NC0046728_Application_20240625

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
Innnirn
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
2A
.=1EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION•N
INFORMATION FOR i
Facility name
1.1
Rocky River WWTP
Mailing address (street or P.O. box)
PO Box 878
City or town
State
ZIP code
Town of Mooresville
NC
28115
ro
EContact
name (first and last)
Title
Phone number
Email address
.�
c
James A. Levis
WWTP Plant Manager
[phone]
[e-mail]
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
R
369 Johnson Dairy Road
City or town
State
ZIP code
Mooresville
NC
28115
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes -* See instructions on data submission 0 No
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
❑v Yes ❑ No SKIP to Item 1.4.
Applicant name
Christopher Carney
Applicant address (street or P.O. box)
W
PO Box 878
o
City or town
State
ZIP code
w
Mooresville
INC
28117
r
Contact name (first and last)
Title
Phone number
Email address
Q
Christopher Carney
Mayor
[phone]
[e-mail]
a
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑r Owner ❑ Operator ❑ Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
Facility and applicant Facility ❑ Applicant ElFacility
0
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.
Existing Environmental Permits
a
0 NPDES (discharges to surface
❑ RCRA (hazardous waste)
❑ UIC (underground injection
R
water)
control)
;_
c
INC 0046728
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
w
a�
y
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
0 Other (specify)
w
404)
CLASS A WQ 0036723
EPA Form 3510-2A (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
1.7
Provide the collections stem information
requested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served
Served
indicate percentage)
47,500
100 % separate sanitary sewer
0 Own El Maintain
a)
% combined storm and sanitary sewer
ElOwn ElMaintain
❑ Unknown
❑ Own ❑ Maintain
c
% separate sanitary sewer
❑ Own ❑ Maintain
R
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
a
% separate sanitary sewer
ElOwn ElMaintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
❑ Unknown
❑ Own ❑ Maintain
2
% separate sanitary sewer ❑ Own ❑ Maintain
N%
combined storm and sanitary sewer ❑ Own ❑ Maintain
c
❑ Unknown ❑ Own ❑ Maintain
Total 47,500
Population
U
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line in miles)
100 /o o o /o 0
1.8
Is the treatment works located in Indian Country?
3
0
U
ElYes 0 No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
c
❑ Yes ❑� No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
7.5 mgd
N
Annual Average Flow Rates Actual
Two Years Ago
Last Year
This Year
0
5.135 mgd
4.905 mgd
5.176 mgd
Maximum Daily Flow Rates Actual
Two Years Ago
Last Year
This Year
9.311 mgd
7.903 mgd
10.11 mgd
1.11
Provide the total number of effluent discharge points to waters of the United States by type.
oTotal
Number of Effluent Discharge Points b T pe
a CL
a'
Combined Sewer
Constructed
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Emergency
Overflows
M
G
1
EPA Form 3510-2A (Revised 3-19) Page 2

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
Xnnnirn
OMB No. 2040-0004
Outfalls Other Than to Waters of the United States
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 United States?
❑ Yes ❑ No 4 SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Im oundment Location and Discharge Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
ElContinuous
gpd
❑ Intermittent
gpd
ElContinuous
❑ Intermittent
1.14
Is wastewater applied to land?
❑ Yes 0 No 4 SKIP to Item 1.16.
0
1.15
Provide the land application site and discharge data requested below.
C
Land Application Site and Discharge Data
o
0
Average Daily Volume
Continuous or
a,
Location
Size
Applied
Intermittent
check one
tiacres
d
gpd
❑ Continuous
o
❑ Intermittent
acres
d
gpd
El Continuous
o
ElIntermittent
acres
d
El Continuous
gpd
❑ Intermittent
R
1.16
Is effluent transported to another facility for treatment prior to discharge?
o
❑ 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 4 SKIP to Item 1.20.
1.19
Provide information on the transporter below.
Transporter 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
EPA Form 3510-2A (Revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving F cility Data
-a
Facility name
Mailing address (street or P.O. box)
d
City or town
State
ZIP code
0
U
Contact name (first and last)
Title
0
d
Phone number
Email address
c
NPDES number of receiving facility (if any) ❑ None
Average daily flow rate mgd
a
0
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do not
0
have outlets to waters of the United States (e.g., underground percolation, underground injection)?
Er
❑ Yes 0 No 4 SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
Method
Disposal Site
Disposal Site
Daily Discharge
(check one)
Description
Volume
.�
acres
gpd
El
❑ Intermittent
acres
gpd
ElContinuous
❑ Intermittent
acres
gpd
ElContinuous
❑ 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.
ti
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
3
El El into marine waters (CWA ElWater quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
0 Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes 0 No 4SKIP 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 responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
0
Contractor name
R
(companyname
0
Mailing address
street or P.O. box
r
City, state, and ZIP
code
L
o
Contact name (first and
U
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
EPA Form 3510-2A (Revised 3-19) Page 4

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NCO046728 Town of Mooresville/Rocky River OMB No. 2040-0004
�nnnirn
SECTION 11 • •' • 1
o Outfalls to Waters of the United States
a
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
LM
0
❑✓ Yes ❑ No 4 SKIP to Section 3.
c
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
r
w
and infiltration.
3,800 d
9p
=
Indicate the steps the facility is taking to minimize inflow and infiltration.
c
The Town of Mooresvilles I & I crew cameras lines and if I & I is found the Town makes necessary repairs or replaces
3
lines as needed
0
c
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
g
specific requirements.)
0�
0
0
❑r Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
c M
(See instructions for specific requirements.)
o
❑✓ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes 0 No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
0
R
1.
d
E
CL
2.
E
0 0
y
3.
d
4.
Cn
R
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
E
a)
Scheduled
Affected
Begin
End
Begin
Attainment of
>
o
Improvement
Outfalls
Construction
Construction
Discharge
Operational
CL E
(from above)
(list o number)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
Level
MMIDDIYYYY
1.
a�
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
EPA Form 3510-2A (Revised 3-19) Page 5

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River OMB No. 2040-0004
nnnirn
SECTION
•' • ON DISCHARGES
3.1
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001
Outfall Number
Outfall Number
State
North Carolina
County
Iredell
w
0
w
City or town
Mooresville
0
c
Distance from shore
ft.
ft.
ft.
rs
n
'i
Depth below surface
ft.
ft.
ft.
c
Average daily flow rate
5.297 mgd
mgd
mgd
Latitude
35' 31' 33"
Longitude
80 4d 56"
"
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
R
o
❑ Yes 0 No 4 SKIP to Item 3.4.
d
R
3.3
If so, provide the following information for each applicable outfall.
y
Outfall Number
Outfall Number
Outfall Number
0
Number of times per year
L
discharge occurs
a
Average duration of each
o
discharge (specify units
Average flow of each
mgd
mgd
mgd
discharge
co
Months in which discharge
occurs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes 0 No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser t pe at each applicable outfall.
CL
Outfall Number
Outfall Number
Outfall Number
d
tp
3
° vi
3 6
Does the treatment works discharge or plan to discharge wastewater to waters of the United States from one or more
12 0
discharge points?
3
0 Yes ❑ No 4SKIP to Section 6.
EPA Form 3510-2A (Revised 3-19) Page 6

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
3.7
Provide the receiving water and related information if known for each outfall.
Outfall Number 001
Outfall Number
Outfall Number
Receiving water name
Dye Creek
Name of watershed, river,
0
or stream system
Yadkin Pee Dee
•L
U.S. Soil Conservation
N
Service 14-digit watershed
N/A
o
code
L
a�
Name of state
management/river basin
Yadkin -Pee Dee (YAD11)
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
7Q10.05 cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CaCO3
3.8
Provide the following information
describing the treatment pr vided for discharges from each outfall.
Outfall Number
Outfall Number
Outfall Number
Highest Level of
❑ Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
0 Secondary
❑ Secondary
❑ Secondary
❑ Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
0
Q
Design Removal Rates by
Outfall
d
BOD5 or CBOD5
90 %
%
%
c
d
E
acci
L
TSS
85 %
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
0 Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
❑ Not applicable
❑ Not applicable
❑ Not applicable
EPA Form 3510-2A (Revised 3-19) Page 7

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
>3
We disinfect using ultraviolet Bulbs (two channels with four banks) prior to our cascade and discharging to Dye Creek.
c
r
c
0
U
Outfall Number 001
Outfall Number
Outfall Number
0CL
r
Disinfection type
uv
tp
N
G
Seasons used
E
r
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
❑ Yes
❑ Yes
❑ Yes
0 No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
0 Yes ❑ 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?
0 Yes ❑ No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number 001
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
5
4
Number of tests of receiving
water
3.13
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
r
0 Yes ❑ No -* SKIP to Item 3.16.
0
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?
❑ Yes 4 Complete Table B, including chlorine. 0 No 4 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?
u,
0 Yes ❑ No
3.16
Does one or more of the following conditions apply?
• The facility has a design flow greater than or equal to 1 mgd.
• The POTW has an approved pretreatment program or is required to develop such a program.
• The NPDES permitting authority has informed the POTW that it must sample for the parameters in Table C, must
sample other additional parameters (Table D), or submit the results of WET tests for acute or chronic toxicity for
each of its discharge outfalls (Table E).
Yes 4 Complete Tables C, D, and E as
0 ElNo 4 SKIP to Section 4.
applicable.
3.17
Have you completed monitoring for all applicable Table C pollutants and attached the results to this application
package?
0 Yes ❑ No
3.18
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
attached the results to this application package?
❑ Yes 0 No additional sampling required by NPDES
permitting authority.
EPA Form 3510-2A (Revised 3-19) Page 8

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nneirn
OMB No. 2040-0004
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
r❑ Yes ❑ No + 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?
0 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) Submitted
Summary of Results
MM/DD/YYYY
11/21 Ceridaphnia dubia Pass - Fat Head Minnow 100%
02/22 Ceridaphnia dubia Pass - Fat Head Minnow 100%
m
11/16/2021
05/22 Ceridaphnia dubia Pass - Fat Head Minnow 76.5%
08/22 Ceridaphnia dubia Pass - Fat Head Minnow 45% (interference)
0
09/22 Fat Head Minnow (re -test) 92%
r
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
o
toxicity?
0 Yes ❑ No 4 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
The lab stated that there appeard to be algea in the (Fat Head Minnow) sample for 8/17/22 which caused interference.
3
We re -sampled on 9/21/22 in the same quarter which resulted in a survival rate of 92% for Fat Head Minnow.
w
We passed the Ceridaphnia dubia testing all four sampling events.
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes 0 No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
We didn't conduct a toxicity reduction evaluation because we had a 92% survial rate for Fat Head Minnow when we
re -sampled on 9/21/22
3.26
Have you completed Table E for all applicable outfalls and attached the results to the application package?
0 Yes ❑ Not applicable because previously submitted
information to the NPDES permitting authority.
4. INDUSTRIAL
DISCHARGES AND i
HAZARDOUSSECTION
4.1
Does the POTW receive discharges from SIUs or NSCIUs?
r❑ Yes ❑ No 4 SKIP to Item 4.7.
4.2
Indicate the number of SIUs and NSCIUs that discharge to the POTW.
Number of SIUs
Number of NSCIUs
y
0
3
4.3
Does the POTW have an approved pretreatment program?
N
_
❑✓ Yes ❑ No
4.4
Have you submitted either of the following to the NPDES permitting authority that contains information substantially
d
identical to that required in Table F: (1) a pretreatment program annual report submitted within one year of the
R
application or (2) a pretreatment program?
0 Yes ❑ No 4 SKIP to Item 4.6.
0
4.5
Identify the title and date of the annual report or pretreatment program referenced in Item 4.4. SKIP to Item 4.7.
L
3
Pretreatment Annual Review - 2021, 2022,2023,
c
4.6
Have you completed and attached Table F to this application package?
-1 Yes ❑ No
EPA Form 3510-2A (Revised 3-19) Page 9

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
4.7
Does the POTW receive, or has it been notified that it will receive, by truck, rail, or dedicated pipe, any wastes that are
regulated as RCRA hazardous wastes pursuant to 40 CFR 261?
❑ Yes 0 No 4 SKIP to Item 4.9.
4.8
If yes, provide the follo ing information:
Annual
Hazardous Waste
Waste Transport Method
Amount of
Units
Number
(check all that apply)
Waste
Received
❑ Truck ❑ Rail
3
❑ Dedicated pipe ❑ Other (specify)
_
r
_
0
U
❑ Truck ❑ Rail
❑ Dedicated pipe ❑ Other (specify)
tll
3
O
>3
N
❑ Truck ❑ Rail
n=
_
❑ Dedicated pipe ❑ Other (specify)
_
U)
d
R
4.9
Does the POTW receive, or has it been notified that it will receive, wastewaters that originate from remedial activities,
y
including those undertaken pursuant to CERCLA and Sections 3004(7) or 3008(h) of RCRA?
0
❑ Yes ❑r No 4 SKIP to Section 5.
.L
Z
4.10
Does the POTW receive (or expect to receive) less than 15 kilograms per month of non -acute hazardous wastes as
specified in 40 CFR 261.30(d) and 261.33(e)?
❑ Yes -* SKIP to Section 5. ❑ No
4.11
Have you reported the following information in an attachment to this application: identification and description of the
site(s) or facility(ies) at which the wastewater originates; the identities of the wastewater's hazardous constituents; and
the extent of treatment, if any, the wastewater receives or will receive before entering the POTW?
❑ Yes ❑ No
SECTION•
OVERFLOWS (40
E
5.1
Does the treatment works have a combined sewer system?
❑ Yes 0 No 4SKIP to Section 6.
R
5.2
Have you attached a CSO system map to this application? (See instructions for map requirements.)
1°
M
❑ Yes ❑ No
R
5.3
Have you attached a CSO system diagram to this application? (See instructions for diagram requirements.)
0
U
❑ Yes ❑ No
EPA Form 3510-2A (Revised 3-19) Page 10

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
5.4
For each CSO outfall, provide the following information. Attach additional sheets as necessary.)
CSO Outfall Number
CSO Outfall Number
CSO Outfall Number
City or town
0
r
Q-
State and ZIP code
N
o
County
3
Latitude
°
0
0
N
U
Longitude
° „
Distance from shore
ft.
ft.
ft.
Depth below surface
ft.
ft.
ft.
5.5
Did the POTW monitor any of the following items in the past year for its CSO outfalls?
CSO Outfall Number
CSO Outfall Number
CSO Outfall Number
Rainfall
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
a�
c
`o
CSO flow volume
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
r
CSO pollutant
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
0
concentrations
Receiving water quality
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
CSO frequency
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Number of storm events
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
5.6
Provide the following information for each of your CSO outfalls.
CSO Outfall Number
CSO Outfall Number
CSO Outfall Number
L
}
Number of CSO events in
events
events
events
the past year
Average duration per
hours
hours
hours
event
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
LL'
0
Average volume per event
million gallons
million gallons
million gallons
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
Minimum rainfall causing
inches of rainfall
inches of rainfall
inches of rainfall
a CSO event in last year
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
❑ Actual or ❑ Estimated
EPA Form 3510-2A (Revised 3-19) Page 11

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
NCO046728
Town of Mooresville/Rocky River
nnnirn
OMB No. 2040-0004
5.7
Provide the information in the table below for each of your CSO outfalls.
CSO Outfall Number
CSO Outfall Number
CSO Outfall Number
Receiving water name
Name of watershed/
y
streams stem
U.S. Soil Conservation
❑ Unknown
❑ Unknown
❑ Unknown
Service 14-digit
watershed code
>
if known
Name of state
a
management/river basin
U.S. Geological Survey
❑ Unknown
❑ Unknown
❑ Unknown
8-Digit Hydrologic Unit
Code if known
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
examples)
SECTION•
d (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
w/ variance request❑� s) wl additional attachments
ElInformation
for All Applicants
❑ Section 2: Additional
0 w/ topographic map ❑r w/ process flow diagram
Information
0 w/ additional attachments
0 w/ Table A ❑ w/ Table D
❑ Section 3: Information on
0 w/ Table B 0 w/ Table E
Effluent Discharges
E
0 w/ Table C 0 w/ additional attachments
Section 4: Industrial
w/ SIU and NSCIU attachments 0 w/ Table F
=
0 Discharges and Hazardous
Wastes
0 w/ additional attachments
Section 5: Combined Sewer
❑
Elw/ CSO map Elw/ additional attachments
zE
Overflows
❑ w/ CSO system diagram
R
Section 6: Checklist and
El wl attachments
Certification Statement
Y
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 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
James A. Levis
Wastewater Treaatment Plant ManagE
Signature
Date signed
EPA Form 3510-2A (Revised 3-19) Page 12

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