NC0056201_Renewal (Application)_20231114

DocuSign Envelope ID: A619B041-91F8ACCF-8394-B95FA4F9FC01
t
North Carolina Laserfiche
Department of Environmental Quality Modified Application Form 2A
Division of Water Resources Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECE/VED
NOV ] 4 ZOrs'
NCDEQ/DWR/NppES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

DocuSign Envelope ID: A619BO41-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO056201
Countryside NC MHP
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 result in denial of the application.)
SECTION
1. BASIC
APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.210)(1) and (9))
Facility name
1.1
Countryside NC MHP
Mailing address (street or P.O. box)
16479 Dallas Pkwy, Ste. 600
City or town
State
ZIP code
o
Addison
TX
75001
E
Contact name (first and last)
Title
Phone number
Email address
o
c
Mr. Taui Ili
Owner
[phone]
[e-mail]
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
cc
U-
3571 Roy Farlow Road
City or town
State
ZIP code
Sophia
NC
27350
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes + 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 ❑ No -+ SKIP to Item 1.4.
Applicant name
AQWA Inc.
Applicant address (street or P.O. box)
2604 Willis Court
E
City or town
State
ZIP code
0
Wilson
NC
27893
Contact name (first and last)
Title
Phone number
Email address
n
Steve Barry
CEO
[phone]
[e-mail]
a
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.)
21 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
E
number for each.
Existing Environmental Permits
n
❑ NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
water)
control)
CD
E
NC0056201
c
o
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
w
rn
y
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
w
404)
Page 1

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
N CO056201
Countryside NC M H P
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)
-a
65 Dwellings SFR
100 % separate sanitary sewer
0 Own El Maintain
x 4 per dwelling
% combined storm and sanitary sewer
❑ Own ❑ Maintain
= 260
❑ Unknown
❑ Own ❑ Maintain
c
% separate sanitary sewer
❑ Own ❑ Maintain
•R
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
Q
0
% separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
E
❑ Unknown
ElOwn ElMaintain
2
% separate sanitary sewer ❑ Own ❑ Maintain
% combined storm and sanitary sewer ElOwn ElMaintain
rn
❑ Unknown El Own El Maintain
Total
260
Population
c�
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line in miles)
100 /° ° /0 °
z'
1.8
Is the treatment works located in Indian Country?
c
'
o
U
❑ Yes ✓❑ 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.
Design Flow Rate
0.015 mgd
=
V y
Annual Average Flow Rates Actual
Two Years Ago
Last Year
This Year
c 0
0.0056 mgd
0.0089 mgd
0.0093 mgd
LL
Maximum Daily Flow Rates Actual
Two Years Ago
Last Year
This Year
0.0070 mgd
0.0197 mgd
0.022 mgd
y
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
o
Total Number of Effluent Discharge Points b T e
a >-
Combined Sewer
Constructed
Q'
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
s
U
Overflows
�
1
Page 2

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO056201
Countryside NC MHP
Modified March 2021
Outfalls Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes ❑✓ No 4 SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Im oundment Location and Dischar a Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
ElContinuous
gpd
❑ Intermittent
s
1.14
Is wastewater applied to land?
❑ Yes ❑ No -+ SKIP to Item 1.16.
0
1.15
Provide the land application site and discharge data requested below.
C
Land Application Site and Discharge Data
Average Daily Volume
Continuous or
Location
Size
Applied
Intermittent
check
one
yacres
d
gpd
❑ Continuous
o
❑ Intermittent
s
acres
d
gpd
❑ Continuous
o
ElIntermittent
acres
d
gpd
El Continuous
❑ Intermittent
1.16
Is effluent transported to another facility for treatment prior to discharge?
o
ElYes ❑✓ 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 -* 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

DocuSign Envelope ID: A619BO41-91 F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO056201
Countryside NC MHP
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
o
Facility name
Mailing address (street or P.O. box)
d
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
L
d
Phone number
Email address
o
NPDES number of receiving facility (if any) ❑ None
Average flail flow rate m d
9 Y 9
CL
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
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
rn
❑ Yes ❑ No 4 SKIP to Item 1.23.
U
6
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
y
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.
d w
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
a a
❑ Discharges into marine waters (CWA El Water quality related effluent limitation (CWA Section
D
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
o
Contractor name
AQWA Inc.
(company name
E
0
Mailing address
2604 Willis Court
street or P.O. box)
$
City, state, and ZIP
Wilson, NC 27896
code
cContact
name (first and
Steve Barry
U
last
Phone number
[phone]
Email address
[e-mail]
Operational and
sampling, monitoring, system
maintenance
and treatment maintenance
responsibilities of
contractor
Page 4

DocuSign Envelope ID: A619BO41-91 F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number Facility Name Modified Application Form 2A
NCO056201 Countryside NC MHP Modified March2021
SECTION 2. ADDITIONAL •• i
o 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?
rn
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.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
3
0
c
t
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
C
specific requirements.)
Co R
0
0
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
c
_ rn
(See instructions for specific requirements.)
� R
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
E
c
2.
E
0 0
(n
3.
Z
d
4.
U )
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Com letion for Im rovements
E
Scheduled
Affected
Begin
End
Begin
Attainment of
o
CL
Improvement
Outfalls
(list outfal
Construction
Construction
Discharge
Operational
level
E
(from above)
number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
MM/DD/YYY
a
1.
d
s
U
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

DocuSign Envelope ID: A619BO41-91 F84CCF-8394-1395FA4179FC01
NPDES Permit Number
Facility Name Modified Application Form 2A
NCO056201
Countryside NC MHP Modified March 2021
SECTION••
• ON i
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
2
m
County
Randolph
O
City or town
Sophia
0
c
s
Distance from shore
1 ft.
ft.
ft.
Q
Depth below surface
1 ft.
ft.
ft.
CD
0
Average daily flow rate
0.0094 mgd
mgd
mgd
Latitude
35' 50 34.5" N
"
Longitude
7EF 54 51.r W
"
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
R
3.3
If so, provide the following information for each applicable outfall.
s
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
mgd
mgd
mgd
0
discharge
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.
3.5
Briefly describe the diffuser b,pe at each applicable outfall.
CL
Outfall Number 001
Outfall Number
Outfall Number
Rip -Rap
0
ui
3 6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
CO
�
one or more discharge points?
CD
❑ Yes ❑ No 4SKIP to Section 6.
M Ap
!''_, 1 4 ..U_J
NCDEQ/D'uV'R/NPDES
Page 6

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO056201
Countryside NC MHP
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
Stream
Name of watershed, river,
Caraway Creek
0
or stream system
Q
U.S. Soil Conservation
Service 14-digit watershed
030401030404
o
code
Name of state
Yadkin Pee -Dee
rn
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 Dot
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)
0
a
Design Removal Rates by
Outfall
d
�
BODs or CBODs
98.0 %D
%D
%D
a�
E
afQi
TSS
62.5 %
%
%
F—
® Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
53.8 D �o
D �o
D �o
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
D�0
D�0
D�D
Page 7

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
N CO056201
Countryside NC M H P
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.
N/A
d
c
c
0
v
o
Outfall Number 001
Outfall Number
Outfail Number
.0
Disinfection type
UV Disinfection
d
0
Seasons used
N/A
a)
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?
0 Yes ❑ No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
❑ Yes ❑✓ No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
rn
=
water
C)
Number of tests of receiving
water
d
_
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?
❑r 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
permitting authority.
Page 8

DocuSign Envelope ID: A619BO41-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO056201
Countryside INC MHP
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 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 your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
MM/DDNYYY
v
d
c
.c
0
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?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
CD
d
LU
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 per ikiiw
Page 9

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name Modified Application Form 2A
NCO056201
Countryside NC MHP Modified March 2021
SECTION•
1
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
El Section 1: Basic Application
❑ w/ variance request(s) ❑ w/ additional attachments
Information for All A licants
❑ Section 2: Additional
❑ w/ topographic map ❑ w/ process flow diagram
Information
❑ w/ additional attachments
0 w/ Table A ❑ wl Table D
❑ Section 3: Information on
✓❑ w/ Table B ❑ wl additional attachments
Effluent Discharges
E
❑ w/ Table C
d
5
Section 4: Not Applicable
c
0
Section 5: Not Applicable
❑ Section 6: Checklist and
❑ w/ attachments
Certification Statement
N
Y
6.2
Certification Statement
U
UI
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
Tauvaga Ili
COO
Si nature
Date signed
DocuSigned by:
11/7/2023
Page 10

DocuSign Envelope ID: A619BO41-91F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number
Facility Name
Cutfall Number
NCO056201
Countryside INC MHP
001
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge Analytical ML or MDL
Pollutant Number of Methods include units
Value Units Value Units Samples
( )
Biochemical oxygen demand ❑ ML
0 BOD5 or ❑ CBOD5 7.5 mg/L 5.0 mg/L Weekly Grab ❑ MDL
report one
Fecal conform 400/100 mL 200/100 mL Weekly Grab El ML
❑ MDL
Design flow rate
pH (minimum)
pH (maximum)
Temperature (winter)
0.015
6.0
9.0
Monitor & Report
MGD
s
Standard :U�I
Standard Units ::i
Monitor & Report
Temperature (summer)
Monitor & Report
Monitor & Report
Total suspended solids (TSS) 45 mg/L 30 mg/L Weekly Grab ❑ ML I
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
EPA Identification Number NPDES Permit Number
NCO056201
Name
Countryside INC MHP
Outfall Number
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant
Analytical
ML or MDL
Number of
Value
Units
Value
Units
Methods
(include units)
Samples
Ammonia (as N)
10.0
mg/L
2.0
mg/L
Weekly
Grab
El ML
❑ MDL
Chlorine
❑ ML
total residual, TRC 2
❑ MDL
Dissolved oxygen
Monitor & Report
nI
>6.0
mg/L
Weekly
Grab
❑ ML
❑ MDL
Nitrate/nitrite
❑ ML
❑ MDL
Neldahl nitrogen
❑ ML
❑ MDL
Oil and grease
❑ ML
❑ MDL
Phosphorus
❑ ML
❑ MDL
Total dissolved solids
❑ 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

DocuSign Envelope ID: A619BO41 -91 F8-4CCF-8394-l395FA4F9FC01
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO056201 Countryside NC MHP
Modified March 2021
•g• •• •�
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)
❑ ML
❑ MDL
OML
Antimony, total recoverable
❑ MDL
❑ ML
Arsenic, total recoverable
❑ MDL
Beryllium, total recoverable
OML
❑ MDL
Cadmium, total recoverable
El ML
❑ MDL
Chromium, total recoverable
El ML
❑ MDL
Copper, total recoverable
DMIL
❑ MDL
Lead, total recoverable
❑ ML
❑ MDL
Mercury, total recoverable
El ML
❑ MDL
Nickel, total recoverable
El ML
❑ MDL
Selenium, total recoverable
❑ ML
❑ MDL
Silver, total recoverable
❑ M❑ I
MDL
Thallium, total recoverable
❑ MI
❑ MDL
Zinc, total recoverable
❑ MI
❑ MDL
11 ML
Cyanide
❑ MDL
Total phenolic compounds
El ML
❑ MDL
Volatile Organic Compounds
❑ ML
rolein
❑ MDL
0 MIL
rylonitrile
❑ MDL
[Benzene
❑ ML
❑ MDL
❑ ML
omoform
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

DocuSign Envelope ID: A619B041-91 F8-4CCF-8394-B95FA4F9FCO1
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NC0056201 Countryside NC MHP
Modified March2021
Maximum Daily Discharge Average Daily Discharge
Pollutant
Analytical ML or MDL
Number of
Value Units Value Units
Method' (include units)
Samples
Carbon tetrachloride
❑ ML
❑ MDL
Chlorobenzene
❑ ML
❑ MDL
Chlorodibromomethane
❑ ML
❑ MDL
Chloroethane
❑ ML
❑ MDL
2-chloroethylvinyl ether
❑ ML
❑ MDL
Chloroform
❑ ML
❑ MDL
Dichlorobromomethane
❑ ML
❑ MDL
1,1-dichloroethane
❑ ML
❑ MDL
1,2-dichloroethane
❑ ML
❑ MDL
trans-1,2-dichloroethylene
❑ ML
❑ MDL
1,1-dichloroethylene
❑ ML
❑ MDL
1,2-dichloropropane
❑ ML
❑ MDL
1,3-dichloropropylene
❑ ML❑
MDL
Ethylbenzene
❑ ML
❑ MDL
Methyl bromide
❑ ML
❑ MDL
Methyl chloride
❑ ML
❑ MDL
Methylene chloride
❑ ML
❑ MDL
,1,,2,2-tetrachloroethane
MML
❑❑
❑ MDL
°ML
❑ MDL
[Tetrachloroethylene
uen
ole
❑ML
L
,11-trichloroethane,
❑ ML
❑ MDL
❑ MIL
,12hlo
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 14

DocuSign Envelope ID: A619B041-91F8-4CCF-8394-B95FA4F9FC01
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCOO562O1 Countryside NC MHP
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units Samples
Trichloroethylene
El ML
❑ MDL
Vinyl chloride
❑ ML❑ MDL
Acid•Extractable Compounds
p-chloro-m-cresol
OML
❑ MDL
2-chlorophenol
D ML
❑ MDL
2,4-dichlorophenol
0 MIL
❑ MDL
2,4-dimethylphenol
0 ML
❑ MDL
4,6-dinitro-o-cresol
❑ ML
❑ MDL
2,4-dinitrophenol
OML
❑ MDL
2-nitrophenol
❑ ML
❑ MDL
4-nitrophenol
0 MIL
❑ MDL
Pentachlorophenol
El ML
❑ MDL
Phenol
❑ ML
❑ MDL
2,4,6-trichlorophenol
OML
❑ MDL
Base -Neutral Compounds
cenaphthene
OMIL
❑ MDL
cenaphthylene
OMIL
❑ MDL
❑ML
❑ MDL
[Anthracene
enzidine
❑ MI❑ MDL
enzo(a)anthracene
OML
❑ MDL
enzo(a)pyrene
0 ML
❑ MDL
4-benzofluoranthene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

DocuSign Envelope ID: A619BO41-91F8-4CCF-8394-B95FA4F9FC01
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NC0056201 Countryside NC MHP
Modified March 2021
• • I • 9
Maximum Daily Discharge Average Daily Discharge
Pollutant Number of
Value Units Value Units Samples
Analytical ML or MDL
Method' (include units)
Benzo(ghi)perylene
❑ ML
❑ MDL
Benzo(k)fluoranthene
El ML
❑ MDL
Bis (2-chloroethoxy) methane
❑ ML
❑ MDL
Bis (2-chloroethyl) ether
❑ ML
❑ MDL
Bis (2-chloroisopropyl) ether
❑ ML
❑ MDL
Bis (2-ethylhexyl) phthalate
❑ ML
❑ MDL
4-bromophenyl phenyl ether
❑ ML
❑ MDL
Butyl benzyl phthalate
❑ ML❑ MDL
2-chloronaphthalene
❑ ML
❑ MDL
4-chlorophenyl phenyl ether
❑ ML
❑ MDL
Chrysene
❑ ML
❑ MDL
di-n-butyl phthalate
❑ ML❑ MDL
di-n-octyl phthalate
❑ ML
❑ MDL
Dibenzo(a,h)anthracene
❑ ML
❑ MDL
1,2-dichlorobenzene
❑ ML❑ MDL
1,3-dichlorobenzene
❑ ML
❑ MDL
1,4-dichlorobenzene
❑ ML
❑ MDL
3,3-dichlorobenzidine
❑ ML❑ MDL
Diethyl phthalate
❑ ML
❑ MDL
Dimethyl phthalate
❑ ML❑ MDL
2,4-dinitrotoluene
❑ ML❑ MDL
U26
,-dinitrotoluene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 16

DocuSign Envelope ID: A619BO41-91 F8-4CCF-8394-B95FA4F9FC01
EPA Identification Number NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
N CO0562O1 Countryside NC M H P
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant Number of
Method' (include units)
Value Units Value Units
Samples
1,2-diphenylhydrazine
11 ML
❑ MDL
Fluoranthene
❑ ML
❑ MDL
Fluorene
❑ ML
❑ MDL
Hexachlorobenzene
❑ ML
❑ MDL
Hexachlorobutadiene
El ML
❑ MDL
Hexachlorocyclo-pentadiene
0 ML
❑ MDL
Hexachloroethane
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
El ML
❑ MDL
Isophorone
❑ ML
❑ MDL
Naphthalene
0 ML
❑ MDL
Nitrobenzene
❑ ML
❑ MDL
N-nitrosodi-n-propylamine
0 ML
❑ MDL
N-nitrosodimethylamine
El ML
❑ MDL
N-nitrosodiphenylamine
0 ML
❑ MDL
Phenanthrene
❑ ML
❑ MDL
Pyrene
0 ML
❑ MDL
1,2,4-trichlorobenzene
❑ 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).
EPA Form 3510-2A (Revised 3-19) Page 17

DocuSign Envelope ID: A619BO41-91 F8-4CCF-8394-B95FA4F9FC01
NPDES Permit Number Facility Name Cutfall Number
NCO056201 Countryside NC MHP
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
7
Pollutant
Analytical ML or MDL
Numbers
list � Value Units Value Units
d Metho(include units)
Samples
❑ No additional sampling is required by NPDES permitting authority.
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18