NC0046809_Renewal (Application)_20160226

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 NC0046809
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
Facility Name Cornerstone Conference and Resource Center
Mailing Address ?(=, ()D0,‘ \5a
City IOECENED/NCDEQ/DWR
cl o w a 5 Su t•n M tt
State / Zip Code a C Z-12 FEB 2 9 ZO B
Telephone Number (33(a) (o S(o - 7 L, Water Quality
Fax Number (.336) COS b_ -1 35'- Permitting Section
e-mail Address doJo;,(\eS G, CC C a L.of s
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road —(S c S V S \-i\4t-\w Al 'Z9
City
s Su;v,.M,;

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 El Number of Employees
Commercial ❑ Number of Employees
Residential ❑ Number of Homes
School El Number of Students/Staff
Other X Explain: Below
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Retreat and camp center with multiple cabins, cafeteria and a 1,450 seat auditorium. Domestic waste
Number of persons served: -30°
5. Type of collection system
X Separate (sanitary sewer only) El 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 X No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
Unnamed tributary to Benaja Creek in the Cape Fear River Basin
8. Frequency of Discharge: Continuous X Intermittent
If intermittent:
Days per week discharge occurs: dependent upon occupancy Duration: continuous
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.
See last page
2 of 4 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 0.020 MGD
Annual Average daily flow 0.0015 MGD (for the previous 3 years)
Maximum daily flow 0.007 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X 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.
RENEWAL 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) 14.7 8.9 mg/1
Fecal Coliform >600 24 #/100 ml
Total Suspended Solids 21.0 21.0 mg/1
Temperature (Summer) 27 26 Deg C
Temperature (Winter) 16 16 Deg C
pH 7.8 6.2 (min) 6-9 SU
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 NC0073571 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.
r vA•12.-(2.k. G,,„,s _)\Q, o(_ OP -co r1
P ' d name of Person Signing Title
Z- - 1(0
Signature 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 of 4 Form-D 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
1. Continue to operate an existing 0.02 MGD wastewater treatment facility with the
following components:
• Splitter box
• Bar screen
• Dual parallel aeration tanks
• Dual parallel clarifiers
• Dual tertiary filters
• Chlorine contact chamber with tablet chlorination
• Tablet dechlorination
• Sludge digester
This facility is located off U.S. Highway 29 North northeast of Browns Summit at
the Cornerstone Conference and Resource Center WWTP in Guilford County.
4 of 4 Form-D 11/12