NC0030139_application_20230227

Whi t Oav" Af(6 0 3O/ 3 y
North Carolina
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < o.1 MGD
and No Pretreatment Program
NPDES Permitting Program
FEB 2 7 2023
NCDEQ/DWR/R!F'DES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
1AhAf-M
Modified March 2021
Form
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
NPDES
the instructions may resuft in denial of the application.)
SECTION
1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.210)(1) and (9))
Facility name
1.1
White Oak Manor Rutherfordton WWTP
Mailing address (street or P.O. box)
400 Rella Blvd, c/o Accounts Payable
City or town
State
ZIP code
o
Seffern
NY
10901
w
EContact
name (first and last)
Title
Phone number
Email address
0
c
Brooke Blanton
Admissions Coordinator
[phone]
bblanton@accordiusrutherfori
r
_
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
188 Oscar Justice Road
UL
City or town
State
ZIP code
Rutherfordton
NC
28139
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑ No
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
0 Yes ❑ No SKIP to Item 1.4.
Applicant name
Water Quality Lab and Operations, Inc.
Applicant address (street or P.O. box)
ca
P.O. Box 1167
c
0
City or town
State
ZIP code
Banner Elk
NC
28604
Contact name (first and last)
Title
Phone number
Email address
Q
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.)
E
0
Existing Environmental Permits
0-
n NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
water)
control)
E
c
NCO030139
o
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
w
N
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
w
404)
Page 1

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
%A/%A/TD
Modified March 2021
1.7
Provide the collections stem information
requested below for the treatment works.
Municipality
Population
Collection System Type
Served
Served
indicate percentage)
Ownership Status
223
100 % separate sanitary sewer
❑ Own 0 Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
Cn
o
% separate sanitary sewer
ElOwn ElMaintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
Q
❑ Unknown
❑ Own ❑ Maintain
a
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
% separate sanitary sewer ❑ Own ❑ Maintain
% combined storm and sanitary sewer ❑ Own ❑ Maintain
Cn
_
I ❑ Unknown ❑ Own ❑ Maintain
Total 223
Population
0
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line in miles
100 % %
1.8
Is the treatment works located in Indian Country?
0
❑ Yes El No
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.
sign Flow Rate
0.015 mgd
Annual Average Flow Rates Actual
Two Years Ago
Last Year
This Year
c
0.0042 mgd
0.0045 mgd
0.0049 mgd
E:
Maximum Daily Flow Rates Actual
Two Years Ago
Last Year
This Year
0.0127 mgd
0.0149 mgd
0.0135 mgd
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
a
Total Number of Effluent Discharge Points by Type
°- CL
Combined Sewer
Constructed
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
Overflows
1
Page 2

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
\A/\A/Tn
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 Impoundment
Location and Discharge Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Im oundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
.a
❑ Intermittent
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.
Land Application Site and Discharge Data
o
Average Daily Volume
Continuous or
a,
Location
Size
Applied
Intermittent
check one
N
acres
gpd
❑ Continuous
0
❑ Intermittent
acres
gpd
❑ Continuous
0
❑ Intermittent
=
acres
d
gpd
El Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
❑ Yes ❑✓ No 4 SKIP to Item 1.21.
o
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.
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
NCO030139
White Oak Manor Rutherford
AnnnrTo
Modified March 2021
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving F
cility Data
Facility name
Mailing address (street or P.O. box)
City or town
State
ZIP code
0
c�
Contact name (first and last)
Title
0
t
Phone number
Email address
Fa
0
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
CL
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 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
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
N
R
acres
gpd
❑ Continuous
❑ Intermittent
ElContinuous
acres
gpd
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
0
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
Cc 0
Section 301(h)) 302(b)(2))
Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes ❑ No +SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
0
0
C
Contractor name
Water Quality Lab & Operation
(company name
E
Mailing address
(street or P.O. box)
P.O. Box 1167
0
City, state, and ZIP
code
Banner Elk, NC 28604
ConL tact name (first and
c �
last)
Paul Isenhour
Phone number
[phone]
Email address
[e-mail]
Operational and
Company employee
maintenance
maintains & operates the
responsibilities of
wastewater treatment plant
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NCO030139 White Oak Manor Rutherford Modified March 2021
1A!\A/TD
ADDITIONALSECTION 2.
0 Outfalls to Waters of the State of North Carolina
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
o
❑ Yes 0 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.
gpd
=
Indicate the steps the facility is taking to minimize inflow and infiltration.
c
0
4-
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
M C
specific requirements.)
C�
0
0-
o
❑ Yes ❑ No
11
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
0 2
(See instructions for specific requirements.)
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
cc
1.
c
a�
E
0
a
2.
E
0
N
3.
M
to
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Im rovements
E
Scheduled
Affected
Begin
End
Begin
Attainment of
>
0
CL
Improvement
Outfalls
(list o
Construction
Construction
Discharge
Operational
p
Level
E
—
(from above)
number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MM/DD/YYYY
1.
4)
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
NCO030139
White Oak Manor Rutherford
%AAA/TD
Modified March 2021
SECTION
3. INFORMATION
ON EFFLUENT DISCHARGES (40 CFR 122.210)(3) to
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
North Carolina
v'
�
County
Rutherford
42
O
1
City or town
Rutherfordton
0
Distance from shore
Q
Depth below surface
ft.
ft.
ft.
0
Average daily flow rate
mgd
mgd
mgd
Latitude
35° 2,� 43" NE]
°
Longitude
sl 5� 36" VEI
° ' "
° ' "
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.
a�
3.3
If so, provide the following information for each applicable outfall.
N
Outfall Number
Outfall Number
Outfall Number
0
Number of times per year
L
discharge occurs
a
Average duration of each
0
discharge(specify units
Average flow of each
mgd
mgd
mgd
0
discharge
co
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 type at each applicable outfall.
CL
Outfall Number
Outfall Number
Outfall Number
L
d
N
vS
3.6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
one or more discharge points?
❑ Yes ❑ No 4SKIP to Section 6.
Page 6

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
%A/\A/TD
Modified March 2021
3.7
Provide the receiving water and related information if known
for each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Receiving water name
Unnamed Tributary
Name of watershed, river,
0
or stream system
Catheys Creek
Q
•L
U.S. Soil Conservation
Service 14-digit watershed
o
code
L
°?
t°
Name of state
management/river basin
Broad 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 provided for discharges from each outfall.
Outfall Number 011
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
ID Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
0
Q
Design Removal Rates by
Outfall
N
d
BOD5 or CBOD5
85 %
%
%
a�
E
m
TSS
85 %
%
%
H
© Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
°
°
°
© Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
® Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
1AAA170
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.
-a
a�
0
a
Outfall Number 001
Outfall Number
Outfall Number
Q-
Disinfection type
Chlorination
a�
0
=
Seasons used
ALL
a
E
L
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?
21 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 0 No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
Number of tests of receiving
=
water
w
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
❑ Yes 4 Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
0 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 0 No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO030139
White Oak Manor Rutherford
%nnnrrn
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 ❑ No + Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
❑ Yes ❑ No + Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to our NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MM/DD/YYYY
m
_
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?
c
❑ Yes ❑ No SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
w
_
a�
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?
❑ Yes ❑ Not applicable because previously submitted
information to the NPDES permitting authority.
Page 9

NPDES Permit Number
Facility Name Modified Application Form 2A
NCO030139
White Oak Manor Rutherford Modified March 2021
%AIIAIrn
SECTION1
CERTIFICATION STATEMENT (40
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
ID Section 1: Basic Application
❑ w/ variance request(s) ❑ w/ additional attachments
Information for All Applicants
❑ Section 2: Additional
El w/ topographic map ❑ w/ process flow diagram
Information
❑ w/ additional attachments
Q w/ Table A ❑ w/ Table D
❑ Section 3: Information on
✓❑ w/ Table B ❑ w/additional attachments
Effluent Discharges
E
❑ w/ Table C
d
_cc
U'
Section 4: Not Applicable
0
-
A
Section 5: Not Applicable
d
U
6: Checklist and
El
0 w/ attachments
cc
Certification
Certification Statement
e
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. 1 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
Paul Isenhour
President
Sig a
Date signed
02/21/2023
FED 2 7 2023
NCDEQ/D1NR/NPDES
Page 10

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Outfa11001
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WOW
Vr'odd
Ak.31�7
A
N00030139 o White Oak Manor WWTP
Latitude: 350 24' 43" N Longitude: 810 55' 36" W
Sub -Basin: 03-08-02 Stream Class: WS-V
Receiving Stream: UT to Cathey's Creek
Ilk
U.S. Hwy 64
_ 1
Facility
Location "
North Rutherford County
Map not to scale
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