NC0075523_Renewal (Application)_20240510

ROY COOPER �, it Aga
Governor ,4 �i �"
ELIZABETH S.RISER - "49
k QUAM N\0\
Secretary :-mot t
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
May 13, 2024
RDH Tire & Retread
Attn: Dennis Phillips, Maintenance Supervisor
PO Box 187
Cleveland, NC 27013-0187
Subject: Permit Renewal
Application No. NC0075523
RDH Tire & Retread
Rowan County
Dear Applicant:
The Water Quality Permitting Section acknowledges the May 10, 2024, receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://www.deq.nc.gov/permits-rules/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
ic L.,JA
Wren T edfor
Administrative Assistant
Water Quality Permitting Section
cc: Scott E. Ragan
ec: WQPS Laserfiche File w/application
DEQ) North Carolina Department of Environmental Qua1Ry I Divlsfon of Water Resources
,./ Mooresville Regional Office 610 East Center Avenue.Suite 30I Mooresvilk.North Carolina 28115
^�y^^ •'a+'v� / 704663.1699

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
OMB No.2040-0004
N 0 0-7 55)3 !�QI{l+re.t ► z_I-4ib! Goo•
U.S.Environmental Protection Agency
Form
*-/EPA Application for NPDES Permit to Discharge Wastewater
NPDES GENERAL INFORMATION
SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1))
1.1 Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned Is the facility a new or existing treatment works
1.1.1 1.1.2 treatingdomestic sewage?
treatment works? g
If yes,STOP.Do NOT complete Er No If yes,STOP. Do NOT [l' No
Form 1.Complete Form 2A. complete Form 1.Complete
Form 2S.
1.2 Applicants Required to Submit Form 1
1.2.1 Is the facility a concentrated animal feeding 1.2.2 Is the facility an existing manufacturing,
operation or a concentrated aquatic animal commercial,mining,or silvicultural facility that is
a production facility? currently discharging process wastewater?
0 Yes 4 Complete Form 1 Er No 'Yes Complete Form No
z and Form 2B. 1 and Form 2C.
c 1.2.3 Is the facility a new manufacturing,commercial, 1.2.4 Is the facility a new or existing manufacturing,
mining,or silvicultural facility that has not yet commercial,mining,or silvicultural facility that
c commenced to discharge? discharges only nonprocess wastewater?
mYes 4 Complete Form 1 No Yes 4 Complete Form [ 'No
and Form 2D. 1 and Form 2E.
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activityor whose RECEIVE
discharge is composed of both stormwater and
non-stormwater? MAY 10 2024
Yes 4 Complete Form 1 Er No
and Form 2F
unless exempted by NCDEQ/DWRINPDES
40 CFR
122.26(b)(14)(x)or
b 15.
SECTION 2.NAME, MAILING ADDRESS, AND LOCATION (40 CFR 122.21(f)(2))
2.1 Facility Name
2.2 EPA Identification Number
0
J
2.3 Facility Contact
Name(first and last) Title Phone number
1
J 7CY "0;'1 /
9.3
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o, Email address
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d 2.4 Facility Mailing Address
Street or P.O.box
/ee, 64,h /49 7
ZIP code
State
City or town � /
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Page 1
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19OMB No.2040-0004
/1/44D75.52.3 ROY- TrL/ �j� .
y 7, 2.5 Facility Location
c Street,route number,or other specific identifier
a 0 / 315 Aec1/1144 , dLt4'
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c County name County code(if known)
0 /•'M C c.V.e4/r
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- City or town State I` ZIP code
z ei Ur/4,,d 44 ZIa ri f. 1 � ��3
SECTION 3. SIC AND NAICS CODES (40 CFR 122.21(f)(3))
3.1 SIC Code(s) Description(optional) 4
201 / �m u--zr 0tJ-a 1 bvii #- Curb, clwcs
N
O
U
N
U
z 3.2 NAICS Code(s) Description(optional)
SECTION 4.OPERATOR INFORMATION (40 CFR 122.21(1)(4))
4.1 Name of Operator
'L N /;re ,e Ke Cde
0 4.2 Is the name you listed in Item 4.1 also the owner?
2 Yes ❑ No
4.3 Operator Status
0 Otherpublic(specify)
� ❑ Public—federal ❑ Public—state ( p fy)
o Private ❑ Other(specify)
4.4 Phone Number of Operator
—70 Li .27F— )‘.;?/
4.5 Operator Address
O
Street or P.O.Box
R
/3 is-- e„
c c City or town State ZIP code
C / J' !H,
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ev
c Email address of operator
O /,4r 4I_-/98 �' a4 ', Cote,
SECTION 5. INDIAN LAND(40 CFR 122.21(f)(5))
c 5.1 Is the facility located on Indian Land?
0 Yes [ o
Page 2
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number /�u Facility Name Form Approved 03105/19
l C U b-I S'S 023 /7d/lT 7;';! li4,A• OMB No.2040-0004
SECTION 6. EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6))
R 6.1 Existings Environmental Permits(check all that apply and print or type the corresponding permit number for each)
R NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of
water) fluids)
us
.AJGOc 7i52J
w a. El (air emissions) ElNonattainment program(CM) 0 NESHAPs(CM)
a
x ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) 0 Other(specify)
SECTION 7. MAP (40 CFR 122.21(f)(7))
a
7.1 Have you attached a topographic map containing all required information to this pplication?(See instructions for
c. specific requirements.)
1- Yes 0 No 0 CAFO—Not Applicable(See requirements in Form 2B.)
SECTION 8.NA7URE OF BUSINESS(40 CFR 122,21(f)(8))
8.1 Describe the nature of your business.
gtJ L
Lt G�-cC/� /f.�/ /? le --rd'41 ,4rt C-
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10
SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9))
9.1 Does yourfacility use cooling water?
E Yes 0 No 4 SKIP to Item 10.1.
9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125,Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your
c NPDES permitting authority to determine whatspecific information needs to be submitted and when.)
V w A/c7 �iltlha Ae;o to �'-.i e,41)ciciv i etn I YnlLl
SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that
apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and
d when.)
❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section
Section 301(n)) 302(b)(2))
❑ Non-conventional pollutants(CWA El Thermal discharges(CWA Section 316(a))
Section 301(c)and(g))
❑ Not applicable
Page 3
EPA Form 3510-1(revised 3-19)

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
; OMB No.2040-0004
4Ga7s�,?.3 fir,lt ,,- /e c.
SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and (d))
11.1 In Column 1 below,mark the sections of Form 1 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
Er Section 1:Activities Requiring an NPDES Permit ❑ w/attachments
[- Section 2:Name, Mailing Address,and Location ❑ w/attachments
12- Section 3:SIC Codes ❑ w/attachments
Section 4:Operator Information ❑ w/attachments
El Section 5:Indian Land ❑ wl attachments
Er Section 6: Existing Environmental Permits ❑ w/attachments
E l`� wl topographic ❑ w/additional attachments
;; Er- Section 7:Map map
co
cSection 8:Nature of Business ❑ w/attachments
wEirr-
Section 9:Cooling Water Intake Structures ❑ wl attachments
r
❑ Section 10:Variance Requests ❑ wl attachments
co ❑ Section 11:Checklist and Certification Statement ❑ wl attachments
Y
d 11.2 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 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
adf%s 6), ✓ *5 .21 4f 7 - 74,1u. S , ,'era.o r
Signature Date signed
/14.41.4not<A*2- . ,' '' &----:" 3—,2 ii
Page 4
EPA Form 3510-1(revised 3-19)

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RDH Tire & Retread - RDH Tire & Retread N -,-
NPDES Permit NC0075523
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1:15.000.000 , __ ,/
Receiving Stream: UT to Beaverdam Creek Stream Class: C
Stream Segment: 12-108-21-5 Sub-Basin#: 03-07-06
River Basin:Yadkin-Pee Dee HUC: 030401020502 SCALE 35.706394°N, -80.66828°W
County: Rowan 1:20,000

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
Expires 07/31/2026
Form U.S. Environmental Protection Agency
2C 0EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS
SECTION 1. OUTFALL LOCATION (40 CFR 122.21(G)(1))
1_1 Provide information on each of the facility's outfalls in the table below.
Ouffa
O Number Receiving Water Name Latitude Longitude
Cc j u i. i3e„K.4,1 de ?)5. 7 46 3 9 Y° N --go i(G 5?- " t'
0
SECTION 2. LINE DRAWING (40 CFR 122.21(G)(2))
a, 2_1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
2 3 balance?(See instructions for drawing requirements.See Exhibit 2G-1 at end of instructions for example.)
J 12
ca ❑ Yes
SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(G)(3))
11 For each ouffall identified under Item 1.1,provide average flow and treatment information.Add additional sheets if
necessary.
"Outfall Number' 00 I
Operations Contributing to Flow
Operation Average Flow
4 (-burr) • 00c,� mgd
mgd
ns
mgd
a
mgd
0
Treatment Units
Description Code from Final Disposal of Solid or
d (include size,flow rate through each treatment unit, Exhibit 2C-2 Liquid Wastes Other Than
retention time,etc.) by Discharge
EPA Form 3510-2C Page 1

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
A/ y— ) �J�j�/ ff ./ /� / Expires 07/31/2026
110 �G'•777 2J /ly /771i'C ~/`*17Y�(' G =.
3.' "Outfall Number"
cont. Operations Contributing to Flow
Operation Average Flow
mgd
mgd
mgd
mgd
Treatment Units
Description Code from Final Disposal of Solid or
(include size,flow rate through each treatment unit, Liquid Wastes Other Than
retention time,etc.) Exhibit 2C-2 by Discharge
c
0
C)
E
ca
co
"Outfall Number*
N Operations Contributing to Flow
o Operation Average Flow
rn mgd
a mgd
mgd
mgd
Description Final Disposal of Solid or
(include size,flow rate through each treatment unit, Code from Liquid Wastes Other Than
retention time,etc.) Exhibit 2C-2 by Discharge
3_2 Are you applying for an NPDES permit to operate a privately owned treatment works?
d ❑ Yes [' No SKIP to Section 4.
N to
3.3 Have you attached a list that identifies each user of the treatment works?
❑ Yes
EPA Form 3510-2C Page 2

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
Expires 07/31/2026
Al 0 a 1 ss.73 130E TtR I/ulru
SECTION 4. INTERMITTENT FLOWS (40 CFR 122.21(G)(4))
41 Except for storm runoff,leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal?
[vrYes 0 No 4 SKIP to Section 5.
4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages, if
necessary.
Frequency Flow Rate
Outfall Operation Average Average Long-Term Maximum Duration
Number (list) Days/Week Months/Year Average Daily
00
5_�',"" `'i" 1'�'~ 5 days/week j 2 months/year ,pooc •=mgd ,,vvCdc' mgd S. days
j7
N ' .1 it r arYc umcs
odays/week months/year mgd mgd days
m days/week months/year mgd mgd days
E
co days/week months/year mgd mgd days
c
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
days/week months/year mgd mgd days
SECTION 5.PRODUCTION (40 CFR 122.21(G)(5))
5_1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your
facility?
❑ Yes [-]/ No 4 SKIP to Section 6.
6 5_2 Provide the following information on applicable ELGs. Regulatory Citation
w ELG Category ELG Subcategory 9 rY
0
0
0
.Q
a
5_3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)?
en ❑ Yes ❑ No 4 SKIP to Section 6.
c
o
5_4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Unit of
J Outfall Operation,Product,or Material Quantity per Day Measure
-0 Number
C)
CA
CO
CO
c
0
C.)
0
0
Page 3
EPA Form 3510-2C

EPA Identification Number / NPDES Permit Number Facility Name OMB No.2040-0004Expires 07/31/2026
jj
in the actualproduction duringthe next permit
limits based on an anticipated increase
requesting alternative Ilm P
Are you q g
(Consult withyour NPDES permitting authority to determine what information needs to be submitted and
term?
when.)
❑ Yes ❑ No
SECTIO, 6. IMPROVEMENTS(40 CFR 122.21(G)(6))
6_1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for
constructing,upgrading,or operating wastewater treatment equipment or practices or any other environmental
programs that could affect the discharges described in this application?
❑ Yes [r No 3 SKIP to Item 6.3.
Briefly identify each applicable project in the table below.
Affected Final Compliance Dates
Brief Identification and Description of Outfalls Source(s)of
Project (list outfall Discharge Required Projected
° number)
E
c
co
a,
co
co
a>
6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental
projects that may affect your discharges)that you now have underway or planned?(optional item)
El Yes ❑ No I,�' Not applicable
SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(G)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and,in turn,the tables you must
complete.Not all applicants need to complete each table.
Table A.Conventional and Non-Conventional Pollutants
7_1 Are you requesting a waiver from your NPDES permitting authority for any Table A pollutants for any of your
outfalls? �,/
El Yes 1: No 4 SKIP to Item 7.3.
7.2 If yes,indicate the applicable outfalls below or check the appropriate box to indicate that you are requesting a waiver
N for all outfalls.Attach waiver request and other required information to the application.
ns
Outfall number Outfall number Outfall number
❑ I am requesting a waiver for some pollutants at all outfalls.
CD
❑ I am requesting a waiver for all pollutants at all outfalls 4 SKIP to Item 7.4.
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
requested and attached the results to this application package?
❑ Yes
uu Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3?(See end of instructions for exhibit.)
❑ Yes No 5 SKIP to Item 7.8.
Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B?
❑ Yes
Page 4
EPA Form 3510-2C

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
P • Expires 07/3112026
_.3 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)
identified in Exhibit 2C-3.
Required GCIMS Fraction(s)
Primary Industry Category (check applicable boxes)
0 Volatile 0 Acid 0 Base/neutral 0 Pesticide
0 Volatile 0 Acid 0 Base/neutral 0 Pesticide
❑Volatile 0 Acid 0 Base/neutral ❑ Pesticide
7_7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes
7_8 Have you checked`Believed Present"or`Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
❑ Yes
Have you provided(1)quantitative data for those Section 1,Table B,pollutants for which you have indicated testing
is required or(2)quantitative data or other required information for those Section 1,Table B, pollutants that you
have indicated are"Believed Present"in your discharge?
❑ Yes
7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, No
then SKIP to Item 7.12.
, 7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have
determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B,
opollutants you have indicated are`Believed Present"in your discharge?
c) ❑ Yes
Table C.Certain Conventional and Non-Conventional Pollutants
7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table C
for all outfalls?
s ❑ Yes
7.13 Have you completed Table C by providing quantitative data for those pollutants that are limited either directly or
c indirectly in an ELG?You must provide quantitative data even if the pollutant is"Believed Absent."
c ❑ Yes [' Not applicable
7.14 Have you completed Table C by providing quantitative data or an explanation for those pollutants for which you have
CD indicated"Believed Present"?
❑ Yes
Table D.Certain Hazardous Substances and Asbestos
7.15 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D
for all outfalls?
❑ Yes
7.16 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged
and(2)providing quantitative data,if available?
❑ Yes No
Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD)
7 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. (K No 4 SKIP to Section 8.
7.18 Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes
Page 5
EPA Form 3510-2C

EPA Identification Number NPDES Permit Number Facility Name
OMB No.2040-0004
Expires 07/31/2026
SECTION 8. USED OR MANUFACTURED TOXICS(40 CFR 122.21(G)(9))
8_1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
3 ❑ Yes Er No- SKIP to Section 9.
List the pollutants below.Attach additional sheets,if necessary.
2 0 1. 4• 7.
'6 $
-a 2. 5'
3. 6. 9•
SECTION 9. BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(G)(11))
9_1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on(1)any of your discharges or(2)a receiving water in relation to your discharge?
❑ Yes 2' No• SKIP to Section 10.
Identify the tests and their urposes below.
Submitted to NPDES Date Submitted
Test(s) Purpose of Test(s)•X permitting Authority?
O
❑ Yes ❑ No
j ❑ Yes ❑ No
❑ Yes ❑ No
SECTION 10.CONTRACT ANALYSES (40 CFR 122.21(G)(12))
10.1_ Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑ Yes Er No 4 SKIP to Section 11.
10.2 Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1 Laboratory Number 2 Laboratory Number 3
Name of
laboratory/firm
M
L Laboratory address
O Phone number
Pollutant(s)analyzed
EPA Form 3510-2C Page 6

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
Expires 07/31/2026
e 00•- .2i '<Oil 7t ;. ,! (0,
SECTION 11.ADDITIONAL INFORMATION (40 CFR 122.21(G)(13))
Has the NPDES permitting authority requested additional information?
❑ Yes Q/ No.4 SKIP to Section 12.
0
E 11.2 List the information requested and attach it to this application.
—
c 1. 4.
m
c
0
a 2. 5.
-0
Q
3. 6.
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(A)AND (D))
12.1 In Column 1 below, mark the sections of Form 2C 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 complete all sections or provide attachments.
Column 1 Column 2
[Section 1:Outfall Location [r w/attachments
❑ Section 2: Line Drawing ❑ wl line drawing ❑ w/additional attachments
w/list of each user of
❑/Section 3:Average Flows and DI w/attachments ❑ privately owned treatment
Treatment works
[a/ Section 4: Intermittent Flows ❑ w/attachments
EEl Section 5:Production El w/attachments
co w/optional additional
n sheets describing any
o ID Section 6: Improvements ❑ w/attachments 0 additional pollution control
co
plans
F
w/request for a waiver and w/explanation for
v ❑ nn supporting information 1'"' identical outfalls
❑ w/small business exemption j—� w/other attachments
co request
a ❑ Section 7: Effluent and Intake w/Table A w/Table B
Characteristics ❑
s
c� El w/Table C w/Table D
❑ w/Table E w/analytical results as an
attachment
❑
Section 8:Used or Manufactured ❑ w/attachments
Toxics
❑
Section 9: Biological Toxicity CI w/attachments
Tests
❑ Section 10:Contract Analyses ❑ w/attachments
❑
Section 11:Additional ❑ w/attachments
Information
[y Section 12:Checklist and ❑ w/attachments
Certification Statement
EPA Form 3510-2C Page 7

EPA Identification Number NPDES Permit Number Facility Name OMB No.2040-0004
Expires 07/31/2026
IOU).55—o23 ?,LOh 7,7..../& It%
SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and (d)) (Continued)
12.2 Provide the following certification. (See instructions to determine the appropriate person to sign the application.)
Certification Statement
dI certify under penalty of law that this document and all attachments were prepared under my direction or
co supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate
c 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,
w including the possibility of fine and imprisonment for knowing violations.
"tiName(print or type first and last name) Official title
_`° cPAA�it
N Alkii's r Pitts /�'/4!./�C���4L �yia.-✓)SO�
d Signature ' Date signed L.,
xa,„-A.4.4„;..ri,„ z.4 -Ir. 5._._3 ..._.,,y
EPA Form 3510-2C Page 8