NC0060623_Renewal (Application)_20240410

RECEIVED
NPDES Permit Number I 18C 11ty N.M.
Nc o O Ioo `� 3 j , _ v° i ►
moameo Appimasm corm u+
Modified March 2021
Form
NC Department of Environmental Quality - Application for NPQ� snhar � lo
form, th In ��FaLVir
NPDES
MINOR SEWAGE FACILITIES (Before completing this pleasure
the Instructions ma result in denial of the application.)
Facility name
The VA I 1g je-
1.1
Mailing address (street or P.O. box)
"�Or
604 Ni ► CO acr
C
City or town _ State ZIP rode
pia ke. row' N C
Contact name (first and last) Title Phone number Email address
nne jepwer Q Wner i �t - 4 13 -13G+ m lynne yc�Qp9
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
ro
I c Vi /la BAG j/ J �/a 1rin�ir% n+c �� k' A/i AVok 44-O
City or tow SAW ZIP code
6-ionevr%le- 1JC ,Z-7©yg
1.2
Is thi 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?
❑ Yes (j"No 4 SKIP to Item 1.4.
Applicant name
Applicant address (street or P.O. box)
City or town
State
ZIP code
SContact
name (first and last)
Title
Phone number
Email address
1.4
is the licant 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 onl one response.)
❑ 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.)
E%Wng Envirormmm iPsm ills.
NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
2r
control)
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
i
`�
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
404)
Page 1
ES

NPDES Permit Number
Facility Name
I /0
Modified Application Form 2A
Modified March 2021
1.7
Provide the collection stem information
re nested below for the4rdatment works.
Municipa>r
Population
Collection System Type
i Served ..
Served
(itcate�ercentage� _.._
_attts
G' % separate sanitary sewer
% combined storm and sanitary sewer
93,Own ❑ Maintain
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
% separate sanitary sewer
❑ Own ❑ " Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
h is
❑ Unknown
❑ Own ❑ Maintain
f
% separate sanitary sewer
❑ Own ❑ Maintain
`
% combined storm and sanitary sewer ❑ Own ❑ Maintain
"'"
❑ Unknown
❑ Own ❑ Maintain
11 separate sanitary sewer
❑ own ❑ Maintain
s
%combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ own ❑ Maintain
Total
Population �QQ
Served
Separate Sanitary Sewer System
Combs d Storm and
Saud Sewer
Total percentage of each type of
j j U %
' %
sewer line (in miles'
C�
1.8
Is the treatment works located in Indian Country?
❑ Yes Eal"No
'
1.9
Does the facility discharge to a receiving water that flows through dian Country?
❑ Yes No
Provide design and actual flow rates in the designated spaces.
buign Flow PhAs .
1.10
mgd
`
Ann'V t1=Avg e"Rates.
` •
TMreifeM ` .� Last ye*
m an 9d
Qc �� mgd
d
(�. �l3 mgd
aria Flotr liars al
"t plrasprs;Ap Yam ''
TWYear
o
mgd Q . 0 / 1� mgd
Q V / % mgd
_
1.11
Provide the total number of effluent discharge points to waters of the State of North Carotin_ a by type,
°Totir�WmbwcfilusrttDiccitet ice.
r .
`
-r_
tMtr+oamd'iCrtfh,eni
Combbod sswer
Bypass
,.{.,�{,.f
Constructed
Emergency
v
�Ytt1iM`@+flulNtlt
Overflows
o
Page 2

NPDES Permit Number
Facft Name
Modified Application Form 2A
/f /C 00606
—ems
WOW Match 2021
Outfalls Other Than to Waters of the Site of North Cardne
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 E�rNo + SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
. merit Loan and "Ep
(Date
Average _ Volume
Congnuous or ktt rmKIent
Location
Discharged to Surface
( (died one)
Impoundmard _
0 Continuous
gpdT
❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
gpd
❑ Continuous
p
❑ Intermittent
1.14
Is wastewater applied to land? —/
El Yes �d No 4 SKIP to Item 1.16.
1.15
Provide the land application site and discharge data requested below.
1
Land Applicadon Site and D",arge Data. -
Cantlnuous a
Average Daily Volume
SUBApplied
-
ECit 0_ one)
m
❑ Continuous
a
acres
gpd'; ❑ Intermittent
❑ Continuous
aces
gpd ❑ Intermittent
O
acres
❑ Continuous
gPd
j ❑ Intermittent
1.16
Is effluent transported to another facility for treatment pno to discharge?
❑ Yes No + 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 trans otter below.
Traha aver 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 FeC�ily Name
Modified Application Form 2A
Modified March 2021
1.20
i In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving factlit .
Reammivino F cility Data
I
:Facility name
Mailing address (street or P.O. box)
-
�
City or town
State
ZIP code
I
Contact name (first and last)
Title
-'`
Phone number
Email address
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
1.21
i
Is the wastewater disposed of inmenned in a manner other than those already mentioned items 1.14 through 1.21 that do
.c
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
❑ Yes 1211" No 4 SKIP to Item 1.23,
1.22
Provide information in the table below on these other disposal methods.
Mior vnlittrer,
-blip)
Methods' A
1.
Locitb;.. of
Slue of
Annual Average :;
Cor&uous orftttemn tent
t
1
D�POW SRO
DtsposatUs
Ilwlymcharp
- (Chock one)
acres
9Pd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
I
❑ 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.
yy�
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
i�_`
❑ 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 re nsibility 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 reseTsibilities.
contractor NtNT!tlon
Coat ectof 3
` CoMraict 3
Contractor name
(company name
G DPI
Mailing address
.
street or P.O. box
/C
City, state, and ZIP
l C
g
code
0�1
Contact name (first and
last)I'
N'l 1 l�Ul
Phone number
3 _ _ q7
Email address
1'1&*,m. �di-n c�
ems boa —ne- ie✓
Operational and
maintenance
Gf G0
responsibilities of
vJ
contractor
Page 4

NPDES Permit Number I Facflq Name nnoamea Rppucauon roan u+
Modified March 2021
SECTIONADDITIONAL
INFORMATION
putfeft to Waters of the We of Norttr CartiIlpa
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes Q---No 4 SKIP to Section 3.
2.2
i Provide the treatment works' current average daily volume of inflow
Average tally Votu"of bttow and MAraflon
gpd
and infiltration.
Indicate the steps the facility is taking to minimize inflow and infiltration.
a
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
❑ Yes ❑ No
F-
2A
Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for speck requirements,)
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No + SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
d
E
a
2.
's
a
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
S
or Actual Dallas of C tlon for Im ravernertts
�I
Mftted fall
out
Begin
End
gulp
si#
(fist outtall
Construcllon
Construction
Qatar
I."
E
{
number
(MWI}DIN"
�IdMfDDIYYYY
(IVMIDDPYYYY)
MMM
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federallstate requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPOES Permit Number Facility Name Modified Application Form 2A
�''/�� (o Modified March 2021
INFORMATIONON
A- r
3.1
Provide the following information for each outfall. (Attach additional sheets d you have more than three outfalls.)
af1t Number
+OutWI Nureber :°
WWI NUnber
State
Nv
County
City or town
Distance from shore
Depth below surface
O ft.
fL
ft.
Average daily flow rate
mgd
mgd
mgd
Latitude
/
"
Longitude
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
❑ Yes No 4 SKIP to Item 3.4.
3.3
If so, provide the following information for each applicable outfall.
Ou#a►FNturnber
OullfaN Number ...
Outfalf Number
Number of times per year
r
discharge occurs
Average duration of each
discharge (specify units
Average flow of each
mgd
mgd
mgd
discharge
Months in which discharge
occurs
3.4
Are any of the outfalls listed under item 3.1 equipped with a diffuser.?
❑ E No 4 SKIP to Item 3.6.
Yes
3.5
Briefly describe the diffuser p.
pe at each applicable outfall.
'OuM,Number
•Ou"Melt._
1�Number
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?
I
❑ Yes El No ,1SKIP to Section 6.
Page 6

NPDES Permit Number
Facility Name Modified Application Form 2A
];�
o6)60
(illa Modified March 2021
3.7
Provide the receiving water and related information if known) for 6dbh outfall.
OutfallIumber
Outfd Number__,_,._
OuaaNA109 r
Receiving water name&"
Ceek
Name of watershed, river,
62qh0/le 91 vc,Y
or stream system
-.1
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basinEP
U.S. Geological Survey
8-digit hydrologic
0,,30 (d to 3
cataloging unit code
Critical low flow (acute)
ds
cfs
cfs
Critical low flow (chronic)
cfs
ds
ds
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CeCO3
3.8
Provide the following information
describing the treatment ravWed for discharges from each outfall.
outfall Number j_ OutWI NumW
Outfit Number
Highest Level of
ffrprimary I ❑ Primary ❑ Primary
Treatment (check all that
❑ Equivalent to ❑ Equivalent to ❑ Equivalent to
apply per outfall)
/Secondary i secondary secondary
Cr Secondary ❑ Secondary ❑ Secondary
❑ Advanced ❑ Advanced ❑ Advanced
[e Other (specify) ❑ Other (specify) ❑ Other (specify)
Design Removal Rates by
Outfall
BOD5 or CBODs
_
L, 3 C� ) %
%
%
TSS
L jQ C%
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
G %
%
%
❑ Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
% ;
%
Other (specify)
❑ Not appNca le
❑ Not applicable
❑ Not applicable
%
Page 7

NPDES Permit Number
/I �� /) / l / �i % f)�
Facility Name
// //6
Modified Application Forth 2A
Modified March 2021
3.9
' Describe the type of disinfection used for the effluent from ea c tfall in the table below. If disinfection varies by
season, describe below.
�pc��u� y%JDI fvrr f f-%G
Wftw*mi w
OWlfill r.,._�.
Disinfection type
�
Seasons used
Dechlorination used? j
❑ Not applicable
❑ Not applicable
❑ Not applicable
El 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?
❑ Yes I 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 + SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permtt reissuance of the facility's
discharges by outfall number or of the receivin water near the discharge points.
Oattt'aH"Number
OwtfaB t�tumt r ,..
Ottttfatt Number
Actft
�`•Ctu ift
,Ache.
cRffonle
Acute
CFiror�c.
Number tests discharge
of of
water
Number of tests of receiving
water
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?
Eir Yes 4 Complete Table B, including chlorine. ❑ No + 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?
Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants r uired by your NPDES permitting authority and
3.18
attached the results to this application package?
❑ Yes No additional sampling required by NPDES
perrrfitfing autho ity.
Page 8

NPDES Permit Number
Al ON1 o 6 ,2,
Fecility Name
V i At-,
Modified Application Form 2A
Modfied March 2021
I
3.19
Has the POTW conducted either (1) minimum of four quarterly" T 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 our NPDES permitting authority and provide a summary of the results.
Date(s) 3abr it*t!
�lMietAmYY}
Summary of. Results
0
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26
3.23
Describe the cause(s) of the toxicity:
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 ❑ Not applicable because previously submitted
information to the NPDES permittina authon'tv.
Page 9

I NPDESS Permit Number Facility Name
Modified Application Form 2A
(�
GC0606 f— l
Modified March 2021
SECTIONri
r
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
Colum 2
Section 1: Basic Application
❑ w/ variance request(s) ❑ w/ additional attachments
Information for All Applicants
Section 2: Additional
w/ topographic map ❑ w/ process flow diagram
Information
❑ w/ additional attachments
❑ /w1 Table A wl Table D
Section 3: Information on
(� w/ Table B ❑ wl additional attachments
Effluent Discharges
❑ w/ Table C
Section 4: Not Applicable
Section 5: Not Applicable
..
`.
---3ect!on 6: Checklist and
❑ w/ attachments
Certification Statement
6.2
Certification Statement
I 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 qualffled 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 Im dsonment for knowing violations. _
Name (print or type first and last name)
Official title
0AC/- >
Signature
Date signed
RECEIVED
APR 10 2L-
NICDEQIDWR/ IP DES
Page 10

NPDES Permit Number
Facility Name
Outfall Number
WA
Modified Application Form 2A
Modified March 2021
c wn q G ••
Pollutant
Maximum Daily Discharge
Average Daily Discharge
Analytical ML or MDL
Value
Units
Value
Units
Number of
Samples
Methods (include units)
Biochemical oxygen demand
IODs or ❑ CBODs
/
jrn S' k)
❑MDL
(report one
`� �
U
Fecal coliform
O
/%?G
C,"� /01-�-X
COt-1A� ryJ / ❑ ML
�i ❑MDL
Design flow rate X
0. Q/5—
0, 0 j! f
5-
pH (minimum)
V/7
pH (maximum)
-7, 3
Temperature (winter)
jC«
Temperature (summer)
Total suspended solids (TSS)
25ya/ L
O /L ❑M❑ MDL
I Sampling shall be conducted according to sufficiently sensitive46st 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

F_�EPA Identificafion Number NPDES Permit Number Facility Name OuNafi Number
Modified Application Form 2A
I Modified March 2021
+: •,•+
,"jig
I
-
Efo1"t
♦
.. ,,.
.1fi81ue
.Ultlls
Value
a .i.
..
l
( IN11t.4)
Ammonia (as N)
5
tyl lG
D ML
Chlorine13
CI MDL
QQ
_
total residual, TRC 2
ML
o MDL
Dissolved oxygen
. d
rV( %L
`�
��`�� — s
rl U
G
Nitrate/nitrite
p ML
13 MDL
Kjeldahl nitrogen
❑ ML
-.-E3
MDL
Oil and grease
(�(�
❑ ML
---
Phosphorus
❑ MDL
p ML
❑MDL
Total dissolved solids
LI 5
m /L
5
m j
51'n?540T-)0i
❑ ML
/L
5amnlinn chail ho rnnriurtad armMi—
+„ o.,ffininn+h,
❑ MDL
,...., r .., ..., Yv %,r*m roo iur me analysis or 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 chorine 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

EPA Ide cation Number NPDES Permit Number Facility Name Outralt Number Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge AvwW Deily Drlcef&V
Poquiant
NIL or MDL
Value
----
UMts Value
Unb
Mna�c.of
Meiltottt
(inctudemnits)
Metals, Cyanide, and Total Phenols
Hardness (as CaCO3)
❑ MIL
❑ MDL_
Antimony, total recoverable
❑ ML
_.
El
Arsenic, total recoverable
-
❑ ML
_..
❑ MDL
Beryllium, total recoverable
❑ ML
❑ MDL
Cadmium, total recoverable
❑ ML
__--
❑ MDL
Chromium, total recoverable
❑ ML
❑ MDL
Copper, total recoverable
❑ MI.
❑ MDL
Lead, total recoverable
_. _
❑ ML
❑ MDL
Mercury, total recoverable
❑ Mt
❑ MDL_
Nickel, total recoverable
❑ ML
__—
❑ MDL
Selenium, total recoverable
❑ ML
❑ MDL
Silver, total recoverable
....
❑ ML0
_- -
MDL
Thallium, total recoverable
❑ MIL
❑ MDL
Zinc, total recoverable
11 ML
❑ MDL
Cyanide
_.
o ML
❑ MDL
Total phenolic compounds
❑ MIL
❑ MDL
le Organic Compounds
crolein
o ML
❑ MDL
crylonitrile
IA
❑ ML❑
MDL❑
MLenzene
❑ MDL
romoform
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

i EPA Identificatlon Number NPDES Pennft Number Faafily Name Outfall Number Modified Application Form 2A
Modified Mardi 2021
''
•• 61291
M dl a D* Dischatrgr3
AVWglEr.f?* tDsclt W
Poll ht
_
L& eu DL-
uatuQ
Unite
Value `'
_
Ufft
NatWw °f
IY~
(ride un sy
SeniPles
. • . r
._•..
Carbon tetrachloride
❑ ML
----------
Chlorobenzene
❑MDL
--❑ ML .,..
❑ MDL
Chlorodibromomethane
o ML
Ch{oroethane
DL
L0M.
_. _-_ ......
2-chloroethylvinyl ether
❑ MDL
❑ ML
Chloroform
—
El MDL
❑ ML -
Dichlorobromomethane
❑ MDL
❑ ML
❑ MDL
1,1-dichloroethane
p ML
1,2-dichloroethane
❑ MDL
-p ML
❑ MDL
trans-1,2-dichloroethylens
❑ Mt
1,1-dichloroethylene
—
❑ MDL
❑ ML
1,2-dichloropropane
❑ MDL
❑ ML
_.
❑ MDL
1,3-dichloropropylone
❑ ML
❑ MDL
Ethylbenzene
❑MI
❑ MDL
Methyl bromide
❑ ML
O MDL
Methyl chloride
p Mt
❑ MDL
Methylene chloride
---
❑ Mi. _-
❑ MDL
1,1,2,2-tetrachloroethane
❑ ML
❑MDL
Tetrachioroethylene
-o
ML-EE
Toluene
r-
0 MDL
0 ML
1,1,1-trichloroethane
❑ MDL
❑ ML
1,1,2-trichloroethane
❑MDL
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 14

EPA Identification Number NPDES Permit Number Fadlity Name OutWI Number � Modified Application Form Modified March 202121
Pollutant
Mwdtrtum Dai13t Olacfie►ge
Average Daily Discharge
Value Units Number of
Samples
Analytical
Methodi
ML or MDL
(include units)
Vwue
Un is
Trichloroethylene
n ML
FI MDL
Vinyl chloride
—_
0ML
❑ MDL
Acid -Extractable Compounds
ploro-m-cresol —
LI ML
J MDL
2-hlorophend
❑ ML
MDL
2,4-dichlorophenol
❑ ML
❑ MDL
2,4-dimethyphenol
El ML
❑MOL
4,i-dinitro-o-cresol
❑ ML
❑MDLc
2,4-dinitrophenol
❑ MDL
2-nitrophenal
_
❑ ML
❑ MDL
4-nitrophend
❑ ML
❑ MDL
Pentachlorophend
❑ ML
❑ MDL
Phenol
❑ ML
❑ MDL
2,4,6-trichlorophenol
❑ ML
❑ MDL
Base -Neutral Compounds
cenaphthene
_
❑ ML
❑ MDL
cenaphthylene
_
❑ ML
❑ MDL
❑ ML
0 MDL
enzidine
jA4nthracene
0 ML
❑ MDL❑
enzo(a)anthracene
ML
❑ MDL
enzo(a)pyrene
❑ ML
❑ MDL
-benzoffuoranthene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

EPA Identificatioe Number NPDE3 Perm t Number Fac�tq Name Outfall Number Modified Application Form 2A
Modified March 2091
"=
Maxlntam Daily lDiSCtbarge
Average My Discharge
:..
Anatytieet
WL or MDL
Valve
Units
Value
----
.UMbs .
F `
' Methodl
(include units)
Benzo(ghi)perylene
❑ ML
Benzo(k)fluoranthene
❑ MDL
❑ ML
❑ MDL
Bis (24kroethoxy) methane
❑ ML
El MDL
Bis (2-chloroethyq ether
❑ ML
Bis (2-chloroisopropyi) ether
❑ MDL
a ML
Bis (2-ethylhexyl) phthalate
❑ MDL
❑ ML_ —
4-bromophenyl phenyl ether
DL
p ML
Butyl benzyl phthalate
❑ M
DL ❑ ML
❑ MD.
2-chioronaphthalene
❑ ML
❑ MDL
4-ctlorophenyl phenyl ether
❑ ML
❑ MDL
Chrysene
❑ ML
❑ MDL
dM-butyl phthalate
❑ ML
❑ MDL
di-n-octyi phthalate
❑ ML
_
❑ MDL
Dibenzo(a,h)anthracene
❑ ML
_.
❑ MDL
1,2-dichlorobenzene
13 ML
❑ MDL
1,3-dichlorobenzene
❑ ML
❑ MDL
1,4-dichiombenzene
❑ ML
❑ MDL
3,3-dichlorobenziclne
❑ ML
Diethyl phthalate
❑ MDL
❑ ML
Dimethyi phthalate
❑ MDL
❑ ML
2,4-dinitrotoluene
❑ MDL
ML
2,6-dinitrotoluene
❑ MDL
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19)
Page 16

EPA Identification Number
NPDES Permit Number Facility Name Ouifall Number
Modified Application Form 2A
Modified March 2021
Mattlmum Dailq Oftt arge Arrm9e My Discharge
Po.uuta
— _ — - . ,_
MDI.
Value
Units
-
Akio
_.
Uft
Number of
Mafpadt (include units)
Sara !es
1,2-diphenylhydrazine
0 ML
❑ MDL
Fluoranthene
❑ ML❑
MDL
Fluorene
D ML
❑ MDL
Hexachlorobenzene
l7Ml _
❑ MDL
Hexachlorobutadiene
❑ ML
_
0 MDL
Hexachlorocycio-pentadiene
0 ML
❑ MDL
Hexachloroethane
❑ ML
❑ MDL
Indeno(1,2,3-cd)pyrene
❑ ML
❑ MDL
Isophorone
❑ ML
❑ MDL
Naphthalene
❑ ML
—
❑ MDL
Nitrobenzene
_
❑ ML
❑ MDL
N-nitrosodi-n-propylamine
_
❑ ML
❑ MDL
N-nitrosodimettrylamine
El ML_❑
_.
MDL
N-nitrosodiphenylamine
❑ ML
❑ MDL
Phenanthrene
0 ML
❑ MDL
Pyrene
I
❑ ML
J
❑ MDL
1,2,4-trichlorobenzene
^
El MIL
❑MDL
oampung snau oe conoucteu accoromg io sumcienuy sensitive test proceaures (i.e., metnoos) approved under 4Q UR 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

NPDES Permit Number FadRty Na----� Oulfall Number WOW Application Form 2A
Modified March 2021
me •s a •�
•-
1Aanimum Daily Discharge Average Dal DIwAa e
pollutant - L_ — _ _. rB .i_ Number of '� Mlaar IM�L
Value Urdu Value .
_ Sam les i
_
❑ 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
_-.
11 MDL
❑ ML
❑ MDL
❑ ML
0 MDL
❑ ML
i Rmmnlinn eh2li ho mminr wi arc
n ;i t, �„fA .i. A. , .
..ou..
❑ MDL
N,,,,, ul ua „ 11,UE11vubj dpPiuvua unuer w k r-K -iso Tor 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

Quad: Southwest Eden, N.C. IVC0060623
Latitude: 36°28' 13"
Longitude: 79°50'21" Stone Highway MHP
Stream Class: WS-IV
Subbasin: 03-02-03
Receiving Stream: UT Buffalo Creek
Facility
Location
N044 SCALE 1:24000