NC0086975_Renewal (Application)_20231130

NPDES Permit Number Facility Name Modified Application Form 2A
NC 0086955 Carteret County-Laurel Rd WTP Mod fled March 2021
SECTION 6.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d))
6.1 In Column 1 below,mark the sections of Form 2A that you have completed and are submitting with your application.For
each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note that not
all applicants are required to provide attachments.
Column 1 Column 2
Section 1. Basic Application 0 w/variance request(s) ❑ wl additional attachments
Information for All Applicants
❑ Section 2:Additional ❑ w/topographic map ❑ w/process flow diagram
Information ❑ w/additional attachments
w/Table A © w/Table D
❑✓ Section 3: Information on © w/Table B ❑ wl additional attachments
Effluent Discharges
E l © w/Table C
d
c' Section 4: Not Applicable
0
Section 5:Not Applicable
d I _
Section 6: Checklist and
❑ ❑v w/attachments
Certification Statement
Y 6.2 Certification Statement
a
d
/certify under penalty of law that this document and all attachments were prepared under my direction or supervision in
U
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 systcm,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
Tommy Burns County Manager
Signature Date signed
11fa3• ad33
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