NC0025453_Effluent Pollutant Scan Waiver CY 2024_20241029

NCDWQ NPDES EFFLUENT POLLUTANT SCAN WAIVER FORM
In lieu of performing the required annual Effluent Pollutant Scan and to satisfy the NPDES reporting
requirement,a municipal wastewater treatment facility may complete and submit this form to NCDWQ if
the following criteria are met:
➢ The facility can still meet the requirement to perform three pollutant scans for its next NPDES
permit application; and
➢ Has a design flow greater than or equal to 1.0 MGD; or
➢ Is required to have a pretreatment program (or has one in place); or
➢ Is otherwise required by the NCDWQ to conduct an annual effluent pollutant scan.
Facility Name: �` I
SG.r"�'5 UTGlnCln LJ!21:�'
NPDES Permit Number: N o f J y f 3 OutfaHNumber:
Effective Date: I p Z� Zc2 (Complete form for each outfall discharging effluent to waters of the state and requiring an annual Effluent Pollutant Scan)
Expiration Date: i 2 > 2�Z�f
Owner Information Person Certifying the Form
Owner/P rmittee Name: Certiflees Name:
own a - r o bo,v;c.I
Title (if applicable): Title or Position with facility:
o N MCSV► e✓ Wctzr +�cIG,MCihu;, �-�,k3 aiti1h
Email Address: Email Address:
Mailing Add ess: Mailing Address:
PO SOX 271 P0G4,x61y
City,State Zip: City,State Zip:
k,VI Svc. BZ Clu, kc+,, "J(- 2'1�'Zt3
Telephone: Telephone:
.51 • 553-S0b'L Q�i c( - Sic{-0 ci 1-7
By completing and submitting this form,I, GGvid W�.,j c. ,(printed name) certify
that the effluent waste stream for the facility and outtall indicated above has not significantly changed
within the past year in a manner that would cause any of the listed parameters to be present or present in
concentrations greater than previously reported and I hereby submit this completed form to satisfy the
NPDES annual Effluent Pollutant Scan reporting requirement for calendar year =10-Ly
I also attest that the facility can still meet the requirement to perform three pollutant scans for the next
NPDES permit application.
Certified by (signature): �-Ie",Z,,
,
Position or title of certifier: SLIP
Date certified: i 0 1 Z
This completed form shall be submitted along with the Discharge Monitoring Report to the fallowing address: Division
of Water Quality/Surface Water Protection Section/Central Files, 1617Mail Senlic•e Center, Raleigh, North Carolina
27699-1617.