NC0029602_Renewal (Application)_20230828

ROY COOPER
Governor
ELIZABETH S. BISER
Secretory
RICHARD E. ROGERS, JR.
Director
Donald Hawks
Yadkin County Board of Education
121 Washington St
Yadkinville, NC 27055-7725
Subject: Permit Renewal
Application No. NCO029602
Forbush Elementary School WWTP
Yadkin County
Dear Permittee:
NORTH CAROLINA
Environmental Quality
August 28, 2023
The Water Quality Permitting Section acknowledges the August 28, 2023 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https•//deq nc gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
ec: WQPS Laserfiche File w/application
Sinceerrely�, du"AK/
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
jjg�D—EQ--
ps�,�V
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road Suite 300 I Winston-Salem. North Carolina 27105
336.776.9800

Yadkin County Board of Education
Renewal request for discharge wastewater
treatment facility:
Forbush Elementary School WWTP
1400 Bloomtown Road,
East Bend, NC 27018
Permit # NCO029602
AUG 2 8 2023
_.1
NCDEo/nwR/NP®ES

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029602
Forbush Elementary School
Modified March 2021
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
Form
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
NPDES
the instructions may result in denial of the application.
SECTION•N
INFORMATION FOR i
Facility name
1.1
Forbush Elementary School
Mailing address (street or P.O. box)
121 Washington St
City or town
State
ZIP code
o
Yadkinville
NC
27055
EContact
name (first and last)
Title
Phone number
Email address
Mitchell T Long
ORC
[phone]
[e-mail].i
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
1400 Bloomtown Road
W
City or town
State
ZIP code
East Bend
NC
27018
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑✓ No
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
❑ Yes 0 No SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
a
a
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Q
CL
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 and applicant
❑ Facility 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
water)
control)
E
NCO029602
0
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
w
y
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
X
404)
w
Page 1

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029602
Forbush Elementary School
Modified March 2021
1.7
Provide the collections stem information
requested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served
Served
indicate percentage)
i
234
100 % separate sanitary sewer
b7 Own EI Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
4)
d
El Unknown
El Own El Maintain
% separate sanitary sewer
❑ Own ❑ Maintain
r
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
0
% separate sanitary sewer
❑ Own ❑ Maintain
CL
% combined storm and sanitary sewer
❑ Own ❑ Maintain
M
❑ Unknown
❑ Own ❑ Maintain
% separate sanitary sewer ❑ Own ❑ Maintain
�.
% combined storm and sanitary sewer ❑ Own ❑ Maintain
`"
❑ Unknown ❑ Own ❑ Maintain
Q
Total
234
d
Population
Served
Combined Storm and
Separate Sanitary Sewer System Sanitary Sewer
Total percentage of each type of
100 %
%
sewer line in miles
Z7
1.8
Is the treatment works located in Indian Country?
c
❑ Yes No _
r-
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
c
❑ Yes ❑ No
1.10
Provide design and actual flow rates in the designated spaces.
Desi n Flow Rate
0.006 mgd
w
Annual Average Flow Rates Actual
cc
Two Years Ago
Last Year
This Year
00.002
mgd
0.002 mgd
o.aoz mgd
y `L
Maximum Daily Flow Rates Actual
d
Two Years Ago
Last Year
This Year
0.002 mgd
0.002 mgd
0.002 mgd
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by t e.
Total Number of Effluent Discharge Points b Type
o a,
0
Combined Sewer
Constructed
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Overflows
U
tq
G
1
Page 2

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029602 Forbush Elementary School Modified March 2021
Outfalls Other Than to Waters of the State of North Carolina
1.12 Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes ❑✓ No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Im oundment Location and Discharge Data
Average Daily Volume Continuous or Intermittent
Location Discharged to Surface (check one)
Impoundment
❑ Continuous
gpd ❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
1.14 Is wastewater applied to land?
❑ Yes 0 No 4 SKIP to Item 1.16.
1.15 Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Average Daily Volume Continuous or
Location Size Applied Intermittent
pp I'k-1, n nl
❑ Continuous
acres
gpd
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
❑ Continuous
acres
gpd
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
❑ Yes © No 4 SKIP to Item 1.21.
1.17 1 Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18 Is the effluent transported by a party other than the applicant?
❑ Yes ❑✓ No 4 SKIP to Item 1.20.
1.19 Provide information on the transporter below.
Transporter Data
Entity name Mailing address (street or P.O. box)
City or town State ZIP code
Contact name (first and last) Title
Phone number Email address
Page 3

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029602
Forbush Elementary School
Modified March 2021
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
facility.
—receiving
Receiving F cility Data
Facility name
Mailing address (street or P.O. box)
a
a�
City or town
State
ZIP code
0
Contact name (first and last)
Title
0
m
Phone number
Email address
a"
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
0
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
0
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
❑ Yes ❑ No -+ SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
o j
I Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
I Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
❑ Continuous
acres
gpd
❑ Intermittent
O
ElContinuous
acres
gpd
❑ Intermittent
❑ Continuous
acres
gpd
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
h
Discharges into marine waters (CWA Water quality related effluent limitation (CWA Section
❑ ❑
Cr
Section 301(h)) 302(b)(2))
❑✓ Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑r 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
o
Contractor name
Lentz Septic Tank Service
com an name
Mailing address
418 Lentz Road,
E
0
street or P.O. box
o
City, state, and ZIP
Statesville, NC 28625
cc
code
Contact name (first and
c03
last)
Jason Lentz
Phone number
[phone]
Email address
[e-mail]
Operational and
Clean Sludge Storage Tanks at
maintenance
the end of School Year.
responsibilities of
Usually in June.
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029602 Forbush Elementary School Modified March 2021
SECTION 2. ADDITIONAL INFORMATION (40 CFR 122.216)(1) and (2))
o Outfalls to Waters of the State of North Carolina
Lc'-: `
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
rn
d
❑ Yes ❑ No 4 SKIP to Section 3.
_0
0
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
gpd
and infiltration.
ZE
Indicate the steps the facility is taking to minimize inflow and infiltration.
v
v
3
0
c
s
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
R a
specific requirements.)
0
o
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
0 R
(See instructions for specific requirements.)
a"
o
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3,
Briefly list and describe the scheduled improvements.
0
w
E
d
a
2.
E
0
d
3.
-a
u�
4.
M
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled
or Actual Dates of Completion for Im rovements
Q
Scheduled
Affected
Outfalls
Begin
End
Begin
Attainment of
Operational
0
Improvement
(list l
Construction
Construction
Discharge
Level
CL
E
_
(from above)
number)
)
(MM/DD(YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MM/DD/YYYY
m
m
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029602 Forbush Elementary School Modified March 2021
SECTION•' • ON I 1
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 1 I
Outfall Number
Outfall Number
State
NC
N
County
Yadkin
City or town
East Bend
0
Distance from shore
10560 ft.
ao
Depth below surface
3 ft.
ft.
ft.
d
0
Average daily flow rate
.002 mgd
mgd
mgd
Latitude
36° oy 34"
Longitude
so 2Y
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
0
0 Yes ❑ No 4 SKIP to Item 3.4.
m
3.3
If so, provide the following information for each applicable outfall.
t
H
Outfall Number 001
Outfall Number
Outfall Number
Number of times per year
170
c
discharge occurs
a
Average duration of each
10 hours
`o
discharge (specify units
oAverage
flow of each
002 mgd
mgd
mgd
y
discharge
yMonths
in which discharge
Jan. - May Aug. -Dec.
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.
3.5
describe the diffuser type at each applicable outfall.
m
—Briefly
-
Outfall Number
Outfall Number
FOutfallNumber
m
H
---
-�
— - - --- ---
I
�
0
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
vi
=i
3 6
one or more discharge points?
0 Yes ❑ No 4SKIP to Section 6.
Page 6

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029602 Forbush Elementary School Modified March 2021
3.7 Provide the receiving water and related information if known for each outfall.
Outfall Number
Outfall Number
Outfall Number
Receiving water name
Logan Creek
Name of watershed, river,
Sub Basin 03 07 02
0
or stream system
L
U.S. Soil Conservation
y
Service 14-digit watershed
n
code
54
Name of state
management/river basin
Yadkin Pee Deer River
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 Doi
Outfall Number
Outfall Number
Highest Level of
❑ Primary
❑ Primary
❑ Primary
Treatment (check all that
El Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
❑ Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
c
0
o.
Design Removal Rates by
Outfall
y
d
a
BODs or CBODs
70 %
%
%
c
d
;_
TSS
70 %
%
%
t=
0 Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
90.6 %
%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029602
Forbush Elementary School
Modified March 2021
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
Ultra Violet disinfection is used through all seasons.
m
c
w
c
o
_.
Outfall Number 1
Outfall Number
Outfall Number
0
n.
Disinfection type
Ultraviolet Light
U
N
61
Seasons used
all
d
E
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
❑ Yes
❑ Yes
❑ Yes
0 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 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
by outfall number or of the receiving water near the discharge points.
—discharges
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
w
Number of tests of discharge
w
water
Number of tests of receiving
water
d
u.j
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 Complete Table B, including chlorine. r❑ No -+ Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
❑ Yes ✓❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results to this application package?
❑ Yes � No additional sampling required by NPDES
permittingauthority.
Page 8

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029602
Forbush Elementary School
Modified March 2021
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
❑ Yes 0 No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MMrooy�
_ - — - -
m
_
w
O
R
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?
a'
❑ Yes ❑ No SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
_
w
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls and attached the results to the application package?
❑ Yes 0 Not applicable because previously submitted
information to the NPDES permittin authority.
Page 9

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029602 Forbush Elementary School Modified March 2021
SECTION. CHECKLIST
AND CERTIFICATION STATEMENT (40
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
6.1
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
❑ wl variance request(s) ❑ wl additional attachments
Information for All Applicants
❑ Section 2: Additional
❑ wl topographic map ❑ wl process flow diagram
Information
❑ wl additional attachments
2 wl Table A ❑ w/ Table D
❑ Section 3: Information on
© w/ Table B ❑ w/ additional attachments
Effluent Discharges
E
❑ w/ Table C
m
a
Section 4: Not Applicable
c
0
w
`—
Section 5: Not Applicable
m
Section 6: Checklist and
0
❑ wl attachments
Certification Statement
w
6.2
Certification Statement
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Mitchell Thomas Long
ORC
Signature
Date signed
&A, W
08/21/2023
P
Page 10

Pollutant
Biochemical oxygen demand
NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NCO029602 Forbush Elementary School 1 Modified March 2021
Maximum Daily Discharge
Valuei Units
Average Daily Discharge---------------
_
Value � Units Number of
samples
Analytical ML or MDL
Method' (include units)
O ML
o BODs or ❑ CBODs
45.0
mg/L
0
mg/I
36
SM521OB-2016
❑ MDL
(report one
Fecal coliform
0
#/100ml
0
#/100ml
36
Colilert-18
O ML
❑ MDL
7-1
Design flow rate
0.006
MGD
0.002
MGD
36
3
s
pH (minimum)
>6.0
standard:�
o
pH (maximum)
<9.0
standards
Temperature (winter)
No limit
C
Temperature (summer)
No limit
C
Total suspended solids (TSS)
45.0
mg/I
4.15
mg/I
36
SM 254OD-2015
2 ML
❑ MDL
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCO029602 Forbush Elementary School 1
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant
Analytical
ML or MDL
Number
Value
Units
Value
Units
Method'
(include units)
Sam les
Ammonia (as N)
No Limit
0.52
mg/1
36
O ML
❑ MDL
Chlorine
❑ ML
total residual, TRC 2
❑ MDL
Dissolved oxygen
No Limit
8.69
mg/I
36
21 ML
❑ MDL
Nitrate/nitrite
El ML
❑ MDL
Kjeldahl nitrogen
OML
0 MDL
Oil and grease
0 ML
❑ MDL
Phosphorus
❑ ML
❑ MDL
Total dissolved solids
0 ML
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NCO029602 Forbush Elementary School
Modified Application Form 2A
Modified March 2021
101 • 1 •
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant
Number of Method' (include units)
Value Units Value Units
Samples
Metals, Cyanide, and Total Phenols
Hardness (as CaCO3)
El ML
❑MDL
Antimony, total recoverable
❑ MDL
Arsenic, total recoverable
El ML
❑MDL
Beryllium, total recoverable
o MLDL
Cadmium, total recoverable
❑ ML
❑ MDL
Chromium, total recoverable
❑ ML
❑ MDL
Copper, total recoverable
OML
❑ MDL
Lead, total recoverable
❑ ML
❑ MDL
Mercury, total recoverable
OML
❑ MDL
Nickel, total recoverable
❑ ML
❑ MDL
Selenium, total recoverable
El ML
❑ MDL
Silver, total recoverable
El ML
❑ MDL
Thallium, total recoverable
❑ ML
❑ MDL
Zinc, total recoverable
El ML
❑ MDL
Cyanide
OML
❑ MDL
Total phenolic compounds 0 ML
--� ❑ MDL
Volatile Organic Compounds
---
Acrolein —-- --
- --
--- ---
❑ ML
❑ MDL
Acrylonitrlle
_
_ _ _
OML
❑ MDL
Benzene
_
❑ ML
❑MDL
Bromoform
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NC0029602 Forbush Elementary School
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' I (include units)
Value Units Value Units Samples
Carbon tetrachloride
El ML
❑ MDL
Chlorobenzene
_ _
El ML
El MDL
Chlorodibromomethane
❑ MElI
MDL
❑ ML
Chloroethane
❑ MDL
2-chloroethylvinyl ether
DIVIL
❑ MDL
❑ MIL
Chloroform
I
❑ MDL
Dichlorobromomethane
_
❑ ML
❑MDL
1,1-dichloroethane
❑ ML
❑MDL
1,2-dichloroethane
_
❑ ML
❑ MDL
trans-1,2-dichloroethylene
0 MIL
❑ MDL
1,1-dichloroethylene
El IVIL
❑ MDL
1,2-dichloropropane
El ML
❑ MDL
1,3-dichloropropylene
OML
❑ MDL
Ethylbenzene
L1 MIL
❑ MDL
Methyl bromide
El ML
❑ MDL
Methyl chloride
F-1 ML
❑ MDL
El ML
Methylene chloride
❑ MDL
1,1,2,2-tetrachloroethane
El ML
❑ MDL
Tetrachloroethylene
Ll ML
❑ MDL
Toluene
El ML
❑ MDL
❑ ML
1,1,1-trichloroethane
❑ MDL
❑ ML
1,1,2-trichloroethane
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 14

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NC0O29602 Forbush Elementary School
Modified March 2021
lot 14 1 •@
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' I (include units)
Value Units Value Units
Samples
Trichloroethylene
E-1 ML
El MDL
❑ ML
Vinyl chloride ❑ MDL
Acid -Extractable Compounds
p-chloro-m-cresol
0 ML
❑ MDL
2-chlorophenol
El ML
❑ MDL
2,4-dichlorophenol
_
0 ML
❑ MDL
2,4-dimethylphenol
El ML
❑ MDL
4,6-dinitro-o-cresol
❑ ML
❑ MDL
2,4-dinitrophenol
OML
❑ MDL
2-nitrophenol
OML
❑ MDL
4-nitrophenol
0 ML
❑ MDL
Pentachlorophenol
OML
❑ MDL
Phenol
El ML
❑ MDL
2,4,6-trichlorophenol
0 ML
❑ MDL
Base -Neutral Compounds
0 ML
Acenaphthene
❑ MDL
Acenaphthylene
OML
❑ MDL
❑ ML
Anthracene
❑ MDL
❑ ML
Benzidine
❑ MDL
OML
Benzo(a)anthracene
❑ MDL
❑ ML
Benzo(a)pyrene
❑ MDL
❑ ML
3,4-benzofluoranthene
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
NC0O29602 Forbush Elementary School
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge
Average Daily Discharge
j
Pollutant i�
—
Analytical
ML or MDL
Number of Method'
include units )
Value Units
Value Units
Samples _
Benzo(ghi)perylene
❑ ML
❑ MDL
El ML
Benzo(k)fiuoranthene
❑ MDL
OML
Bis (2-chloroethoxy) methane
❑ MDL
0 ML
Bis (2-chloroethyl) ether
❑ MDL
Bis (2-chloroisopropyl) ether
11 ML
❑ MDL
Bis (2-ethylhexyl) phthalate
0 MIL
❑ MDL
4-bromophenyl phenyl ether
11 ML
❑ MDL
Butyl benzyl phthalate
OMIL
❑ MDL
2-chloronaphthalene
OML
❑ MDL
4-chlorophenyl phenyl ether
0 ML
❑ MDL
OML
Chrysene
❑ MDL
di-n-butyl phthalate
OML
❑ MDL
di-n-octyl phthalate
Ll ML
❑ MDL
Dibenzo(a,h)anthracene
OML
❑ MDL
1,2-dichlorobenzene
❑ ML
❑ MDL
1,3-dichlorobenzene
El ML
❑ MDL
❑ ML
1,4-dichlorobenzene
❑ MDL
3,3-dichlorobenzidine
❑ ML
❑ MDL
Diethyl phthalate
OML
❑ MDL
Dimethyl phthalate
El ML
❑ MDL
❑ ML
2,4-dinitrotoluene
❑ MDL
❑ ML
2,6-dinitrotoluene
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 16

EPA Identification Number I NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO029602 Forbush Elementary School
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units Sample-.
❑ ML
1,2-diphenylhydrazine
❑ MDL
❑ ML
Fluoranthene
❑ MDL
❑ ML
Fluorene
❑MDL
❑ ML
Hexachlorobenzene
❑ MDL
Hexachlorobutadiene
❑ ML
❑ MDL
Hexachlorocyclo-pentadiene
0 ML
❑ MDL
Hexachloroethane
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
0 ML
❑ MDL
❑ ML
Isophorone
❑ MDL
Naphthalene
El ML
❑ MDL
❑ ML
Nitrobenzene
❑ MDL
N-nitrosodi-n-propylamine
0 ML
❑ MDL
N-nitrosodimethylamine
0 MIL
❑ MDL
N-nitrosodiphenylamine
OML
❑ MDL
❑ ML
Phenanthrene
❑ MDL
❑ ML
Pyrene
❑ MDL
❑ ML
1,2,4-tdchlorobenzene
❑ MDL
t Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A (Revised 3-19) Page 17

NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO029602 Forbush Elementary School
Modified March 2021
Dischar a
Maximum paily Discharge Average DailyNumber
Pollutant --- of
Analytical ML or MDL
y
(list) Value Units Value Units
Method' (include units)
Sample
❑ No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
-
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or requlrea
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18

91
NCO029602 - Forbush Elementary School WWTP
County:
Yadkin
Latitude:
36007'34"
Longitude:
80029'51"
Sub -Basin:
03-07-02
Stream Class:
WS-IV
Receiving Stream: Logan Creek
Facility'
Location