NC0084832_Permit Issuance_20160620

Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
Corernor
DONALD R. VAN DER VAART
searelmy
S. JAY ZIMMERMAN
Dh-ecror
June 20, 2016
Mr. James Cheshire
Research & Analytical Laboratories, Inc.
P.O. Box 1487
Kernersville, NC 27285-1457
Subject: Issuance of NPDES Permit NCO084832
Nikola's Restaurant & High Meadows Inn,
WWTP, Class WW-2
Alleghany County
Dear Mr. Cheshire:
The Division of Water Resources (the Division) hereby issues the attached NPDES permit for the
subject facility. 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 October 15, 2007, or as subsequently amended.
We have made the following updates to your previous permit with no subsequent changes from the
draft permit mailed to you:
➢ Section A. (2) has been added to require electronic submission of effluent data. Federal
regulations require electronic submittal of all discharge monitoring reports (DMRs), effective
December 21, 2016.
➢ Regulatory citations have been added to the permit.
➢ An updated outfall map has been included.
Starting on December 21, 2016, federal regulations require electronic submittal of all discharge
monitoring reports (DMRs) and specify that, if a state does not establish a system to receive such
submittals, then permittees must submit DMRs electronically to the Environmental Protection
Agency (EPA). The final NPDES Electronic Reporting Rule was adopted and became effective on
December 21, 2015.
The requirement to begin reporting discharge monitoring data electronically using the NC DWR's
Electronic Discharge Monitoring Report (eDMR) internet application has been added to your final
NPDES permit. [See A. (2)] For information on eDMR, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http7//deg.ne.gov/about/divisions/water-resources/edmr.
For more information on EPA's final NPDES Electronic Reporting Rule, please visit the following
web site:
http7//www2 ena eov/compliance/final-national-uollutant-discharge-elimination-system-nudes-
electronic-reporting-rule.
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable, you have the right to an adjudicatory hearing, upon written request submitted within
thirty (30) days after receiving this letter. Your request must take the form of a written petition
State of North Caroline I Enviromental Quality I Water Resources
1617 Mail service Center I Raleigh, North Carolina 27699-1617
919 807 6300

conforming to Chapter 150B of North Carolina General Statutes, and you must file it with the Office
of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless
such a demand is made, this permit shall remain final and binding.
Please note that this permit is not transferable except after notice to the Division. The Division may
require modification or revocation and reissuance of the permit. This permit does not affect the legal
requirements to obtain other permits which maybe required by the Division of Water Resources or
any other Federal, State, or Local governmental permits that may be required.
If you have questions, or if we can be of further service, please contact Jennifer Busam at
[e-mail]] or call [phone].
spe ally,
S. Jay Zimmerman, P.G.Xor
Division of Water Resources, NCDEQ
Enclosure: NPDES Permit NC0084832 (Issuance Final)
hc: Central Files
NPDES Program Files
WSRO Files
ec: Nikola's Restaurant & High Meadows Inn, LLC [[e-mail]]
Mr. James M. Cheshire [[e-mail]]

Permit NC0084832
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other
lawful standards and regulations promulgated and adopted by the North Carolina
Environmental Management Commission, and the Federal Water Pollution Control
Act, as amended,
Nikola's Restaurant & High Meadows Inn, LLC
is hereby authorized to discharge wastewater from a facility located at the
Nikola's Restaurant & High Meadows Inn WWTP
NC Highway 21
Roaring Gap
Alleghany County
to receiving waters designated as Laurel Branch (Laurel Creek) in subbasin 05-07-03 of the
New River Basin in accordance with effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III and IV hereof.
This permit shall become effective August 1, 2016.
This permit and authorization to discharge shall expire at midnight on March 31, 2021.
Signed this day June 20, 2016.
S.04 Zimmerman, P.G., Dir
Division of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 6

Permit NCO084832
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are
hereby revoked, and as of this issuance, any previously issued permit bearing this number
is no longer effective. Therefore, the exclusive • authority to operate and discharge from this
facility arises under the permit conditions, requirements, terms, and provisions included
herein.
Nikola's Restaurant & High Meadows Inn, LLC
is hereby authorized to:
1. Continue to operate an existing 0.025 MOD extended aeration wastewater
treatment system with the following components:
♦ Aeration basin with diffused air
♦ Secondary clarifier with sludge air lifts and in -plant pumps
♦ Chlorination
♦ Dechlorination
This facility is located at the Nikola's Restaurant & High Meadows Inn WWTP
off of NC Highway 21, Roaring Gap, in Alleghany County.
2. Discharge from said treatment works via Outfall 001, at the location specified
on the attached map into Laurel Branch (Laurel Creek) [10-9-10-2)] currently
classified C-Trout waters in subbasin 05-07-03 [HUC: 05050001041 of the New
River Basin.
Page 2 of 6

Permit NCO084832
Part I
A. (1 ) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS .
[15A NCAC 02B.0400 et seq., 15A NCAC 02B.0500 et seq.]
Beginning with the permit effective date and lasting until expiration, the Permittee is
authorized to discharge treated domestic wastewater from Outfall 001. Such
discharges shall be limited and monitored' by the Permittee as specified below:
,; .�,{ .�
-UEN.1I T��"NSr
, t, O1tTOR11�. �EQUy EMEND S �r
EFFLUENj `GI�ARi'T�ERST�Ie,S
�� .r
1..,r-
---,h 011t y
'�.al, �
_ ::;�`:� ` =-
��r
Meas re ent Samp Sample
Par r eferr,Code
Aueae ---
Maki um�
.
FsFrequen`c`jI Type Location
Influent or
Flow 50050
0.025 MGD
Weekly
Instantaneous
Effluent
BOD, 5-day, (20°C) C0310
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Solids C0530
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
NH3 as N - *Summer C0610
11.0 mg/L
35.0 mg/L
Weekly
Grab
Effluent
NH3 as N - *Winter C0610
Weekly
Grab
Effluent
Fecal Coliform 31616
200/100 ml
400/100 ml
Weekly
Grab
Effluent
(geometric mean)
Total Residual Chlorine 3 50060
28 Ng/L
2/Week
Grab
Effluent
pH 00400
> 6.0 and < 9.0 standard units
Weekly
Grab
Effluent
Oil and Grease 00556
30.0 mg/L
60.0 mg/L
Monthly
Grab
Effluent
Effluent,
Temperature (*C) 00010
Weekly
Grab
Upstream &
Downstream 2
Effluent,
Dissolved Oxygen 00300
Weekly
Grab
Upstream &
Downstream 2
*Summer.* April 1- October 31
*Winter: November 1- March 31
Footnotes:
1. No later than December 21, 2016, the permittee shall begin submitting discharge
monitoring reports electronically using the NC DWR's eDMR application system [see A.
(2)].
2. Upstream= at NC Highway 21 bridge. Downstream= at Mountain View Road bridge.
3. The Division shall consider all effluent TRC values reported below 50 jig/L to be in
compliance with the permit. However, the Permittee shall continue to record and submit
all values reported by a North Carolina certified laboratory (including field certified), even
if these values fall below 50 jig/L.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER
THAN TRACE AMOUNTS.
Page 3 of 6

Permit NCO084832
A. (2) ELECTRONIC REPORTING OF MONITORING REPORTS
[NCGS 143-215.1 (b)]
Federal regulations require electronic submittal of all discharge monitoring reports
(DMRs) and program reports and specify that, if a state does not establish a system
to receive such submittals, then permittees must submit monitoring data and reports
electronically to the Environmental Protection Agency (EPA). The final NPDES
Electronic Reporting Rule was adopted and became effective on December 21, 2015.
NOTE: This special condition supplements or supersedes the following sections
within Part II of this permit (Standard Conditions for NPDES Permits):
• Section B. (11.) Signatory Requirements
• Section D. (2.) Reporting
• Section D. (6.) Records Retention
• Section E. (5.) Monitoring Reports
1. Reporting Requirements [Supersedes Section D. (2.) and Section E. (5.) (all
Effective December 21, 2016, the permittee shall report discharge monitoring data
electronically using the NC DWR's Electronic Discharge Monitoring Report (eDMR)
internet application.
Monitoring results obtained during the previous- month(s) shall be summarized for
each month and submitted electronically using eDMR. The eDMR system allows
permitted facilities to enter monitoring data and submit DMRs electronically using
the internet. Until such time that the state's eDMR application is compliant with
EPA's Cross -Media Electronic Reporting Regulation (CROMERR), permittees will be
required to submit all discharge monitoring data to the state electronically using
eDMR and will be required to complete the eDMR submission by printing, signing,
and submitting one signed original and a copy of the computer printed eDMR to the
following address:
NC DEQ / Division of Water Resources / Water Quality Permitting Section
ATTENTION: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
If a permittee is unable to use the eDMR system due to a demonstrated hardship or
due to the facility being physically located in an area- where less than 10 percent of
the households have broadband access, then a temporary waiver from the NPDES
electronic reporting requirements may be granted and discharge monitoring data may
be submitted on paper DMR forms (MR 1, 1.1, 2, 3) or alternative forms approved by
the Director. Duplicate signed copies shall be submitted to the mailing address
above. See "How to Request a Waiver from Electronic Reporting" section below.
Page 4 of 6

Permit NCO084832
Regardless of the submission method, the first DMR is due on the last day of the
month following the issuance of the permit or in 'the case of a new facility, on the last
day of the month following the commencement of discharge.
Starting on December 21, 2020, the permittee must electronically report the
following compliance monitoring data and reports, when applicable:
• Sewer Overflow/ Bypass Event Reports;
• Pretreatment Program Annual Reports; and
• Clean Water Act (CWA) Section 3 (.. uRepZts.
The permittee may seek an electronic reporting waiver from the Division (see "How to
Request a Waiver onic Reporting" section below) .
2. Electronic Submissions
In accordance with 40 CFR 122.41(1) (9), the permittee must identify the initial
recipient at the time of each electronic submission. The permittee should- use the
EPA's website resources to identify the initial recipient for the electronic submission.
Initial recipient of electronic NPDES information from NPDES-regulated facilities
means the entity (EPA or the state authorized by EPA to implement the NPDES
program) that is the designated entity for receiving electronic NPDES data [see 40
CFR 127.2(b)].
EPA plans to establish a website that will also link to the appropriate electronic
reporting tool for each type of electronic submission and for each state. Instructions
on how to access and use the appropriate electronic reporting tool will be available as
well. Information on EPA's NPDES Electronic Reporting Rule is found at:
http• / /www2.epa.ov/ compliance/ final -national -pollutant -discharge -elimination-
system-npdes-electronic-reporting-rule.
Electronic submissions must start by the dates listed in the "Reporting
Requirements" section above.
3. How to Request a Waiver from Electronic Reporting
The permittee may seek a temporary electronic reporting waiver from the Division. To
obtain an electronic reporting waiver, a permittee must first submit an electronic
reporting waiver request to the Division. Requests for temporary electronic reporting
waivers must be submitted in writing to the Division for written approval at least
sixty (60) days prior to the date the facility would be required under this permit to
begin submitting monitoring data and reports. The duration of a temporary waiver
shall not exceed 5 years and shall thereupon expire. At such time, monitoring data
and reports shall be submitted electronically to the Division unless the permittee re-
applies for and is granted a new temporary electronic reporting waiver by the
Division. Approved electronic reporting waivers are not transferrable. Only
permittees with an approved reporting waiver request may submit monitoring data
and reports on paper to the Division for the period that the approved reporting waiver
request is effective.
Page 5 of 6

Permit NCO084832
Information on eDMR and the application for a temporary electronic reporting waiver
are found on the following web page:
http: / Ideg.nc.gov/about/divisions/water-resources/edmr
4. Signatory Requirements f Supplements Section B. (11. j (b) and Supersedes
Section B. � 11.1 (d)l
�descri
%Rs submitted to the permit issuing authority shall be signed by a person
Fart ec n B. (11.) (a) or by a duly authorized representative of that
person as described in Part II, Section B. (11.)(b). A person, and not a position, must
be delegatedmsignatory=authority for e15MR repnrting purposes.
For eDMR submissions, the person signing and submitting the DMR must obtain an
eDMR user account and login credentials to access the eDMR system. For more
information on North Carolina's eDMR system, registering for eDMR and obtaining an
eDMR user account, please visit the following web page:
http: / / deg.nc.gov/about/divisions/water-resources /edmr
Certification. Any person submitting an electronic DMR using the state's eDMR
system shall make the following certification [40 CFR 122.221. NO OTHER
STATEMENTS OF CERTIFICATION WILL BE ACCEPTED:
"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 fines
and imprisonment for knowing violations. "
5. Records Retention jSupplements Section D. (6.�1
The permittee shall retain records of all Discharge Monitoring Reports, including
eDMR submissions. These records or copies shall be maintained for a period of at
least 3 years from the date of the report. This period may be extended by request of
the Director at any time [40 CFR 122.4 1].
Page 6 of 6

Nikola's Restaurant & High Meadows Inn, LLC
Nikola's Restaurant & High Meadows Inn WWTP
NPDES Permit NCO084832
Stream Segment: 10-9-10-2 Stream Class: C-Trout
River Basin: New Sub -Basin 4: 05-07-03
County: Alleghany HUC: 0505000104
Receiving Stream: Laurel Branch (Laurel Creek)
SCALE 36.407778-, :0

Winston-Salem Journal
Advertising Affidavit
P.O Box 3159
Winston-Salem, INC 27102
NCDENR/DWQIPOINT SOURCE BRANCH
ATTN: WREN THEDFORD
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
Account Number
3376309
Date
May 06, 2016
Date Category Description Ad Size Total Cost
05/0612016 Legal Notices PUBLIC NOTICE North Carolina Environmental Management C 1 x 53 L 326.99
PUBLIC NOTICE
North Carolina Environmental
Publisher Of the
Management Commission/
NPDES Unit
1617 Mail Service Center
Winston-Salem Journal
Raleigh, NC 27699-1617
' Forsyth County
Y t
Notice of Intent to Issue
NPDES Wastewater Permit
The North Carolina Environmental
Before the undersigned, a Notary Public of Forsyth County, North Carolina, duly
Management Commission proposes
commissioned, qualified, and authorized by law to administer oaths, personally appeared D.
to issue a NPDESt wastewater dis-
charge
charge pertni[ to the person(s) listed
H. Stanfield, who b being duly sworn deposes
Y g Y p ses and says: that he is the Controller of the
below. Written comments regarding
Winston-Salem Journal, engaged in the publishing of a newspaper known as
accept -
a will a accept-
the proposed perdays
ad until 30 days after the publish
Weston -Salem Journal, published, issued and entered as second class mail in the City of
P ty
date of this notice. The Director of
the NC Division of Water Resources
Winston-Salem, in said County and State: that he is authorized to make this affidavit and
(DWR) may hold a public hearing
swom statement: that the notice or other legal advertisement, a true copy of which is
should there be a significant degree
attached hereto, was published in the Winston-Salem Journal on the following dates:
of public interest. Please mail com-
ments and/or information requests
to DWR at the above address. inter-
05/06/2016
ested persons may visit the DWR at
512 N. Salisbury Street Raleigh, NC
to review information on file. Addi-
and that the said newspaper in which such notice, paper document, or legal advertisement
permits
nodal is notice m on a DESfound
and this notice may be found on our
was published was, at the time of each and eve such publication, a newspaper meetin all
P every pg
website: http://deq.nc.gov/about/
the requirements and qualifications of Section 1-597 of the General Statutes ofNorth
divisions/water-resources/water-
resources-permits/wastewater-
Carolina and was a qualified newspaper within the meaning of Section 1-597 of the General
9g
bran ch/npdes-wastewate r/p u blic-
Statutes of North Carolina.
notices, or by calling [phone].
Nikola's Restaurant has requested
renewal of permit N00084832 for
This 6th day of May, 2016
Nikolas Restaurant & High Meadows
10./►W/,t+
Inn WWTP/ Alleghany County; Fa-
cility discharges to Laurel Branch/
(signalwe o persr n nm ing affidavit)
New River Basin. Three parameters
are water quality limited.
Aqua North Carolina, Inc. has re-
Swom to and subscribed before me, this 6th day of May, 20 6
quested renewal of permit N000
78158 for Olde Beau Golf Club
-
WWTP in Allegheny County; this
permitted facility discharges to an
unnamed tributary to Laurel Branch/
(No A ry Public)
New River Basin. Five parameters
are water quality limited.
WSJ: May 6, 2016
oO
My commission expires L 2? L020 KIMALEY JOHNSON
l NOTARY PUBLIC
FORSYTH COUNTY
THIS IS NOT A BILL. PLEASE PAY FROM INV t61Ec( kLAAltfril(OtralclGs -24.

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile
home parks, etc) that can be administratively renewed with minor changes, but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Jennifer D. Busam — 4/27/2016
Permit Number
NCO084832
Facility Name
Nikola's Restaurant & High Meadows Inn
W WTP
Basin Name/Sub-basin number
New / 05-07-03
Receiving Stream
Laurel Bra
ch Laurel Creek)
Stream Classification in Permit
C; Tr6Uj
Stream Index: 10-9-10-2
Does permit need Daily Max NH3 limits?
No — already present
Does permit need TRC limits/language?
No — already resent
Does permit have toxicity testing?
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
Yes; for DO and temperature
Is the stream impaired on 303(d) list)?
No
Any obvious compliance concerns?
No. No enforcements during the current
permit cycle. A few NOVs from frequency
violations.
Any permit mods since lastpermit?
No
New expiration date
03/31/2021
Changes to 2011 Permit?
Added eDMR requirements
Added regulatory citations
Created a new outfall ma
Changes to Draft Permit?
Most Commonly Used Expedited Language:
• 303(d) language for Draft/Final Cover Letters: "Please note that the receiving stream
is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List.
Addressing impaired waters is a high priority with the Division, and instream data will
continue to be evaluated. If there is noncompliance with permitted effluent limits and
stream impairment can be attributed to your facility, then mitigative measures may be
required".
• TRC language for Compliance Level for Cover Letters/Effluent Sheet Footnote:
"The facility shall report all effluent TRC values reported by a NC certified laboratory
including field certified. However, effluent values below 50 µg/L will be treated as zero
for compliance purposes."

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit 000084832
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 & 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]
Fax Number
e-mail Address [e-mail]
RKEIVE INCDEGYDWR
2. Location of facility producing discharge: FEB U 5 2016
Check here if same address as above ❑ Water Quality
Street Address or State Road NC Highway 21 Permitting Section
City
State / Zip Code
County
Roaring Gap
NC / 28683
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
Kemersville
State / Zip Code
NC / 27284
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
infoanrandalabs,com
1 of 3 Form-D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Fao9ft Generating astewater(check all that applyr
Industrial
❑
Number of Employees
Commercial
®
Number of Employees 7
Residential
❑
Number of Homes
School
❑
Number of Students/ Staff
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Restaurant
Number of persons served: l=
S. Type of collection system
® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes ® No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfalij:
Laurel Branch
S. Frequency of Discharge: ® Continuous ❑ 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 FcawD 11112

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 Q.0008 MGD (for the previous 3 years)
Maximum daily now 0.0043 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
,NEW AEZ&CAIWPS: Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples, for all other parameters 24-how 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.AIEWAL APPLiCAM: Provide the highest single reading (Daily Maximum) and Monthly Average over
the nast 36 months for parameters currently in your hermit. Mark other parameters "N/A".
- -- - - - - Parameter
Daily
Maximum
Monthly
Averse
Units of
Measurement
Biochemical Oxygen Demand (BODs)
19
6.09
Mg/l
Fecal Coliform
18
< I
Col/ 100 ml
Total Suspended Solids
31.3
6.49
Mg/l
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)
UIC (SDWA)
NPDES NCO084832
PSD (CAA)
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or rill (Section 404 or CWA)
Other
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.
Ycyv%ccS ik. M-et lAkfe.
Printed name of Person Signing Title
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 One 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 of 3 Form-D 11/12