NC0020737_application_20230306

Kings Mounrain RECEIVED
- NORTH CAROLINA hzi*V. &d MAR 0 6 2023
NC DENR / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: NPDES Permit # NC 0020737 RENEWAL
Dear Permit Writer,
NCDEQ/DWR/NPDES
CERTIFIED MAIL: 7020 3160 0001 4732 6990
The City of Kings Mountain, Pilot Creek WWTF desires to renew NPDES permit # NC0020737. All required
documentation is included in the attached renewal application. This facility is a 6MGD Activated Sludge treatment
unit. Solids are removed by the belt filter press and hauled to the Cleveland County Landfill. TCLIP testing has been
completed and acceptable.
Since the last renewal of our NPDES permit, we have not had any changes to the operations of the facility. The
facility has however increased technology in the SCADA system. SCADA systems are located at the influent and
throughout the facility to monitor any event which needs immediate assisting. Employee are to report to the SCADA
call within 30 minutes of receiving the SCADA alarm. The following operations are recorded daily and alarms are set
in the event operations are not normal:
• Pretreatment: Monitoring of pH in the four major pump stations
• Head -works: Pump operation status
• Influent: Flow and pH
• Basins: pH, DO, return rates and blowers operations status
• Chlorine Contact chambers (3): Feed rates and flow
• Sulfur dioxide: Feed rate
• Effluent: Flow, pH and DO
• Digester holding tank volumes
Concerning the requirement for 24-hour manned operations of our wastewater treatment plant, our plant is not now
manned continuously by a certified operator. However, an operator is at the plant a minimum of 4 hours every day,
including holidays. We do have what we believe, and our experience has proven adequate, measures in place to
protect both the plant and the environment.
We hereby apply for a waiver of this rule and submit information which we believe will demonstrate the adequacy of
our system to prevent our having to add a minimum of four persons to our staff to act as watchmen.
Thank you for your consideration in the above matters. If you need additional information, please call 704-734-4525.
Sincerely,
Richelle Putnam, WWTP Supervisor/ORC
City of Kings Mountain I Pilot Creek WWTP I PO Box 429 1 Kings Mountain, NC 28086
Phone: [phone] [e-mail] I www.cityofkm.com

EPA Identification Number
100000058965
NPDES Permit Number
NCO020737
Facility Name
Pilot Creek WWTF
Form Approved 03/05/19
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
2A
PA i�EApplication for NPDES Permit to Discharge Wastewater
NPDES
NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION
1. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122,21(j)(1) and (9))
1.1 Facility name
Pilot Creek Wastewater Treatment Facility
Mailing address (street or P.O. box)
PO Box 429
City or town
State
ZIP code
0
Kings Mountain
NC
28086
:�
EContact
name (first and last)
Title
Phone number
Email address
Richelle Putmam
WWTP Supervisor/ORC
[phone]
richelle.putnam [e-mail]
_
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
cc
200 Potts Creek Road
LL
City or town
State
ZIP code
Kings Mountain
NC
28086
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission 0 No
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
❑ Yes 0 No 4 SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
0
:.r
0
E
0
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
a
Q.
`r
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑ Owner ❑ Operator 0 Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
2 Facility ❑ 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
water)
control)
E
_
NCO020737
0
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
_
w
CD
N
E] Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
w
404)
EPA Form 3510-2A (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
OMB No. 2040-0004
1.7
Provide the collections stem information requested below for the treatment works.
Municipality
Population
Collection System Type
Served
Served
indicate percentage)
Ownership Status
-a
4,900
6,242
100 % separate sanitary sewer
ID Own 0 Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
cn
ElUnknown
ElOwn ElMaintain
c
% separate sanitary sewer
❑ Own ElMaintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
a
❑ Unknown
❑ Own ❑ Maintain
a
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
°'.
% separate sanitary sewer ❑ Own ❑ Maintain
U)
% combined storm and sanitary sewer ❑ Own ❑ Maintain
o
ElUnknown ElOwn El Maintain
Total 11,142
Population
�i
Served
Separate Sanitary Sewer System Combined Storm and
SanitaSewer0
Total percentage of each type of
sewer line in miles
100 %
'
1.8
Is the treatment works located in Indian Country?
o
❑ Yes 0 No
0
a
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes 21 No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
6.0 mgd
U)
Annual Average Flow Rates Actual
9
Two Years Ago
Last Year
This Year
c 0
1.6446 mgd
1.5263 mgd
1.4606 mgd
Maximum Daily Flow Rates Actual
o
Two Years Ago
Last Year
This Year
4.0575 mgd
3.4665 mgd
2.832 mgd
1.11
Provide the total number of effluent discharge points to waters of the United States by type.
0
Total Number of Effluent Discharge Points by Type
a0 >
"�'
Treated Effluent
Untreated Effluent
Combined Sewer
Bypasses
Constructed
Emergency
•Q
Overflows
Overflows
U)
1-C
0
0
0
0
EPA Form 3510-2A (Revised 3-19) Page 2

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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 21 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
Location
Discharged to Surface
Continuous or Intermittent
Impoundment
(check one)
ElContinuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
gp d
El Continuous
i,
❑ Intermittent
w
1.14
Is wastewater applied t0 land?
❑ Yes 0 No 4 SKIP to Item 1.16.
0
1.15
Provide the land application site and dischar a data requested below.
_T
Land Application Site and Discharge Data
G
Location
Size
Average Daily Volume
Continuous or
Intermittent
a�
Applied
check one
y
acres
d
gpd
❑ Continuous
0
❑ Intermittent
-�
acres
gpd
El Continuous
0
❑ Intermittent
acres
d
gpd
El Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
o
❑ 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 0 No + 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
EPA Form 3510-2A (Revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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.
Receiving F
cillity Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
t
Phone number
Email address
c
CL
NPDES number of receiving facility (if any) ElNone
Average daily flow rate mgd
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
0
have outlets to waters of the United States (e.g., underground percolation, underground injection)?
❑ Yes ❑ No 4 SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
)
Information on Other
Disposal Methods
0
Disposal
Method
Location of
Size of
Annual Average
Daily Discharge
Continuous or Intermittent
Description
Disposal Site
Disposal Site
Volume13
(check one)
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
ElContinuous
❑ Intermittent
acres
gpd
ElContinuous
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
❑ Discharges into marine waters (CWA © Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
❑ Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes 0 No +SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
0
0
Contractor name
cc
(company name
E
0
Mailing address
c
street or P.O. box
o
City, state, and ZIP
code
L
c
Contact name (first and
c.>
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
EPA Form 3510-2A (Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
100000058965 NCO020737 Pilot Creek WWTF OMB No. 2040-0004
SECTIONADDITIONAL INFORMATION41 and
c Outfalls to Waters of the United States
a,
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
o
❑ Yes ❑ No 4 SKIP to Section 3.
0
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
and infiltration.
312,520 gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
W 2020= 0.398902mgd 2021=0.28765mgd 2022=0.25095S
y+
Have repaired collection sysems through CIPP, smoke testing and manhole rehab.
0
y:-
s
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
cc C
specific requirements.)
t�
0
❑✓ Yes ❑ No
r0
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
`�
a..
O
(See instructions for specific requirements.)
_ co
0
0 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
1 Belt press repairs are scheduled to begin at the end of February. Rollers, belts and other equipment will be replaced.
w
E
As
a.
2.
E
0
a
3.
a�
4.
co
-a
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Affected
Begin
End
Begin
Attainment of
>
0
CL
Improvement
Outfalls
l
(list outfanumber)
Construction
Construction
Discharge
Operational
p
Level
E
(from above)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MMIDDlYYYY
d
w
Cn
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:
EPA Form 3510-2A (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
100000058965 NCO020737 Pilot Creek WWTF OMB No. 2040-0004
SECTION 3. INFORMATION ON EFFLUENT DISCHARGES (40 CFR 122.210)(3) to (5))
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001
Outfall Number
Outfall Number
State
NC
County
Cleveland
0
w
City or town
Kings Mountain
0
c
0
.6-
Distance from shore
3 ft.
ft.
ft.
CL
.=
Depth below surface
0 ft.
ft.
ft.
0
Average daily flow rate
1.54 mgd
mgd
mgd
Latitude
36 15 649" NF]
0 1
Longitude
8f 2ti 636" VEI
"'
0 "
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
o
❑ Yes 0 No -* SKIP to Item 3.4.
a
3.3
If so, provide the following information for each applicable outfall.
cc
s
Outfall Number
Outfall Number
Outfall Number
0
Number of times per year
0
discharge occurs
a
Average duration of each
`0
discharge (specify units
Average flow of each
mgd
mgd
mgd
0
discharge
y
Months in which discharge
occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes 0 No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser pe at each applicable outfall.
CL
Outfall Number
Outfall Number
Outfall Number
L
d
0
c vi
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?
0 Yes ❑ No 4SKIP to Section 6.
EPA Form 3510-2A (Revised 3-19) Page 6

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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
Buffalo Creek
Name of watershed, river,
0
or stream system
to Creek Sub -division of Broad
Q
•L
U.S. Soil Conservation
Service 14-digit watershed
Buffalo River
o
code
L
Name of state
management/river basin
•�
U.S. Geological Survey
Z
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 provided for discharges from each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Highest Level of
❑ Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
El Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
0
Q•
Design Removal Rates by
0
Outfall
0
...
BOD5 or CBOD5
85 %
%
c
E
TSS
85 %
%
%
® Not applicable
El Not applicable
El Not applicable
Phosphorus
%
® Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
EPA Form 3510-2A (Revised 3-19) Page 7

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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.
.a
a�
c
0
U
c
Outfall Number 001
Outfall Number
Outfall Number
Disinfection type
Chlorine
0
Seasons used
All
E
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
0 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 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number 001
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
14
Number of tests of receiving
water
3.13
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
cc
-
❑✓ Yes ❑ No -* SKIP to Item 3.16.
A
cc
0
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
=
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
=
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
A
package?
w
21 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).
Yes 4 Complete Tables C, D, and E as
❑ ❑ No 4SKIP 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
❑✓ Yes ❑permitting
authority.
EPA Form 3510-2A Revised 3-19) Page 8

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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?
nv No + Complete tests and Table E and SKIP to
Yes ❑
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ 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
MM/DD/YYYY
All analysis yielded PASS results. Dates are as follows:
2/18/20, 4/28/20, 7/27/20,11/2020
2/9/21, 5/4/21, 7/29/21, 11/15/21
=
1/27/22, 5/11/22, 11/9/22, 1/1/23
0
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
c
toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
4)
0
w
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 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?
0 Yes ❑ Not applicable because previously submitted
information to the NPDES permitting authority.
SECTION
4. INDUSTRIAL
DISCHARGES r HAZARDOUS WASTES (40 CIFIR
Does the POTW receive discharges from SIUs or NSCIUs?
4.1
0 Yes ❑ No SKIP to Item 4.7.
4.2
Indicate the number of SIUs and NSCIUs that discharge to the POTW.
Number of SIUs
Number of NSCIUs
0
8
7
a
4.3
Does the POTW have an approved pretreatment program?
N
�
0 Yes ❑ No
-a
4.4
Have you submitted either of the following to the NPDES permitting authority that contains information substantially
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?
❑ Yes ❑ No -+ SKIP to Item 4.6.
0
4.5
Identify the title and date of the annual report or pretreatment program referenced in Item 4.4. SKIP to Item 4.7.
v
City of Kings Mountain, Pilot Creek 2021 PAR emailed to division on 2/8/2022
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 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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 © No 4 SKIP to Item 4.9.
4.8
If yes, provide the following information:
Annual
Hazardous Waste
Waste Transport Method
Amount of
Units
Number
(check all that apply)
Waste
Received
❑ Truck ❑ Rail
❑ Dedicated pipe ❑ Other (specify)
_
0
U
❑ Truck ❑ Rail
❑ Dedicated pipe ❑ Other (specify)
0
-a
N
❑ Truck ❑ Rail
=
Dedicated pipe ❑ Other (specify)
4.9
Does the POTW receive, or has it been notified that it will receive, wastewaters that originate from remedial activities,
y
including those undertaken pursuant to CERCLA and Sections 3004(7) or 3008(h) of RCRA?
0
❑ 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 wastewater's hazardous constituents; and
the extent of treatment, if any, the wastewater receives or will receive before entering the POTW?
❑ Yes ❑ No
SECTION• -• • -0
5.1 Does the treatment works have a combined sewer system?
E
❑ Yes ❑ No 4SKIP to Section 6.
5.2
Have you attached a CSO system map to this application? (See instructions for map requirements.)
_
❑ Yes ❑ No
a.
0
5.3
Have you attached a CSO system diagram to this application? (See instructions for diagram requirements.)
0
❑ Yes ❑ No
EPA Form 3510-2A (Revised 3-19) Page 10

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000OS896S
NCO020737
Pilot Creek WWTF
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
=
0
•CLState
and ZIP code
o
County
Latitude
° '
°
0
0
U
Longitude
"
°
"
Distance from shore
Depth below surface
ft.
ft.
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
a�
`0
r_
CSO flow volume
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
=
2
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
the past year
cc
cAverage
duration per
hours
hours
hours
c
event
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
w
million gallons
million gallons
million gallons
o
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
❑ Actual or ❑ Estimated
EPA Form 3510-2A (Revised 3-19) Page 11

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
100000058965
NCO020737
Pilot Creek WWTF
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/
streams stem
N
a;
U.S. Soil Conservation
❑ Unknown
❑ Unknown
❑ Unknown
Service 14-digit
=
watershed code
_'>
if known
Name of state
or
management/river basin
U)
U.S. Geological Survey
❑ Unknown
❑ Unknown
❑ Unknown
8-Digit Hydrologic Unit
Code if known
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
exam les
SECTION•
.i
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
0 Section 1: Basic Application
0 w/ variance request(s) ❑ w/ additional attachments
Information for All Ap licants
21 Section 2: Additional
El w/ topographic map w/ process flow diagram
Information
❑ w/ additional attachments
21 w/ Table A 0 w/ Table D
❑ Section 3: Information on
❑ w/ Table B ❑ w/ Table E
Effluent Discharges
[�] w/ Table C ❑ w/ additional attachments
Section 4: Industrial
✓❑ w/ SIU and NSCIU attachments ❑ w/ Table F
N
0 Discharges and Hazardous
❑
c
Wastes
wl additional attachments
;'
5: Combined Sewer
El
El wl CSO map El wl additional attachments
Overflows
Overflows
❑ w/ CSO system diagram
Section 6: Checklist and
❑
❑ w/ attachments
Certification Statement
x
6.2
Certification Statement
1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
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
rC
;
C vn 6
axc
Signature
Date signed
EPA Form 3510-2A (Revised 3-19) Page 12

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