system;
k. 25,000 to 81,999 laying hens,if the AFO uses other than a liquid manure handling system;
I. 10,000 to 29,999 ducks(if the AFO uses other than a liquid manure handling system);ore
m. 1,500 to 4,999 ducks(if the AFO uses a liquid manure handling system);and
2. Either one of the following conditions are met:
a. Pollutants are discharged into waters of the United States through a man-made ditch,flushing system,or other similar man-
made device;or
b. Pollutants are discharged directly into waters of the United States which originate outside of and pass over,across,or
through the facility or otherwise come into direct contact with animals confined in the operation.
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY(defined at§122.24)means a hatchery,fish farm,or other facility which
contains,grows,or holds aquatic animals in either of the following categories,or which the Director designates as such on a case-by-case
basis:
A. Cold water fish species or other cold water aquatic animals including,but not limited to,the Salmonidas family of fish(e.g.,trout and
salmon)in ponds,raceways,or other similar structures which discharge at least 30 days per year but does not include:
1. Facilities which produce less than 9,090 harvest weight kilograms(approximately 20,000 pounds)of aquatic animals per year;
and
2. Facilities which feed less than 2,272 kilograms(approximately 5,000 pounds)of food during the calendar month of maximum
feeding.
B. Warm water fish species or other warm water aquatic animals including,but not limited to,the Ameiuridae, Cetrarchiclae,and
Cyprinidae families of fish(e.g.,respectively,catfish,sunfish,and minnows)in ponds,raceways,or other similar structures which
discharge at least 30 days per year,but does not include;
1. Closed ponds which discharge only during periods of excess runoff;or
2. Facilities which produce less than 45,454 harvest weight kilograms(approximately 100,000 pounds)of aquatic animals per year.
CWA means the Clean Water Act(formerly referred to as the Federal Water Pollution Control Act or Federal Water Pollution Control Act
Amendments of 1972)Public Law 92-500,as amended by Public Law 95-217,Public Law 95-576,Public Law 96-483 and Public Law
97-117,33 U.S.C.1251 et seq.
CWA AND REGULATIONS means the Clean Water Act(CWA)and applicable regulations promulgated thereunder. In the case of an
approved State program,it includes State program requirements.
2A-12

FORM 2A—GLOSSARY CONTINUED
DAILY DISCHARGE means the"discharge of a pollutant"measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling.For pollutants with limitations expressed in units of mass,the"daily discharge"is
calculated as the total mass of the pollutant discharged over the day.For pollutants with limitations expressed in other units of
measurement,the"daily discharge"is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the"discharge of a pollutant."
DIRECTOR means the Regional Administrator or the State Director,as the context requires,or an authorized representative.When there
is no"approved State program,"and there is an EPA administered program,"Director"means the Regional Administrator.When there is
an approved State program,"Director"normally means the State Director.In some circumstances,however, EPA retains the authority to
take certain actions even when there is an approved State program.(For example,when EPA has issued an NPDES permit prior to the
approval of a State program,EPA may retain jurisdiction over that permit after program approval,see§123.1.)In such cases,the term
"Director"means the Regional Administrator and not the State Director.
DISCHARGE(OF A POLLUTANT)means:
• Any addition of any pollutant or combination of pollutants to waters of the United States from any point source;or
• Any addition of any pollutant or combination of pollutants to the waters of the contiguous zone or the ocean from any point source
other than a vessel or other floating craft which is being used as a means of transportation.
This definition includes discharges into waters of the United States from:surface runoff which is collected or channelled by man;
discharges through pipes,sewers,or other conveyances owned by a State,municipality,or other person which do not lead to a treatment
works;and discharges through pipes,sewers,or other conveyances,leading into privately owned treatment works.This term does not
include an addition of pollutants by any"indirect discharger'.
DISCHARGE MONITORING REPORT means the EPA uniform national form,including any subsequent additions,revisions,or
modifications for the reporting of self-monitoring results by permittees.DMRs must be used by"approved States"as well as by EPA.EPA
will supply DMRs to any approved State upon request.The EPA national forms may be modified to substitute the state agency name,
address,logo,and other similar information,as appropriate,in place of EPA's.
DRAFT PERMIT means a document prepared under§124.6 indicating the Director's tentative decision to issue or deny,modify,revoke
and reissue,terminate,or reissue a"permit."A notice of intent to terminate a permit,and a notice of intent to deny a permit,as discussed
in§124.5,are types of"draft permits."A denial of a request for modification,revocation and reissuance,or termination,as discussed in
§124.5,is not a"draft permit,"A"proposed permit"is not a"draft permit."
EFFLUENT LIMITATION means any restriction imposed by the Director on quantities,discharge rates,and concentrations of"pollutants"
which are'discharged"from"point sources"into'beaters of the United States,"the waters of the"contiguous zone,"or the ocean.
EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administrator under section 304(b)of the CWA to adopt or
revise"effluent limitations."
ENVIRONMENTAL PROTECTION AGENCY(EPA)means the United States Environmental Protection Agency.
FACILITY or ACTIVITY means any NPDES"point source"or any other facility or activity(including land or appurtenances thereto)that is
subject to regulation under the NPDES program.
GENERAL PERMIT means an NPDES"permit"issued under§ 122.28 authorizing a category of discharges under the CWA within a
geographical area.
HAZARDOUS SUBSTANCE means any substance designated under 40 CFR part 116 pursuant to section 311 of the CWA.
INDIAN COUNTRY(or INDAN LANDS)means:
• All land within the limits of any Indian reservation under the jurisdiction of the United States Government,notwithstanding the
issuance of any patent,and,including rights-of-way running through the reservation;
• All dependent Indian communities with the borders of the United States whether within the originally or subsequently acquired territory
thereof,and whether within or without the limits of a state;and
• All Indian allotments.the Indian titles to which have not been extinguished,including rights-of-way running through the same.
INDIAN TRIBE means any Indian Tribe,band,group,or community recognized by the Secretary of the fnterior and exercising
governmental authority over a Federal Indian reservation.
INDIRECT DISCHARGE means a nondomestic discharger introducing"pollutants"to a"publicly owned treatment works."
2A-13

FORM 2A—GLOSSARY CONTINUED
LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM(defined at§122.26(b)(4))means all municipal separate storm sewers that
are either:
(i)Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census(Appendix F of 40 CFR 122);or
(ii)Located in the counties listed in appendix H of 40 CFR 122,except municipal separate storm sewers that are located in the
incorporated places,townships or towns within such counties;or
(iii)Owned or operated by a municipality other than those described in paragraphs(i)or(4)and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs(i)or(ii).In making this determination
the Director may consider the following factors:
(A)Physical interconnections between the municipal separate storm sewers;
(B)The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph(i);
(C)The quantity and nature of pollutants discharged to waters of the United States;
(D)The nature of the receiving waters;and
(E)Other relevant factors;or
(iv)The Director may,upon petition,designate as a large municipal separate storm sewer system,municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional,watershed,or
other appropriate basis that includes one or more of the systems described in paragraphs(i),(ii),(iii).
LOG SORTING AND LOG STORAGE FACILITIES(defined at§ 122.27)means facilities whose discharges result from the holding of
unprocessed wood,for example,logs or roundwood with bark or after removal of bark held in self-contained bodies of water(mill ponds or
log ponds)or stored on land where water is applied intentionally on the logs(wet decking).(See 40 CFR 429,subpart I,including the
effluent limitations guidelines.)
MAJOR FACILITY means any NPDES"facility or activity"classified as such by the Regional Administrator,or,in the case of"approved
State programs,"the Regional Administrator in conjunction with the State Director.
MAXIMUM DAILY DISCHARGE LIMITATION means the highest allowable"daily discharge."
MEDIUM MUNICIPAL SEPARATE STORM SEWER SYSTEM(defined at§122.26(b)(7))means all municipal separate storm sewers that
are either:
(i)Located in an incorporated place with a population of 100,000 or more but less than 250,000,as determined by the 1990 Decennial
Census by the Bureau of the Census(appendix G of 40 CFR 122);or
(ii)Located in the counties listed in appendix I of 40 CFR 122,except municipal separate storm sewers that are located in the incorporated
places,townships or towns within such counties;or
(iii)Owned or operated by a municipality other than those described in paragraph(i)or(ii)and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraph(i)or(ii). In making this determination
the Director may consider the following factors:
(A)Physical interconnections between the municipal separate storm sewers;
(B)The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph(i);
(C)The quantity and nature of pollutants discharged to waters of the United States;
(D)The nature of the receiving waters;or
(E)Other relevant factors;or
(iv)The Director may,upon petition,designate as a medium municipal separate storm sewer system,municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional,watershed,or
other appropriate basis that includes one or more of the systems described in paragraphs(i),(ii),(iii)of this section.
2A-14

FORM 2A—GLOSSARY CONTINUED
MUNICIPALITY means a city,town,borough,county, parish,district,association,or other public body created by or under State law and
having jurisdiction over disposal of sewage,industrial wastes,or other wastes,or an Indian tribe or an authorized Indian tribal organization,
or a designated and approved management agency under section 208 of the CWA.
MUNICIPAL SEPARATE STORM SEWER(defined at§122.26(b)(8))means a conveyance or system of conveyances(including roads
with drainage systems,municipal streets,catch basins,curbs,gutters,ditches,man-made channels,or storm drains):
• Owned or operated by a State,city,town,borough,county,parish,district,association,or other public body(created by or pursuant to
State law)having jurisdiction over disposal of sewage,industrial wastes,stormwater,or other wastes,including special districts under
State law such as a sewer district,flood control district or drainage district,or similar entity,or an Indian tribe or an authorized Indian
tribal organization,or a designated and approved management agency under section 208 of the CWA that discharges to waters of the
United States.
• Designed or used for collecting or conveying stormwater.
• Which is not a combined sewer;and
• Which is not part of a POTW as defined at 40 CFR 122.2.
MUNICIPAL SLUDGE(see sewage sludge)
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM(NPDES)means the national program for issuing,modifying,revoking
and reissuing,terminating,monitoring and enforcing permits,and imposing and enforcing pretreatment requirements,under sections 307,
402,318,and 405 of the CWA.The term includes an"approved program."
NEW DISCHARGER means any building,structure,facility,or installation:
• From which there is or may be a"discharge of pollutants;"
• That did not commence the"discharge of pollutants"at a particular"site'prior to August 13, 1979;
• Which is not a"new source;"and
• Which has never received a finally effective NPDES permit for discharges at that"site."
This definition includes an"indirect discharger"which commences discharging into"waters of the United States"after August 13, 1979.It
also means any existing mobile point source(other than an offshore or coastal oil and gas exploratory drilling rig or a coastal oil and gas
developmental drilling rig)such as a seafood processing rig,seafood processing vessel,or aggregate plant,that begins discharging at a
"site"for which it does not have a permit;and any offshore or coastal mobile oil and gas exploratory drilling rig or coastal mobile oil and gas
developmental drilling rig that commences the discharge of pollutants after August 13, 1979,at a"site"under EPA's permitting jurisdiction
for which it is not covered by an individual or general permit and which is located in an area determined by the Regional Administrator in
the issuance of a final permit to be an area of biological concern.In determining whether an area is an area of biological concern,the
Regional Administrator shall consider the factors specified in 40 CFR 125.122(a)(1)through(10).
An offshore or coastal mobile exploratory drilling rig or coastal mobile developmental drilling rig will be considered a"new discharger"only
for the duration of its discharge in an area of biological concern,
NEW SOURCE means any building,structure,facility,or installation from which there is or may be a"discharge of pollutants,"the
construction of which commenced:
• After promulgation of standards of performance under section 306 of the CWA which are applicable to such source,or
• After proposal of standards of performance in accordance with section 306 of the CWA which are applicable to such source,but only
if the standards are promulgated in accordance with section 306 within 120 days of their proposal.
OWNER OR OPERATOR means the owner or operator of any"facility or activity"subject to regulation under the NPDES program.
PERMIT means an authorization,license,or equivalent control document issued by EPA or an"approved State"to implement the
requirements of this part and parts 123 and 124."Permit'includes an NPDES"general permit"(§ 122.28).Permit does not include any
permit which has not yet been the subject of final agency action,such as a"draft permit"or a"proposed permit."
PESTICIDE DISCHARGES TO WATERS OF THE UNITED STATES FROM PESTICIDE APPLICATION means the application of
biological pesticides,and the application of chemical pesticides that leave a residue,from point sources to waters of the United States.In
the context of this definition of pesticide discharges to waters of the United States from pesticide application,this does not include
agricultural storm water discharges and return flows from irrigated agriculture,which are excluded by law(33 U.S.C. 1342(I);33 U.S.C.
1362(14)).
PESTICIDE RESIDUE for the purpose of determining whether a NPDES permit is needed for discharges to waters of the United States
from pesticide application,means that portion of a pesticide application that is discharged from a point source to waters of the United
States and no longer provides pesticidal benefits.It also includes any degradates of the pesticide.
2A-15

FORM 2A—GLOSSARY CONTINUED
POINT SOURCE means any discernible,confined,and discrete conveyance,including but not limited to,any pipe,ditch,channel,tunnel,
conduit,well,discrete fissure,container,rolling stock,concentrated animal feeding operation,landfill leachate collection system,vessel or
other floating craft from which pollutants are or may be discharged.This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff.(See§122.3).
POLLUTANT means dredged spoil,solid waste, incinerator residue,filter backwash,sewage,garbage,sewage sludge,munitions,
chemical wastes,biological materials,radioactive materials(except those regulated under the Atomic Energy Act of 1954,as amended(42
U.S.C.2011 at seq.)),heat,wrecked or discarded equipment,rock,sand,cellar dirt and industrial.municipal,and agricultural waste
discharged into water.It does not mean:
• Sewage from vessels;or
• Water,gas,or other material which is injected into a well to facilitate production of oil or gas,or water derived in association with oil
and gas production and disposed of in a well,if the well used either to facilitate production or for disposal purposes is approved by
authority of the State in which the well is located,and if the State determines that the injection or disposal will not result in the
degradation of ground or surface water resources.Note:Radioactive materials covered by the Atomic Energy Act are those
encompassed in its definition of source,byproduct,or special nuclear materials.Examples of materials not covered include radium
and accelerator-produced isotopes.See Train v.Colorado Public Interest Research Group, Inc.,426 U.S.1 (1976).
PRIMARY INDUSTRY CATEGORY means any industry category listed in the NRDC settlement agreement(Natural Resources Defense
Council at al.v.Train,8 E.R.C.2120(D.D.C.1976),modified 12 E.R.C. 1833(D.D.C.1979));also listed in appendix A of part 122.
PRIVATELY OWNED TREATMENT WORKS means any device or system which is(1)used to treat wastes from any facility whose
operator is not the operator of the treatment works and(2)not a"POTW."
PROCESS WASTEWATER means any water which,during manufacturing or processing,comes into direct contact with or results from the
production or use of any raw material,intermediate product,finished product,byproduct,or waste product.
PROPOSED PERMIT means a state NPDES"permit"prepared after the close of the public comment period(and,when applicable,any
public hearing and administrative appeals)which is sent to EPA for review before final issuance by the State.A"proposed permit"is not a
"draft permit."
PUBLICLY OWNED TREATMENT WORKS or POTW(defined at§403.3)means a treatment works as defined by CWA Section 212,
which is owned by a state or municipality(as defined by CWA Section 502(4)).This definition includes any devices or systems used in the
storage,treatment,recycling,and reclamation)of municipal sewage or industrial wastes of a liquid nature.This definition also includes
sewers,pipes,and other conveyances only if they convey wastewater to a POTW.The term also means the municipality as defined in
CWA Section 502(4),which has jurisdiction over the indirect discharges to and the discharges from such a treatment works.
REGIONAL ADMINISTRATOR means the Regional Administrator of the appropriate Regional Office of the Environmental Protection
Agency or the authorized representative of the Regional Administrator.
ROCK CRUSHING AND GRAVEL WASHING FACILITIES(defined at§122.27)means facilities which process crushed and broken
stone.gravel,and riprap(See 40 CFR 436,subpart B,including the effluent limitations guidelines).
SCHEDULE OF COMPLIANCE means a schedule of remedial measures included in a"permit`,including an enforceable sequence of
interim requirements(for example,actions,operations,or milestone events)leading to compliance with the CWA and regulations.
SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.
SEWAGE FROM VESSELS means human body wastes and the wastes from toilets and other receptacles intended to receive or retain
body wastes that are discharged from vessels and regulated under section 312 of the CWA,except that with respect to commercial
vessels on the Great Lakes this term includes graywater.For the purposes of this definition,"graywater"means galley,bath,and shower
water.
SEWAGE SLUDGE means any solid,semi-solid,or liquid residue removed during the treatment of municipal waste water or domestic
sewage.Sewage sludge includes,but is not limited to,solids removed during primary,secondary,or advanced waste water treatment,
scum,septage,portable toilet pumpings,type III marine sanitation device pumpings(33 CFR 159),and sewage sludge products.Sewage
sludge does not include grit or screenings,or ash generated during the incineration of sewage sludge.
SILVICULTURAL POINT SOURCE(defined at§122.27)means any discernible,confined,and discrete conveyance related to rock
crushing,gravel washing,log sorting,or log storage facilities which are operated in connection with silvicultural activities and from which
pollutants are discharged into waters of the United States.This term does not include non-point source silvicultural activities such as
nursery operations,site preparation,reforestation and subsequent cultural treatment,thinning,prescribed burning,pest and fire control,
harvesting operations,surface drainage,or road construction and maintenance from which there is natural runoff.However,some of these
activities(such as stream crossing for roads)may involve point source discharges of dredged or fill material which may require a CWA
Section 404 permit(see 33 CFR 209.120 and part 233).
2A-16

FORM 2A--GLOSSARY CONTINUED
SITE means the land or water area where any"facility or activity"is physically located or conducted,including adjacent land used in
connection with the facility or activity.
SLUDGE-ONLY FACILITY means any"treatment works treating domestic sewage"whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d)of the CWA and is required to obtain a permit under§ 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d)of the CWA
which govern minimum requirements for sludge quality,management practices,and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.
STATE means any of the 50 States,the District of Columbia,Guam,the Commonwealth of Puerto Rico,the Virgin Islands,American
Samoa,the Commonwealth of the Northern Mariana Islands,the Trust Territory of the Pacific Islands,or an Indian Tribe as defined in
these regulations which meets the requirements of§123.31 of this chapter.
STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an"approved program,"or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies,"State Director"
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.
STORMWATER(or STORM WATER)(defined at§ 122.26(b)(13))means stormwater runoff,snow melt runoff,and surface runoff and
drainage.
STORMWATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY(defined at§122.26(b)(14))means the discharge from any
conveyance that is used for collecting and conveying stormwater and that is directly related to manufacturing,processing or raw materials
storage areas at an industrial plant.The term does not include discharges from facilities or activities excluded from the NPDES program
under this part 122.For the categories of industries identified in this section,the term includes,but is not limited to,stormwater discharges
from industrial plant yards;immediate access roads and rail lines used or traveled by carriers of raw materials, manufactured products,
waste material,or by-products used or created by the facility; material handling sites;refuse sites;sites used for the application or disposal
of process waste waters(as defined at 40 CFR 401);sites used for the storage and maintenance of material handling equipment;sites
used for residual treatment,storage,or disposal;shipping and receiving areas;manufacturing buildings;storage areas(including tank
farms)for raw materials,and intermediate and final products;and areas where industrial activity has taken place in the past and significant
materials remain and are exposed to stormwater. For the purposes of this paragraph,material handling activities include storage,loading
and unloading,transportation,or conveyance of any raw material,intermediate product,final product,by-product or waste product.The
term excludes areas located on plant lands separate from the plant's industrial activities,such as office buildings and accompanying
parking lots as long as the drainage from the excluded areas is not mixed with stormwater drained from the above described areas.
Industrial facilities(including industrial facilities that are federally,State,or municipally owned or operated that meet the description of the
facilities listed in paragraphs 1 through 14 below)include those facilities designated under the provisions of 40 CFR 122.26(a)(1)(v).The
following categories of facilities are considered to be engaging in "industrial activity"for purposes of 40 CFR 122.26(b)(14):
1. Facilities subject to stormwater effluent limitations guidelines,new source performance standards,or toxic pollutant effluent standards
under 40 CFR Subchapter N(except facilities with toxic pollutant effluent standards which are exempted under paragraph 11 below);
2. Facilities classified as Standard Industrial Classification 24, Industry Group 241 that are rock crushing,gravel washing,log sorting,or
log storage facilities operated in connection with silvicultural activities defined in 40 CFR 122.27(b)(2)—(3)and Industry Groups 242
through 249;26(except 265 and 267),28(except 283),29,311,32(except 323),33,3441,373;(not included are all other types of
silvicultural facilities);
3. Facilities classified as Standard Industrial Classifications 10 through 14(mineral industry)including active or inactive mining
operations(except for areas of coal mining operations no longer meeting the definition of a reclamation area under 40 CFR 434.11(1)
because the performance bond issued to the facility by the appropriate SMCRA authority has been released,or except for areas of
non—coal mining operations which have been released from applicable State or Federal reclamation requirements after
December 17, 1990)and oil and gas exploration,production,processing,or treatment operations,or transmission facilities that
discharge stormwater contaminated by contact with or that has come into contact with,any overburden,raw material,intermediate
products,finished products,byproducts or waste products located on the site of such operations;(inactive mining operations are
mining sites that are not being actively mined,but which have an identifiable ownerloperator;inactive mining sites do not include sites
where mining claims are being maintained prior to disturbances associated with the extraction,beneficiation,or processing of mined
materials,nor sites where minimal activities are undertaken for the sole purpose of maintaining a mining claim);
4. Hazardous waste treatment,storage,or disposal facilities,including those that are operating under interim status or a permit under
subtitle C of RCRA;
5. Landfills,land application sites,and open dumps that receive or have received any industrial wastes(waste that is received from any
of the facilities described under this subsection)including those that are subject to regulation under subtitle D of RCRA;
6. Facilities involved in the recycling of materials,including metal scrapyards,battery reclaimers,salvage yards,and automobile
junkyards,including but limited to those classified as Standard Industrial Classification 5015 and 5093;
2A-17

FORM 2A-GLOSSARY CONTINUED
7. Steam electric power generating facilities,including coal handling sites;
8. Transportation facilities classified as Standard Industrial Classifications 40,41,42(except 4221 25),43,44,45,and 5171 which have
vehicle maintenance shops,equipment cleaning operations,or airport deicing operations.Only those portions of the facility that are
either involved in vehicle maintenance(including vehicle rehabilitation,mechanical repairs,painting,fueling,and lubrication),
equipment cleaning operations,airport deicing operations,or which are otherwise identified under paragraphs 1-7 or 9-11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system,used in the
storage treatment,recycling,and reclamation of municipal or domestic sewage,including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility,with a design flow of 1.0 mgd or more,or required to have an approved
pretreatment program under 40 CFR 403.Not included are farm lands,domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility,or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing,grading and excavation,except operations that result in the disturbance of less than five acres
of total land area.Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20,21,22,23,2434,25,265,267,27,283,285,30,31 (except 311),323,34
(except 3441),35,36,37(except 373),38,39,and 4221-25.
TOXIC POLLUTANT means any pollutant listed as toxic under section 307(a)(1)or,in the case of"sludge use or disposal practices,"any
pollutant identified in regulations implementing section 405(d)of the CWA.
TREATMENT WORKS TREATING DOMESTIC SEWAGE(TWTDS)means a POTW or any other sewage sludge or waste water
treatment devices or systems,regardless of ownership(including federal facilities),used in the storage,treatment,recycling,and
reclamation of municipal or domestic sewage,including land dedicated for the disposal of sewage sludge.This definition does not include
septic tanks or similar devices.For purposes of this definition,"domestic sewage"includes waste and waste water from humans or
household operations that are discharged to or otherwise enter a treatment works.In States where there is no approved State sludge
management program under section 405(f)of the CWA,the Regional Administrator may designate any person subject to the standards for
sewage sludge use and disposal in 40 CFR 503 as a"treatment works treating domestic sewage,"where he or she finds that there is a
potential for adverse effects on public health and the environment from poor sludge quality or poor sludge handling,use or disposal
practices,or where he or she finds that such designation is necessary to ensure that such person is in compliance with 40 CFR 503.
UPSET(defined at§122.41(n))means an exceptional incident in which there is unintentional and temporary noncompliance with
technology based permit effluent limitations because of factors beyond the reasonable control of the permittee.An upset does not include
noncompliance to the extent caused by operational error,improperly designed treatment facilities,inadequate treatment facilities,lack of
preventive maintenance,or careless or improper operation.
VARIANCE means any mechanism or provision under section 301 or 316 of the CWA or under 40 CFR 125,or in the applicable"effluent
limitations guidelines"which allows modification to or waiver of the generally applicable effluent limitation requirements or time deadlines of
the CWA.This includes provisions which allow the establishment of alternative limitations based on fundamentally different factors or on
sections 301(c),301(g),301(h),301(1),or 316(a)of the CWA.
WATERS OF THE UNITED STATES as defined at§122.2.
WHOLE EFFLUENT TOXICITY(WET)means the aggregate toxic effect of an effluent measured directly by a toxicity test.
2A-18

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO020290 Burnsville WWTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2A `yERilk Application for NPDES Permit to Discharge Wastewater
NPDES NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION 1.BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.210)(1)and(9))
1.1 Facility name
Town of Burnsville VVWTP
Mailing address(street or P.O.box)
P.O.Box 97
City or town State ZIP code
o Burnsville NC 28714
V
EContact name(first and last) Title Phone number Email address
cShane Dale Public Works Director [phone] [e-mail]
Location address(street,route number,or other specific identifier) ❑Same as mailing address
ca 812 Pine Swamp Road
City or town State ZIP code
Burnsville NC 28714
1.2 Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑r No
requirements for new dischargers.
1.3 Is applicant different from entity listed under Item 1.1 above?
❑✓ Yes ❑ No+SKIP to Item 1.4.
Applicant name
Water Quality Lab and Operations,Inc.
= Applicant address(street or P.O.box)
a
P.O.Box 1167
0
City or town State ZIP code
E Banner Elk NC 28604
yC
Contact name(first and last) Title Phone number Email address
a Paul Isenhour President [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 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
a ❑ NPDES(discharges to surface ❑ RCRA(hazardous waste) ❑ UIC(underground injection
;a
water) control)
N00020290
n ❑ PSD(air emissions) ❑ Nonattainment program(CAA) ❑ NESHAPs(CAA)
c
eJ
co
Ocean dumping MPRSA Dredge or fill CWA Section Other(specify)
y ❑ P g{ ) ❑ 9 { ❑
6 404)
EPA Form 3510-2A(Revised 3-19) Pagel

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO020290 Burnsville WWTP 0MB No.2040-0004
1.7 Provide the collections stem information requested below for the treatment works.
Municipality Population Collection System Type Ownership Status
Served Served indicate percentage)
Commercial, 4003 100 %separate sanitary sewer ❑ Own 0 Maintain
Residential %combined storm and sanitary sewer ❑ Own ElMaintain
CD ❑ Unknown ❑ Own ❑ Maintain
c %separate sanitary sewer ❑ Own ❑ Maintain
%combined storm and sanitary sewer ❑ Own ❑ Maintain
3 ❑ Unknown ❑ Own ❑ Maintain
IL %separate sanitary sewer ❑ Own ❑ Maintain
%combined storm and sanitary sewer ❑ Own ❑ Maintain
E ❑ Unknown ElOwn ElMaintain
p; %separate sanitary sewer ❑ Own ❑ Maintain
%combined storm and sanitary sewer ❑ Own ❑ Maintain
❑ Unknown ❑ Own ❑ Maintain
Total 4003
Population
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of /o
o 0
sewer line in miles) 100 /o
' 1.8 Is the treatment works located in Indian Country?
c
o ❑ Yes ❑ No
U
1.9 Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes ❑r No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
0.800 mgd
Annual Average Flow Rates Actual
Two Years Ago Last Year This Year
c o 0.6587 mgd 0.8257 mgd 0.5852 mgd
C "CD Maximum Daily Flow Rates Actual
Q Two Years Ago Last Year This Year
1.4 mgd 1.936 mgd 1.28E mgd
y 1.11 Provide the total number of effluent discharge points to waters of the United States by type.
Total Number of Effluent Discharge Points b Tvpe
a o Constructed
CD >�
Treated Effluent Untreated Effluent Combined Sewer Bypasses Emergency
T Overflows Overflows
Mn
� 1
EPA Form 3510-2A(Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
1VC0020290 Burnsville WWTP OMB No.2040-0004
Outfalls Other Than to Waters of the United States
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 United States?
❑ 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
ElContinuous
gpd ❑ Intermittent
w 1.14 Is wastewater applied to land?
❑ Yes ❑✓ No 4 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
Q Continuous or
° Location Size Average Daily Volume Intermittent
L, Applied check one
yacres d ❑ Continuous
n gpd ❑ Intermittent
r ❑ Continuous
acres
gpd ❑ Intermittent
a ❑ Continuous
acres gpd ❑ Intermittent
1.16 Is effluent transported to another facility for treatment prior to discharge?
a
[I Yes ❑✓ No 4 SKIP to Item 1.21.
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.Q.box)
City or town State ZIP code
Contact name(first and last) Title
Phone number Email address
EPA Form 3510-2A(Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105119
NCO020290 Burnsville WWTP OMB No.2040-0004
1.20 In the table below,indicate the name,address,contact information,NPDES number,and average daily flow rate of the
receiving facility.
Receivina F cilitv Data
Facility name Mailing address(street or P.O.box)
City or town State ZIP code
0
Contact name(first and last) Title
0
.e
a Phone number Email address
c NPDES number of receiving facility(if any) ❑None Average daily flow rate m da
A
c 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do not
d
have outlets to waters of the United States(e.g.,underground percolation,underground injection)?
LM
❑ Yes ❑ No 4 SKIP to Item 1.23.
1.22 Provide information in the table below on these other disposal methods.
d Information on Other Dis osal Methods
'c Disposal Annual Average
Continuous or Intermittent
Method Dis osal Site Dis osal Site Daily Discharge
Description p p Volume (check one)
❑ Continuous
acres gpd ❑ Intermittent
❑ Continuous
acres gpd ❑ 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.
m h 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
oCr
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
r Contractor name
Water Quality Labs
E (company name
L Mailing address
c street or P.O.box P.O. Box 1167
3 City,state,and ZIP Banner Elk,NC 28604
code
last)
tact name(first and Paul Isenhour
Phone number [phone]
Email address [e-mail]
Operational and Operations&Maintenance
maintenance
responsibilities of
contractor
EPA Form 3510-2A(Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105119
NCO020290 Burnsville WWTP OMB No.2040-0004
SECTIONDD • •' • i
o Outfalls to Waters of the United States
c 2A Does the treatment works have a design flow greater than or equal to 0.1 mgd?
M
c 0 Yes ❑ No 4 SKIP to Section 3.
`0 2.2 Provide the treatment works'current average daily volume of inflow Average Dairy Volume of Inflow and Infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Volume of daily l&I is unknown.However,a study undertaken by the town by engineering firm McGill and Associates
indicated that as much as 64%of the flow at the plant over a 1-year period may have been I&I.The Town is working with
ar the same firm and DWR on an established SOC to complete necessary upgrades for I&I mitigation.
c
2.3 Have you attached a topographic map to this application that contains all the required information?(See instructions for
C u specific requirements.)
`C" 10
o
o ❑r Yes ❑ No
E 2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
c a,
(See instructions for specific requirements.)
o ❑✓ Yes ❑ No
2.5 Are improvements to the facility scheduled?
0 Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
0
'a 1 Refurbish west side sewer interceptor
m
E
a. 2.Refurbish or replace east side sewer interceptor
E
0
3.New gear drive for 0.5 MGD side of the plant
'e
m
0 4.Upgrade 0.5 MGD side of the plant to include new headworks,blower electric upgrades,and construction of a new lab
R 2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Im rovements
E Affected Attainment of
Scheduled Outfalls Begin End Begin Operational
o Improvement Construction Construction Discharge Level
(from above) (list outfall (MM/DDNYYY) (MM/DD/YYYY) (MM/DD/YYYl�
number) (MM/DD/YYYY
1 001 09/30/2024
m
y 2. 001
3. 001 05/25/2024
4. 001 12/31/2026
2.7 Have appropriate permits/clearances concerning other federal/state requirements been obtained?Briefly explain your
response.
El Yes ❑ No ❑ None required or applicable
Explanation:
DWR is aware of the Town's planned and in-process upgrades to address I&I.For item 4,the project is to be initiated by
2024 and completed by 2026,so no permits are required at this time.Item 2 is pending fund acquisition.
EPA Form 3510-2A(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0020290 Burnsville WWTP OMB No.2040-0004
SECTION • ' • ON 1 1
3.1 Provide the following information for each outfall.(Attach additional sheets if you have more than three outfalls.)
Outfall Number 001 Oultall Number Outfall Number
State North Carolina
County Yancey
3
City or town Burmsville
0
c
s Distance from shore
a
•L
Depth below surface
Average daily flow rate 0.6889 mgd mgd mgd
Latitude 35' 54 17' "
Longitude 82 19' 59" "
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.
d
0 3.3 If so,provide the following information for each applicable outfall.
t
w Outfall Number Outfall Number Outfall Number
0
Number of times per year
° discharge occurs
a Average duration of each
`o discharge(specify units
Average flow of each
R discharge mgd mgd mgd
CAI Months in which discharge
occurs
3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes [] No 4 SKIP to Item 3.6.
d 3.5 Briefly describe the diffuser type at each applicable outfall.
a
Outfall Number Outfall Number Outfall Number
d
3
L7
v� 3 6 Does the treatment works discharge or plan to discharge wastewater to waters of the United States from one or more
d � discharge points?
w ❑ Yes ❑ No+SKIP to Section 6,
EPA Form 3510-2A(Revised 3-19) Page 6

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
NCO020290 Burnsville WWTP OMB No.2040-0004
3.7 Provide the receiving water and related information if known for each outfall.
Outfall Number 001 Outfall Number Outfall Number
Receiving water name Cane River
Name of watershed,river, Cane River
0
or stream system
Q U.S.Soil Conservation
Service 14-digit watershed
is code
=' Name of state
t6 French Broad River Basin
a�
management/river basin
U.S.Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow(acute) cfs 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 pr vided 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)
c
O
Q, Design Removal Rates by
Outfall
U)
d
BODs or CBODs 85 % % %
w
TSS 85 % % %
L
F
❑Not applicable ❑Not applicable ❑ Not applicable
Phosphorus 75 % /o° o
/o
❑Not applicable ❑Not applicable ❑ Not applicable
Nitrogen 75 % ° °
Other(specify) 0 Not applicable ❑Not applicable ❑Not applicable
EPA Form 3510-2A(Revised 3-19) Page 7

EPA Identification Number NPIJES Permit Number Facility Name Form Approved 03/05119
NCO020290 Burnsville WWTP OMB No.2040-0004
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.
Chlorination and Dechlorination
w
C
_
0
c�
o Outfall Number Outfall Number Outfall Number
a Disinfection type
ea
H
d
G
Seasons used
d
E
Dechlorination used? ❑ Not applicable ❑ Not applicable ❑ Not applicable
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package?
El 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 3 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 001 Outfall Number Outfall Number
Acute Chronic Acute Chronic Acute Chronic
Number of tests of discharge o 16
water
Number of tests of receiving 0 0
water
3,13 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes ❑ No 4 SKIP to Item 3,16.
c 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?
F ❑ Yes-*Complete Table B,including chlorine. ❑ No+ Complete Table B,omitting chlorine.
3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
w ❑✓ Yes ❑ No
3.16 Does one or more of the following conditions apply?
• The facility has a design flow greater than or equal to 1 mgd.
• The POTW has an approved pretreatment program or is required to develop such a program.
• The NPDES permitting authority has informed the POTW that it must sample for the parameters in Table C,must
sample other additional parameters(Table D),or submit the results of WET tests for acute or chronic toxicity for
each of its discharge outfalls(Table E).
O Yes+ Complete Tables C,D,and E as ❑ No 4 SKIP to Section 4.
applicable.
3.17 Have you completed monitoring for all applicable Table C pollutants and attached the results to this application
package?
❑✓ Yes ❑ No
3.18 Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
attached the results to this application package?
No additional sampling required by NPDES
El Yes 0permitting authority.
EPA Form 3510-2A(Revised 3-19) Page 8

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105119
NCO020290 Burnsville WUVTP OMB No.2040-0004
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 ❑ 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?
0 Yes ❑ No+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
MMIDDNM
Submitted via eDMR.Second species test results are included in Table E.
d
a
c
.c
0
0 3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
o toxicity?
RM
c ❑ Yes No 4 SKIP to Item 3.26.
3.23 Describe the cause(s)of the toxicity:
c
d
w
3.24 Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 3 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 permittinq authority.
SECTION -D•
4.1 Does the POTW receive discharges from SIUs or NSCIUs?
❑ Yes ❑✓ No 4 SKIP to Item 4.7.
49 4.2 Indicate the number of SIUs and NSCIUs that discharge to the POTW.
Number of SIUs Number of NSCIUs
N
Q
4.3 Does the POTW have an approved pretreatment program?
iO ❑ Yes ❑ No
s
-o
4.4 Have you submitted either of the following to the NPDES permitting authority that contains information substantially
m identical to that required in Table F:(1)a pretreatment program annual report submitted within one year of the
application or(2)a pretreatment program?
R
u
H ❑ Yes ❑ No 4 SKIP to Item 4.6.
c
W 4.5 Identify the title and date of the annual report or pretreatment program referenced in Item 4.4.SKIP to Item 4.7.
c
4.6 Have you completed and attached Table F to this application package?
❑ Yes ❑ No
EPA Form 3510-2A(Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03105/19
NC0020290 Burnsville WWTP OMB No.2040-0004
4.7 Does the POTW receive,or has it been notified that it will receive,by truck,rail,or dedicated pipe,any wastes that are
regulated as RCRA hazardous wastes pursuant to 40 CFR 261?
❑ Yes ❑r No 4 SKIP to Item 4.9.
4.8 If yes,provide the folio win information:
Annual
Hazardous Waste Waste Transport Method Amount of units
Number (check all that apply) Waste
Received
❑ Truck ❑ Rail
3 ❑ Dedicated pipe ❑ Other(specify)
0
t�
o ❑ Truck ❑ Rail
❑ Dedicated pipe ❑ Other(specify)
0
R
El Truck El Rail
-a
❑ Dedicated pipe ❑ Other(specify)
c
e�
a
d
4.9 Does the POTW receive,or has it been notified that it will receive,wastewaters that originate from remedial activities,
including those undertaken pursuant to CERCLA and Sections 3004(7)or 3008(h)of RCRA?
.c
❑ Yes ❑✓ No 4 SKIP to Section 5.
4.10 Does the POTW receive(or expect to receive)less than 15 kilograms per month of non-acute hazardous wastes as
= specified in 40 CFR 261.30(d)and 261.33(e)?
❑ Yes 4 SKIP to Section 5. ❑ No
4.11 Have you reported the following information in an attachment to this application:identification and description of the
site(s)or facility(ies)at which the wastewater originates;the identities of the wastewaters hazardous constituents;and
the extent of treatment,if any,the wastewater receives or will receive before entering the POTW?
❑ Yes ❑ No
SECTION • OVERFLOWS(40
5.1 Does the treatment works have a combined sewer system?
e ❑✓ Yes ❑ No-SKIP to Section 6.
JS
"a 5.2 Have you attached a CSO system map to this application?(See instructions for map requirements.)
Q- ❑ Yes ❑ No
0
5.3 Have you attached a CSO system diagram to this application?(See instructions for diagram requirements.)
U
❑ Yes ❑ No
EPA Form 3510-2A(Revised 3-19) Page 10

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/051119
NCO020290 Burnsville WWTP OMB No.2040-0004
5.4 For each CSO outfall,provide the following information. Attach additional sheets as necessary.)
CSO Outfall Number CSO Outfall Number CSO Outfall Number
= City or town
a
a State and ZIP code
c County
75 Latitude
0
CA cA Longitude
Distance from shore ft. ft. ft.
Depth below surface ft.
5.5 Did the POTW monitor any of the following items in the past year for its CSO outfalls?
CSO Outfall Number CSO Outfall Number CSO Outfall Number
Rainfall ❑Yes ❑ No ❑ Yes ❑ No ❑Yes ❑No
o CSO flow volume ❑Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑No
w
CSO pollutant ❑ Yes ❑ No ❑Yes ❑ No ❑Yes ❑No
0 concentrations
Receiving water quality ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑ No
CSO frequency ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑ No
Number of storm events ❑Yes ❑No ❑Yes ❑No ❑ Yes ❑No
5.6 Provide the following information for each of your CSO outfalls.
CSO Outfall Number CSO Outfall Number_ CSO Outfall Number
Number of CSO events in events events events
U the past year
to
c Average duration per hours hours hours
event ❑Actual or❑ Estimated ❑Actual or❑ Estimated ❑Actual or❑ Estimated
d
million gallons million gallons million gallons
0 Average volume per event
❑Actual or❑Estimated ❑Actual or❑Estimated ❑Actual or❑Estimated
Minimum rainfall causing inches of rainfall inches of rainfall inches of rainfall
a CSO event in last year ❑Actual or❑ Estimated ❑Actual or❑Estimated 1 ❑Actual or❑Estimated
EPA Form 3510-2A(Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05119
NC0020290 Burnsville WWTP OMB No.2040-0004
5.7 Provide the information in the table below for each of your CSO outfalls.
CSO Outfall Number_ CSO Outfall Number CSO Outfall Number
Receiving water name
Name of watershed/
H streams stem
a; U.S.Soil Conservation ❑Unknown ❑Unknown ❑Unknown
Service 14-digit
I watershed code
'> if known
Name of state
management/river basin
U.S.Geological Survey ❑Unknown ❑ Unknown ❑Unknown
B-Digit Hydrologic Unit
Code if known
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
examples)
SECTION • ,
6.1 In Column 1 below,mark the sections of Form 2A that you have completed and are submitting with your application.For
each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note that not
all applicants are required to provide attachments.
Column 1 Column 2
❑ Section 1:Basic Application ❑ w/variance request(s) wl additional attachments
Information for All Applicants
❑
Q Section 2:Additional ❑ w/topographic map 0 wl process flow diagram
Information ❑ w/additional attachments
0 w/Table A ❑ wl Table D
Section 3:Information on 0 w/Table B w/Table E
Effluent Discharges
E 0 w/Table C ❑ wl additional attachments
R Section 4: Industrial r
❑ wl SIU and NSCIU attachments ❑ wl Table F
❑ Discharges and Hazardous
a Wastes El wl additional attachments
V
❑ Section 5:Combined Sewer Elwl CSO map Elwl additional attachments
m Overflows
� ❑ wl CSO system diagram
a Section 6:Checklist and
'�° ❑ Certification Statement ❑ wl attachments
Ul
M 6.2 Certification Statement
d
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 orpersons 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 Sa ).e_
) Official title , 1
54Rn e- far rc, G)v f kS Drrejer
Signature Date signed
3
EPA Form 3510-2A(Revised 3-19) Page 12

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