NC0036251_Permit Issuance_20000614

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
1 ILT?3A
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
June 14, 2000
Rodger and Candy Popkin, Owners/Directors
Blue Star Camps, Incorporated
3595 Sheridan Street, Suite 107
Hollywood, Florida 33021
Subject: Final Permit
Camp Blue Star WWTP
NPDES Permit NCO036251
Henderson County
Dear Mr. Popkin:
In accordance with the application for a permit for effluent discharge from Camp Blue Star's
wastewater treatment plant, the Division is forwarding herewith the Camp's NPDES permit renewal
and modification. The modification includes the requested increase in design flow to 0.06 MGD. This
permit is issued pursuant to the requirements of North Carolina General Statute 143-215.1 and the
Memorandum of Agreement between North Carolina and the U.S. Environmental Protection Agency
dated December 6, 1983.
No public comments were received on the draft and no changes were made with this final
_ permit (from the original draft permit).
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty
(30) days following receipt of this letter. This request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings, Mail Service Center 6714, Raleigh, North Carolina 27699-6714. Unless such
a demand is made, this permit shall be final and binding.
Please take notice that this permit is not transferable except after notice to the Division of
Water Quality. The Division of Water Quality may require modification or revocation and reissuance of
the permit.
This permit does not affect the legal requirements to obtain other permits which may be
required by the Division of Water Quality, the Division of Land Resources, the Coastal Area
Management Act, or any other federal or local governmental permit.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 919 733-5083, extension 510 (fax) 919 733.0719
An Equal Opportunity Affirmative Action Employer Susan.A.Wilson®ncmail.net

Camp Blue Star
Page 2 of 2
If you have any questions concerning this permit, please contact Susan Wilson at telephone
number [phone], ext. 510.
Sincerely,
ORIGINAL SIGNED BY
BILL REID
Kerr T. Stevens
Enclosures: NPDES Permit No. NC0036251
cc: Asheville Regional Office, Water Quality
Tom Rosenburg, Associate Director
P.O. Box 1029
Hendersonville, NC 28793
Point Source Compliance/ Enforcement Unit
Technical Assistance and Certification
Central Files
NPDES Files e

Permit No. NCO036251
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions of North Carolina General Statute 143-215.1, other lawful standards
and regulations promulgated and adopted by the North Carolina Water Quality Commission, and the
Federal Water Pollution Control Act, as amended,
BIue Star Camps, Incorporated
is hereby authorized to discharge wastewater from a facility located at
Camp Blue Star
Off NCSR 1127
Henderson County
to receiving waters designated as Mud Creek in the French Broad River Basin
in accordance with the discharge limitations, monitoring requirements, and other conditions set forth in
Parts I, II, III, and N hereof.
This permit shall become effective July 1, 2000.
This permit and the authorization to discharge shall expire at midnight on June 30, 2005.
Signed this day June 14, 2000. ORIGINAL SIGNED ITV
BILL REID
Kerr T. Stevens, Director
Division of Water Quality
By the Authority of the Environmental Management Commission
Camp Blue Star WWTP
NPDES No. NCO036251

Permit No. NCO036251
SUPPLEMENT TO PERMIT COVER SHEET
Blue Star Camps Incorporated
Camp Blue Star
is hereby authorized to:
1. Continue to operate an existing 0.06 MGD dual train extended aeration package plant,
aerated sludge holding, equalization, tablet chlorination/ dechlorination located at
Camp Blue Star Summer Camp, off NCSR 1127, Henderson County, and
2. Discharge wastewater from said treatment works at the location specified on the
attached map into Mud Creek which is classified C waters in the French Broad River
Basin.
Camp Blue Star WWTP
NPDES No. NC0036251

Camp Blue Star
NPPE5 No. NCO036251 STANDINGSTONE MTN. QUADRANGLE
Henderson County NORTH CAROLINA-SOUTH CAROLINA .
7.5 MINUTE SERIES (TOPOGRAPHIC) 194-NE
950 000 FEET N.C.1 1620'HENDERSONVILLE 6 MI.! 1363 82' 30'
_ 7M Lg 66_�I
i � \a�,•.':+u � ° 1T' n I Creek � I
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ROAD CLASSIFICATION
PRIMARY HIGHWAY LIGHT -DUTY ROAD, HARD OR
HMO SURFACE IMPROVED SURFACE
SECONDARY HIGHWAY
HARD SURFACE =111111K=1 UNIMPROVED ROAD
Latitude 35°14'48" Longitude 82°32'13"
Map # G 8 NE Sub -basin 040302
Stream Class C
Discharge Class 13
Receiving Stream Mud Creek/French Broad
Design Q 0. MGC>�
SCALE4 00
11 MILE
->�.ra-mnne.'-cam
1 7000 FEET
1 1 KILOMETER
� ew
CONTOUR INTERVAL •0 FEET
QUAD LOCATION Blue Star Camps, Inc.
NCO036251
Henderson County
WWTP

Permit NCO036251
A. (1.) EFFLUENT LBUTATIONS AND MONITORING REQUIREMENTS — FINAL
During the period beginning upon the effective date of the permit and lasting until expiration, the Permittee is
authorized to discharge from outfall 001. Such discharges shall be limited and monitored by the Permittee as
specified below:
EFFLUENT
CHARACTERISTICS
LIMITS
MONITORING REQUIREMENTS
Monthly
Averse
Daily Maximum
Measurement
Frequency
Sample
Type
Sample Location
Flow
0.06 MGD
Continuous
Recording
Influent or Effluent
BOD, 5 day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
Total Suspended Residue
30.0 mg/L
45.0 mg/L
Weekly
Composite
Effluent
NHs as N
(April 1— October 31
3.0 mg/L
Weekly
Composite
Effluent
NHs as N
November 1— March 31
9.0 mg/L
Weekly
Composite
Effluent
Fecal Coliform
(geometric mean
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine
28 Ng/L
2/Week
Grab
Effluent
Temperature (°C)
Daily
Grab
Effluent
pH1
Weekly
Grab
Effluent
Footnotes:
1. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

PUBLIC NOTICE
NOTIFICATION OF
INTENT TO ISSUE A
NPDES WASTEWATER
PERMIT
On the basis of thorough
staff review and applica-
tion of NC General Stat-
ute 143.21, Public law
92-500 and other lawful
standards and regula-
tions, the North Carolina
Environmental Manage-
merit Commission pro-
poses to issue a National
Pollutant Discharge Elim-
ination System (NPDES)
wastewater clischar e
permit to the persons)
listed on the attached pa-
ges effective 45 days
from the publish date of
this notice.
Written comments
regard-
ing the proposed permit
will be accepted until 30
days after the publish
date of this notice. All r
comments received prior
to that date are consid-
ered in the final determi-
nations regarding the
Proposed permit. The Di- j
rector of the NC Division
of Water quality may de-
cide to hold a public I
meeting for the proposed
permit should the DM-
sion receive a significant
degree of public interest.
Copies of the draft permit
and other supporting in-
formation on file used to
determine conditions
Present in the draft per-
mit are available upon
request and payment of
the costs of reproduction. -
Mail comments:. and/or
requests for information
to the NC Division of We- _
ter quality. at the above
address or call Ms.
Christie Jackson at (919)
733-5083, extension 'ai
538. Please include the 1
=rmit -number
in any com-
/VLl e)v.
CAROLINA /35 , 70
tSON COUNTY -
IDAVIT OF PUBLICATION
he undersigned, a Notary Public of said County
e, duly commissioned, qualified, and authorized
a administer oaths, personally appeared
who
duly sworn, deposes and says: that he is
trsonville Newspaper Corporation, engaged in the
ion of a newspaper known as The Times -News,
d, issued, and entered as second class mail in the
lendersonville, in said County and State; that he is
ed to make this affidavit and sworn statement;
notice of other legal advertisement, a true opy of
I attached hereto, was published in Th !!leee
i the following dates:
3//P/0O Mee
9 a00
at the said newspaper in which such notice, Paper,
ent, or legal advertisement was published was, at
ire of each and every publication, a newspaper meet -
of the requirements and qualifications of Section I.
the General Statutes of North Carolina and was a
ed newspaper within the meaning of Section 1-597 of
eneral Statutes of North Carolina.
day of 11 (,Q r-e. k 20 UG
ED)
to and subscribed before me, this u
20 �0
Notary Public
expires: -' CJ'-6 _ L —i
persons may also —visit'
the Division of Water is [phone]
Quality at 512 N. Salis-
bury Street, Raleigh, NC
27604-1148 between the
hours of 8:00 'a.m. and
5:00 P.M. 10 review Infor-
mation on file.
NPDES Permit Number
-JNC0036251, Blue Star
Camps, Incorporated/
CAMP BLUE STAR,
3595 .Sheridan Street,
Suite 107, Hollywood, FL i
.33021 has applied for a
Modification for a facility
located in Henderson I
County discharging treat-
- ed wastewater into Mud
_ Creek in the French
Broad River Basin. Cur-
rently - ammpn'a,,qu.:, and
chlorine are water ality
limited. This discharge
may affect future,alloca-
tions in this portion of the
receiving stream.
�4CIO
n

03/02/2000 13:40
I UCT 516
DENR/DW9
FACT SHEET FO):t NPDES PERMIT DEVELOPMENT
NPDES No. NCO0862$1, Camp Blue Star VAV IP
Facilility Information
,4»licarit/Facllit Name:
Blue Star Camps, Inc./ CamBlue Star WWTP
Applictuit Address:
3595 Sheridan Street, Suite 107,14oll wood, FL 33021
Facility Address:
P.O. Box 1029 Crab Creek Road Hendersonville NC 28793
PermttteA Flow
0.04 MUD (requeating flow of 0.06 MGD)
Type of Waste:
100%Domestic
Iraclil /Permit Status;
Modification
County:
Henderson
Receivlri Stream:
Mud Creek
ReidenalOffice:
I ARO
Stream Classification:
C. SI: 6-53
USGS Topo Quad:
GBNB
30:3(d) LigtC.d?:
yes
Permit Writer:
S. Wilson
Subbasin:
040302
Date:
February , 2000
Drainage Area (mi2):
0.7
I
Surnmer 7Q 10 (cfs)
0.27
Whiter 7QIO (0fs):
0.44
Averse. V low (cfsl:
2.0
IWC' (%):
269h
Primary SIC Code:
4952
SUMMARY
('amp Blue Star is currently permitted for 0.04 MGD flow. An ATC approved 217198 included a dual train 0.06
M(;D extended aeration package plant: However, the permitted flow of 0.04 MGD remained (mostly due to the
lW..rrrdtlac's lack of knowledge of actual flow amounts). The camp now requests that the flow he increased to 0.06
MOD, flow value., for July 1999 indicated a monthly average of 0.045 MGD (0,032 MGD max.). This facility im
seasonally operated. The existing plant (including current chlorine contact tank) has adequate capacity Io treat
00,000 gpd.
Per ARO. oo alternatives it) discharge currently exist (mountainous terrain, no nearby sewer lines).
Mud (reek appears on the draft 303d list for the entire stream length. It is questionable as to the impact of this
diwhargo on Mud Creek; hnhitat degradation is the primary reason for Mud Creek being listed on the draft 2000
303d list. This discharge is in the headwaters of Mud Creek. Limits to protect WQ (regardless of 303 d lis(ing)
have been drafted fir this paper expansion request.
MXIC:rIY TESTING;:
None required -• 100'b domestic facility.
COMPI.IANC,F SUMMARY:
The I'aeffity has had spriradic compliance problems with flow.
I 51'REAM MONITORING:
('amp Blue Star is required to monitor for temperature and fecal coliform inetream. Downstream focal values appear
inure elevated than upstream in some cases, but this does not appear to be attributable to the discharger.
hisln-atn nannturing will be eliminated (fecal soli is not on draft 303 d list! 2000. and ambient monitoring stations
exist along Mud (.leek)
3/3Iv0 — F94- Roy r TUEi RAmfC D.CcaILG2 I� 8� 1�vcs. ale hse-I" of 'I unuT-.
"nNW-,O 1-2- 44 01;P Pl,45rnl ?r-Anl 0111-( iNl s . Co�ldz A rs� �A�r (Z\ATr� u wok�D
('amp BllleStar tw,00i6,iil gt Cf 30
NPnF,S,ihrdifie;uinrt /

PR[)PU: ED CHANGES:
Limits for NH3 N reflect limits hase;d on ammonia toxicity at 7Q10 flow 13 mgll .utnmer, 9 my:11 winter]. 'lilt!
prupured ammonia limits may be difficult for the facility to meet consistently due it) the wasonal nature oil* Zhu
discharge.
T'hr facility An should have a residual chlorine limit of 2$ ugll. [This could be phused in it' ne f3---le
PR POSED SCHEDULE FOR PERMIT ISSUANCE:
Craft Permit to Public Notiuu: Match 8. 2000 (est.)
Permit Scheduled to Issue.' April 249 2000
STATE CONTACT:
If you have any questions on tiny of the above information or on the attached permit, plenite coninct Skis -an Wilst III at
[phone] ext. 510.
+'GIONAL. OFFICE COMMENT:
NAME: 74`4�
r
DATE: 0 C
Ca nis 111tw Slat N(N)036251
.I'D1:S Vinditiculiort
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NCO036251
Facility: Camp Blue Star - expansion request to 0.06 MGD (from 0.04 MGD)
Discharge to: Mud Creek
Stream class and index #: 6-55
Residual Chlorine
Ammonia as NI-13
(summer)
7010 (CFS)
0.27
7Q10 (CFS)
0.27
DESIGN FLOW (MGD)
0.06
DESIGN FLOW (MGD)
0.06
DESIGN FLOW (CFS)
0.093
DESIGN FLOW (CFS)
0.093
STREAM STD (UG/L)
17.0
STREAM STD (MG/L)
1.0
UPS BACKGROUND LEVEL (UG/L)
0
UPS BACKGROUND LEVEL (MG/L)
0.22
IWC (%)
25.62
IWC (%)
25.62
Allowable Conc. (ug/1)
66.35
Allowable Concentration (mg/1)
3.26
•
minimum = 2
Ammonia as NH3
(winter)
7Q10 (CFS)
0.44
Fecal Limit
200/100ml
DESIGN FLOW (MGD)
0.06
Ratio of 2.9 :1
DESIGN FLOW (CFS)
0.093
STREAM STD (MG/L)
1.8
UPS BACKGROUND LEVEL (MG/L)
0.22
IWC (%)
17.45
Allowable Concentration (mg/1)
9.28
minimum = 4

o S2 s .%
i n T h e B l u e
July 9, 1999
Mr. Dave Goodrich
DWQ/DEHNR
1617 Mail Services Center
Raleigh, NC 29535-0617
Dear Mr. Goodrich:
Ridge M o u n t a i ns for Boys and Girls.
Re: NPDES NCO036251
Blue Star Camps, Inc.
Henderson County
JUL 2 0 1999 D
This is a request for an NPDES permit modification to change the monthly average flow limitation
from .040 mgd to .060 mgd for the above referenced NPDES permit.
The .040 mgd permit limit was based on an older WWTP facility that was subsequently turned
into an equalization basin to serve a new dual path .060 mgd activated sludge unit that was placed
into service in May, 1998, A request for permit modification, along with the Authorization to
Construct, was not requested at that time due to questionable flow data. Estimates (guesstimates)
of actual flows were made. Essentially, no one was able to confirm (with factual documentation)
actual daily or monthly average flow because of an existing maintenance situation concerning the
flow meter. This condition has now been corrected.
With an accurate flow measuring device in service, early July `99 flow data indicates a peak
month (July) flow expected to average approximately .045 mgd with daily peak flows of
approximately .052 mgd. This circumstance, if not considered and corrected, will result in a
violation of the existing NPDES permit flow limit for July (and possibly August) of this year even
through the new WWTP is now properly sized at .060 mgd, is operating well and producing an
excellent quality effluent that meets all other permit limitation and stream quality standards easily
(whether concentration based or mass based).
Mr. Tom Kilpatrick, DDK Environmental, Inc. (the ORC and WWTP operator) has discussed the
3595 Sheridan Street, Suite 107, Hollywood, FL 33021 / [phone] / Miami: [phone] / Fax: [phone]
P.O. Box 1029, Crab Creek Road, Hendersonville, NC 28793 / [phone] / Fax: [phone]
wwwbluestarcamps.com
Rodger and Candy Popkin, Owners and Directors Herman and Rosalie Popkin, Founders
Tom Rosenberg and lason Popkin, Associate Dimcors
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Mr. Dave Goodrich, NCDEHNR
Page Two
July 9, 1999
situation with Mr. Roy Davis, DEHNR, Western Regional Office. Mr. Davis advises a permit
modification is the proper course of action. I feel assured that Mr. Davis will respond in a
positive manner on our aspiration to be a responsible NPDES permittee.
For your information, Blue Star Camps, Inc. is a seasonal summer camp operating primarily from
June through August with a peak occupance of 1,050 people (July) consisting of an international
clientele. Blue Star Camps, Inc. is environmentally progressive in all areas but notably attentive
its role, position and obligations regarding the local environment, stream quality and WWTP
effluent quality. Blue Star Camps, Inc. offer special education and tours to both counselors and
campers with regard to how it operates both the water and wastewater systems to be
environmentally sensitive and friendly. We do not wish to be in a position of non-compliance for
an oversight with the regulatory sector.
Therefore, this is a request for an advisable correction to this situation: to be handled in the most
expedient manner, whether it be by permit modification, letter of variance (until new NPDES
permits are revised for French Broad River systems in September 2000, etc) or whatever means
you may suggest to facilitate the matter in order to keep Blue Star Camps, Inc. in a position of
full compliance with NPDES limitations and environmental expectations.
We hope you can appreciate the urgency of our concerns and very much appreciate your attention
to this situation. If you have any questions or need additional information, please feel free to call
me at 828-692-3591 or Mr. Tom Kilpatrick of DDK Environmental, Inc. at 828-664-5589.
Sincerely0,
U
om Rosenberg
Associate Director
cc: Roy Davis DEHNR, Western Regional Office
Tom Kilpatrick, DDK Environmental Inc.
Rodger, Candy & Jason Popkin

S3 `se�� 451/ s� szrr
in The Blue Ridge
March 1, 2000
Mr. Charles Weaver
NCDEHNR/DWQ/NPDES Unit
1617 Mail Services Center
Raleigh, NC 27699-1617
Dear Mr. Weaver:
Mountains for Boys and G irIs.
Re: NPDES Permit Renewal Application
NPDES Permit #NC 0036251
Blue Star Camps, Inc.
Henderson County
Please consider this request for renewal of the subject NPDES permit.
Changes to the facility since the last renewal are as follows:
After receiving authorization to construct, the existing system was modified in
1998. The modifications consisted of converting the existing .048 MGD in -
ground aeration tanks to serve as additional flow equalization capacity and adding
a new .060 MGD "package" extended aeration treatment plant.
System components now consist of a bar screen, equalization basin (60,000 gals
capacity) with mechanical pre -aeration, dual influent grinder pumps (70gpm),
flow splitter box, dual path aeration basins (30,000 gals capacity each) with
mechanical aeration, dual clarifiers, sludge holding tank (10,000 gals capacity),
chlorine contact chamber with tablet feed, dechlorination chamber with tablet feed
and an effluent flow meter.
A request to modify the existing permit from .048MGD to .060 MGD was submitted in July,
1999. This request is currently under consideration by your office at this time. However,
enclosed is a completed NPDES Permit Application - Short Form D - for renewal.
3595 Sheridan Street, Suite 107, Hollywood, FL 33021 / [phone] / Miami: [phone] / Fax: [phone]
P.O. Box 1029, Crab Creek Road, Hendersonville. NC 28793 / [phone] / Fax: [phone]
www.bluestarcamps.com
yives,kras
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Rodger and Candy Popkin, Owners and Directors Henan and Rosalie Popkin. Founders
Tom Rosenberg and lason Popkin. Assaciate Directors

Page Two
Mr. Charles Weaver
March 1, 2000
Sludge generated at this facility is pumped and hauled to a Class IV facility in Henderson County
for additional treatment and final disposal.
If you have any questions or need additional information, please feel free to call me at 828-692-
3591 or our plant operator, Tom Kilpatrick, at 828-891-2010.
Sincerely,
lz�'��
Tom Rosenberg
Associate Director
cc: Tom Kilpatrick
Rodger, Candy & Jason Popkin

S3� s v/ st,"40wez�
1n The Blue Ridge Mountains for Boys and Girls.
March 1, 2000
Blue Star Camps
Sludge Management Plan
Sludge generated at the Blue Star Camps facility is pumped and hauled to a Class IV facility in
Henderson County for additional treatment and final disposal.
j
Rosenberg
Associate Director
3595 Sheridan Street, Suite 107, Hollywood, FL 33021 / (9541963-4494 / Miami: [phone] / Fax: [phone]
P.O. Box 1029, Crab Creek Road, Hendersonville, NC 28793 / [phone] / Fax: [phone]
www.bluestarcamps.com
Rodger and Candy Popkin, Owners and Dinedon Herman and Rosalie Popkin. Founders
Tom Rosenberg and Iason Popkin, Assaiale Directors
•
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NPDES PERMIT APPLICATION - SHORT FORM D
To be filed only by dischargers of 100% domestic wastewater (< 1 MGD flow)
N. C. Department of Environment and Natural Resources
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
North Carolina NPDES Permit Number NC003(p2 S
(if known)
Please print or type
I. Mailing address of applicant/permittee:
Facility Name
-6( U e S+u r Camp s
Owner Name
�I ooGE R "D af.i uvnn l o 0x-1 n
Street Address
p box I ) 2q r_a� L,C- OW.
city
VMAo6,z',S0tJ qkll�
State
t�
ZIP Code
287�3
Telephone Number
( $Z$) (P 2 - 3Sgi I
Fax Number
(182 ) 02 - 70 3 J
e-mail Address
TO IM(P15WESTA(L C4MAPS.
2. Location of facility producing discharge:
Name (If different from above) 904V
Facility Contact Person
I—om 1\ 05t ]3ek.Cr
Street Address or State Road ca-06 Use-EK . 2C(�-43 S 0-1127
City / Zip Code
County
f�1 tJG 2 s�
Telephone Number
U1'd, - 3S�I f
3. Reason for application:
Expansion/Modification *
Existing Unpermitted Discharge
Renewal X New Facility
* Please provide a description of the expansion/modification:
4. Description of the existing treatment facilities (list all installed components with
000
capacities): - 2flU=. ss et eo Arr ,
^i'►1�cTR�A�tiIcJ� �Q,JcrsS i S T p�cA-�. �`�.n A 2 ;Boni n� ��JA-..� �/k��J
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G,1� sc.2E� ,
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tee.
psi �1((�0 a )0 &ALS. CkPA4T�)Ld 11T14 MCC rt cat '�2E - (��121�-7► , �J Pam- ae'-� s �► Cz2 r Ala a.l M Ps '] c�CsPr�'1),
FIXW SPUTTa BCX " pJA�- B 2i Aee i k art VSi 4 S 00, 000 GA... Ch4c o ^? t,:� ArC4 Q ITA Wlc"uhW 1(k
S �,Jt�(s£iti1(t iIS� O �JO GA+1.S , (AP�Cr i GiliJ2lt�c h�.
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t+c TP2ca-'tV �fsh-J u s D I su A (4&L> 1 o 1 pC, ,'� kJ �t 2S tJ �= M J D �-L /k' C-�A-S�s C. s �, 31VI) ► nl
i�ke FRca 0e ' 2. A, j
Page 1 of 2 Version 699

NPDES PERAUT APPLICATION - SHORT FORM D
To be filed only by dischargers of 100% domestic wastewater (<1 MGD flow)
5. Description of wastewater (check all that apply):
Type of Facility Generating Wastewater
Industrial Number of Employees (&fLOr
Commercial Number of Employees
Residential Number of Homes Z
School Number of ars /Staff Oa 34IMeKt,rse.aso�
Other (5JMMc k c *%e) o
Describe the source(s) of wastewater (example: subdivision, mobile home park, etc.):
c4Z%.r>zcA's somo%ek eAe^e .
S. Number of separate wastewater discharge pipes (wastewater outfalis):
oar
7. U the facility has multiple discharge outfalls, record the source(s) of wastewater for each
outfall:
W h%
S. Name of receiving stream(s) (Provide a map showing the exact location of each outfall):
µ Ito C,Q.E`.c.. , a Gt ASS G S'fi2��M 04 FfIEAUk 1 &060
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing
Title
ture of Annlfcant
to
North Carolina General Statute 143-215.6(b)(2) provides that: Any person who knowingly makes any false statement representation, or
certification in any application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any
recording or monitoring device or method required to be operated or maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a fine not to exceed $10,000, or by
imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than $10,000 or
imprisonment not more than 5 years, or both for a similar offense.)
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