NC0084832_Renewal Application_20160205

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MOD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit f NC0084832
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name Nikola's Restaurant lis High Meadows Inn, LLC
Facility Name Nikola's Restaurant& High Meadows Inn WWTP
Mailing Address P.O. Box 222
City Roaring Gap
State / Zip Code NC / 28668
Telephone Number [phone] RECEIVED1Nc:UtUIDWR
Fax Number -- FEB 0 5 2.016
e-mail Address dzp©embarqmail.com Water Quality
• pclinlining Oeotion
2. Location of facility producing discharge:
Check here if same address as above 0
Street Address or State Road NC Highway 21
City Roaring Gap
State / Zip Code NC / 28683
County Alleghany
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Research &Analytical Laboratories, Inc.
Mailing Address 106 Short Street
City Kernersville
State / Zip Code NC / 27284
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
1 of 3 Form-D 11112

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial ® Number of Employees 7
Residential 0 Number of Homes
School 0 Number of Students/Staff
Other 0 Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Restaurant
Number of persons served: N/A
5. Type of collection system
® Separate (sanitary sewer only) 0 Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification numbers) 001
Is the outfall equipped with a diffuser? 0 Yes No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Laurel Branch
8. Frequency of Discharge: ® Continuous 0 Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
*0.025 MGD wastewater treatment system
*Aeration basin with diffused air
*Secondary clarifier with sludge air lifts and in-plant pumps
*Chlorination
*Dechlorination
2 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.025 MGD
Annual Average daily flow 0.0008 MGD (for the previous 3 years)
Maximum daily flow 0.0043 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
NEW APPLICANTS:Provide data for the parameters listed.Fecal Coliform, Temperature and pH shall be grab
samples,for all other parameters 24-hour composite sampling shall be used.If more than one analysis is reported,
report daily maximum and monthly average.If only one analysis is reported, report as daily maximum.
RE.IIIZWAL APPLICANTS: Provide the highest single reading(Daily Maximum)and Monthly Average over
the past 36 months for parameters currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BODS) 19 6.09 Mg/1
Fecal Coliform 18 <1 Col/100 ml
Total Suspended Solids 31.3 6.49 Mg/1
Temperature (Summer) 27 22.9 °C
Temperature (Winter) 11 10.5 °C
pH 8.9 8.05 Std. Units
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES NC0084832 Dredge or fill (Section 404 or CWA)
PSD(CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
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.
5OVANtS M. Woes kAkce. AvAVcriv 2eA Atetej
Printed name of Person Signing Title
otiti.All In Oilteh;e/ tse l_l_ lkx,
Si re of Applicant Date
North Carolina General Statute 143-215.6 (b)(2) states: 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$25,000,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$25,000 or imprisonment not more than 5 years,or both,for a similar offense.)
3 013 Form-D 11112

riRESEARCh & ANALyTICAL
LAbORATORIES, INC.
Analytical/Process Consultations
1 February 2016 RECEIVED/NCDEUDWR
FEB 052016
N.C. DENR
Water quality
Division of Water Quality Permitting Section
NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: NPDES Permit Renewal Application
Nikola's Restaurant & High Meadows Inn WWTP
NPDES Permit No. NC0084832
To Whom It May Concern:
Enclosed are one (1) signed original and two (2) copies of the NPDES Permit Application: Form D
requesting renewal of NPDES Permit No. NC0084832. There have been no significant changes to
wastewater treatment facility.
If you should have any questions concerning this application renewal please so advise.
Best Regards,
9....., -,7';? 2... 4,7e.:
James M. Cheshire
Authorized Agent
P.O. Box 473• 106 Short Street• Kernersville, North Carolina 27284•336-996-2841 • Fax [phone]
www.randalabs.com