NC0059536_Renewal (Application)_20241118

ROY COOPER {i _
I.
Governor ,
MARY PENNY KELLEY ' ,,nr�0, 44
Secretary
RICHARD E.ROGERS,JR. NORTH CAROLINA
DirectorEnvironmental Quality
November 18, 2024
Hilltop Living Center
Attn: Tisha Tuttle, President
212 Plemmons Dr
Linwood, NC 27299
Subject: Permit Renewal
Application No. NC0059536
Hilltop Living Center WWTP
Davidson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the November 15, 2024, receipt of your permit renewal application
and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://www.deq.nc.gov/permits-rules/environmental-application-tracker
n about the permit, please contact the primaryreviewer of the application usingthe
Ifyou have anyadditional questions
q pP
links available within the Application Tracker.
Sincerely,jril"
Wren- hedf. .
Administrative Assistant
Water Quality Permitting Section
ec: WQPS Laserfiche File w/application
D_E Qom, North Carolina Department of Environmental Quality oad,S iof Water Resources
'�d/p Winston-Salem Regional Office 450 West Harxs AUII Road,Suite 300 Winston-Salem,North Carolina 27105
ma r 336 776 9800

kerNekba, LI to( P'env\
EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
Form U.S.Environmental Protection Agency
2A eiEPA Application for NPDES Permit to Discharge Wastewater
NPDES NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION 1.BASIC APPLICATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.21(j)(1)and(9))
1.1 Facility name
Plemmons Enterprises Inc.t/a Hilltop Living Center
Mailing address(street or P.O.box)
212 Plemmons Dr.
City or town State ZIP code
o Linwood NC 27299
Contact name(first and last) Title Phone number Email address
Tisha Tuttle President [phone] [e-mail]
Location address(street,route number,or other specific identifier) m Same as mailing address
u_
City or town State ZIP code
1.2 Is this application for a facility that has yet to commence discharge? R CEI v ED
❑ Yes 4 See instructions on data submission ❑✓ No 5 ZOZ4
requirements for new dischargers. NOV
1.3 Is applicant different from entity listed under Item 1.1 above?
❑ Yes IDNo 4 SKI1 1 (4/OW9/MP®E
Applicant name
= Applicant address(street or P.O.box)
0
City or town State ZIP code
co Contact name(first and last) Title Phone number Email address
1.4 Is the applicant the facility's owner,operator,or both?(Check only one response.)
❑✓ Owner ❑ Operator ❑ Both
1.5 To which entity should the NPDES permitting authority send correspondence?(Check only one response.)
❑ Facility ❑ Applicant ❑✓ Facility and applicant
(they 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
° ✓❑ NPDES(discharges to surface 0 RCRA(hazardous waste) ❑ UIC(underground injection
water) control)
E NC0059536
2 ❑ PSD(air emissions) ❑ Nonattainment program(CM) ❑ NESHAPs(CM)
cc)
co ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section ❑ Other(specify)
404)
EPA Form 3510-2A(Revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
1.7 Provide the collection system information requested below for the treatment works.
Municipality Population Collection System Type
Served Served (indicate percentage) Ownership Status
%separate sanitary sewer ❑ Own 0 Maintain
d %combined storm and sanitary sewer 0 Own 0 Maintain
d 0 Unknown ❑ Own 0 Maintain
c %separate sanitary sewer 0 Own ❑ Maintain
g %combined storm and sanitary sewer 0 Own 0 Maintain
S ❑ Unknown 0 Own 0 Maintain
as %separate sanitary sewer ❑ Own 0 Maintain
- %combined storm and sanitary sewer 0 Own 0 Maintain
o 0 Unknown 0 Own ❑ Maintain
E
%separate sanitary sewer 0 Own ❑ Maintain
> %combined storm and sanitary sewer 0 Own 0 Maintain
cn
c 0 Unknown 0 Own ❑ Maintain
"� Total
cu Population
c Served
Separate Sanitary Sewer System Combined Storm and
_ Sanitary Sewer
Total percentage of each type of
sewer line(in miles)
1.8 Is the treatment works located in Indian Country?
o ❑ Yes ❑✓ No
U
R 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
0.003 mgd
= _Annual Average Flow Rates(Actual)
a2. Two Years Ago _ Last Year This Year
0 0.0022 mgd 0.0013 mgd Waiver Sept'23 mgd
cc—
Maximum Daily Flow Rates(Actual)
43)
CI I
Two Years Ago _ Last Year This Year
0.0072 mgd 0.0038 mgd Waiver Sept'23 mgd
H 1.11 Provide the total number of effluent discharge points to waters of the United States by type.
o Total Number of Effluent Discharge Points by Type
a a. Constructed
CD Combined Sewer
>
Treated Effluent Untreated Effluent Bypasses Emergency
as .a Overflows Overflows
0
N_
6 1
I
EPA Form 3510-2A(Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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 Impoundment Location and Discharge Data
Average Daily Volume
Location Discharged to Surface Continuous or Intermittent
Impoundment (check one)
❑ Continuous
gpd ❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
-0
1.14 Is wastewater applied to land?
❑ Yes ❑ No 4 SKIP to Item 1.16.
0 1.15 Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Continuous or
Location Size Average Daily Volume Intermittent
Applied (check one)
N acresgpd 0 Continuous
o 0 Intermittent
_0 acres d 0 Continuous
o gp 0 Intermittent
-a 0 Continuous
acres gpd 0 Intermittent
3 1.16 Is effluent transported to another facility for treatment prior to discharge?
❑ Yes ❑ No 4 SKIP to Item 1.21.
0
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
II
EPA Form 3510-2A(Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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 Facility Data
-o Facility name Mailing address(street or P.O.box)
0
0
City or town State ZIP code
0
U
Contact name(first and last) Title
0
5 Phone number Email address
n
oNPDES number of receiving facility(if any) 0 None Average daily flow rate mgd
0
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
o have outlets to waters of the United States(e.g.,underground percolation,underground injection)?
0En
Yes ❑✓ No 4 SKIP to Item 1.23.
s
0
0 1.22 Provide information in the table below on these other disposal methods.
d 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)
co Description _ Volume
ch
7 acres gpd ID Continuous
o ❑ Intermittent
❑ Continuous
acres gpd ❑ Intermittent
acresgpd ❑ Continuous
❑ 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.
a, w Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
w z ❑ Discharges into marine waters(CWA ❑ Water quality related effluent limitation(CWA Section
Section 301(h)) 302(b)(2))
❑✓ 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 ❑ No+SKIP 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
wContractor name Joe Shaffer,operator Jeff Walser,Back up operator
( (company name)
0 L Mailing address
c (street or P.O.box)
o City,state,and ZIP
5
code
0 Contact name(first and
c.) last)
Phone number [phone] [phone]
Email address [e-mail] [e-mail]
Operational and Operator Back up Operator
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
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
SECTION 2.ADDITIONAL INFORMATION(40 CFR 122.21(j)(1)and(2))
o Outfalls to Waters of the United States
= 2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
rn
o ❑ 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
0
and infiltration.
gpd
47.
Indicate the steps the facility is taking to minimize inflow and infiltration.
0
2.3 Have you attached a topographic map to this application that contains all the required information?(See instructions for
e specific requirements.)
rn�
0 ❑ Yes ❑ No
E 2.4 Have you attached a process flow diagram or schematic to this application that contains all the required information?
3 co
o (See instructions for specific requirements.)
LT o ❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
0
is 1.
C
C)
E
C)
fl 2.
o
3.
-c
d
4.
0
a 2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Affected Attainment of
d Scheduled Begin End Begin
Outfalls Operational
o Improvement Construction Construction Discharge
(from above) (list outfal (MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY) Level
numberber)) (MM/DD/YYYY)
v
m
1.
d
o 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:
Renewal of 5 year permit
EPA Form 3510-2A(Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
SECT!'N 3.INFORMATION ON EFFLUENT DISCHARGES(40 CFR 122.21(j)(3)to(5))
3.1 Provide the following information for each outfall.(Attach additional sheets if you have more than three outfalls.)
Outfall Number 1 Outfall Number Outfall Number
State North Carolina
County Davidson
0 City or town Linwood
0
.Q Distance from shore 0 ft. ft. ft.
Depth below surface o ft. ft. ft.
Average daily flow rate mgd mgd mgd
Latitude
Longitude °
3.2 Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
❑ Yes ❑✓ No 4 SKIP to Item 3.4.
24)
3.3 If so,provide the following information for each applicable outfall.
Outfall Number Outfall Number Outfall Number
0
Number of times per year
0 discharge occurs
a Average duration of each
discharge(specify units)
c Average flow of each
discharge mgd mgd mgd
Months in which discharge
occurs
3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ❑✓ No 4 SKIP to Item 3.6.
3.5 Briefly describe the diffuser type at each applicable outfall.
n
Outfall Number Outfall Number Outfall Number
U)
N
u..
ui 3.6 Does the treatment works discharge or plan to discharge wastewater to waters of the United States from one or more
discharge points?
w ❑ Yes ❑✓ No 3SKIP 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
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
3.7 Provide the receiving water and related information(if known)for each outfall.
Outfall Number Outfall Number Outfall Number
Receiving water name
Name of watershed,river,
0 or stream system
U.S.Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
U.S.Geological Survey
8-digit hydrologic
ce cataloging unit code
Critical low flow(acute) 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 provided for discharges from each outfall.
Outfall Number Outfall Number Outfall Number
Highest Level of 0 Primary 0 Primary 0 Primary
Treatment(check all that 0 Equivalent to 0 Equivalent to 0 Equivalent to
apply per outfall) secondary secondary secondary
❑ Secondary 0 Secondary ❑ Secondary
❑ Advanced 0 Advanced 0 Advanced
❑ Other(specify) 0 Other(specify) 0 Other(specify)
c
Design Removal Rates by
Outfall
N
BODt or CBODs
TSS
0 Not applicable 0 Not applicable 0 Not applicable
Phosphorus %
❑Not applicable 0 Not applicable 0 Not applicable
Nitrogen %
Other(specify) 0 Not applicable ❑ Not applicable 0 Not applicable
EPA Form 3510-2A(Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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.
_
0
_ Outfall Number Outfall Number Outfall Number
0
Disinfection type
Seasons used
Dechlorination used? ❑ Not applicable ❑ Not applicable ❑ Not applicable
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No 0 No
3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package?
❑ 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?
❑ 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 Outfall Number Outfall Number
Acute Chronic Acute Chronic Acute Chronic
Number of tests of discharge
water
Number of tests of receiving
water
3.13 Does the treatment works have a design flow greater than or equal to 0.1 mgd?
❑ Yes 0 No 4 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. ❑ No 4 Complete Table B,omitting chlorine.
c 3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
w ❑ 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 ❑ No 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?
❑ 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 ❑ 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
NC0059536 Hilltop Living Center WWTP OMB No.2040-0004
Ij 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?
❑ Yes 0 No 4 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?
El Yes 0 No 4 Provide results in Table E and SKIP to
Item 3.26.
3.21 Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s)Submitted Summary of Results
(MM/DD/YYYY)
� I
C
CO 3.22 Regardless of how you provided your WET testing data to the NPDES permitting authority,did any of the tests result in
toxicity?
❑ Yes ❑ No 4 SKIP to Item 3.26.
d 3.23 Describe the cause(s)of the toxicity:
c
C
w
3.24 Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25 Provide details of any toxicity reduction evaluations conducted.
3.26 Have you completed Table E for all applicable outfalls and attached the results to the application package?
El Yes ❑ Not applicable because previously submitted
information to the NPDES •ermittin. authorit .
SECTION 4.INDUSTRIAL DISCHARGES AND HAZARDOUS WASTES(40 CFR 122.21(j)(6)and(7))
4.1 Does the POTW receive discharges from SIUs or NSCIUs?
❑ 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
0
12 4.3 Does the POTW have an approved pretreatment program?
CO ❑ Yes
_ ❑ No
4.4 Have you submitted either of the following to the NPDES permitting authority that contains information substantially
4 identical to that required in Table F:(1)a pretreatment program annual report submitted within one year of the
application or(2)a pretreatment program?
y ❑ Yes ❑ No 4 SKIP to Item 4.6.
0
To 4.5 Identify the title and date of the annual report or pretreatment program referenced in Item 4.4.SKIP to Item 4.7.
4.6 Have you completed and attached Table F to this application package?
❑ Yes ❑ No
EPA Form 3510-2A(Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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?
0 Yes 0 No 4 SKIP to Item 4.9.
4.8 If yes,provide the following information:
Annual
Hazardous Waste Waste Transport Method Amount of Units
Number (check all that apply) Waste
Received _
❑ Truck 0 Rail
❑ Dedicated pipe ❑ Other(specify)
0
v
❑ Truck 0 Rail
❑ Dedicated pipe ❑ Other(specify)
0
-0
N ❑ Truck ❑ Rail
_ ❑ Dedicated pipe ❑ Other(specify)
R 4.9 Does the POTW receive,or has it been notified that it will receive,wastewaters that originate from remedial activities,
including those undertaken pursuant to CERCLA and Sections 3004(7)or 3008(h)of RCRA?
❑ Yes 0 No 4 SKIP to Section 5.
11) 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)?
0 Yes 4 SKIP to Section 5. 0 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?
0 Yes 0 No
SECTION 5.COMBINED SEWER OVERFLOWS(40 CFR 122.210)(8))
5.1 Does the treatment works have a combined sewer system?
rn ❑ Yes 0 No 4SKIP to Section 6.
5.2 Have you attached a CSO system map to this application?(See instructions for map requirements.)
a. ❑ Yes 0 No
co
5.3 Have you attached a CSO system diagram to this application?(See instructions for diagram requirements.)
o 0 Yes 0 No
U
EPA Form 3510-2A(Revised 3-19) Page 10

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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
0- State and ZIP code
0
u)
o County I
al
= Latitude " I
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 El No
a)
c
oo CSO flow volume El Yes ❑ No ❑ Yes CI No El Yes ❑ No
CSO pollutant 0 Yes 0 No 0 Yes 0 No 0 Yes 0 No
o concentrations
co
0 Receiving water quality El Yes El No ❑ Yes El No 0 Yes 0 No
CSO frequency ❑ Yes 0 No El Yes ❑ No El Yes 0 No
i Number of storm events 0 Yes 0 No 0 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
cu Number of CSO events in events events events
y the past year
C
a
c Average duration per hours hours hours
0 event
c 0 Actual or 0 Estimated 0 Actual or❑ Estimated 0 Actual or 0 Estimated
CD
o Average volume per event
million gallons million gallons million gallons
`n
ci 0 Actual or 0 Estimated 0 Actual or❑ Estimated 0 Actual or 0 Estimated
Minimum rainfall causing inches of rainfall inches of rainfall inches of rainfall
a CSO event in last year 0 Actual or 0 Estimated ❑Actual or 0 Estimated 0 Actual or 0 Estimated
EPA Form 3510-2A(Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
NC0059536 Hilltop Living Center WWTP 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/
stream system
a` U.S.Soil Conservation 0 Unknown 0 Unknown 0 Unknown
Service 14-digit
= watershed code
"> (if known)
Name of state
management/river basin
ccnn U.S.Geological Survey 0 Unknown 0 Unknown 0 Unknown
8-Digit Hydrologic Unit
Code(if known)
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
exam Iles
SECTION 6.CI-ECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(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
Information for All Applicants
❑ Section 2:Additional ❑ wl topographic map ❑ wl process flow diagram
Information ❑ w/additional attachments
❑ w/Table A ❑ wl Table D
0 Section 3: Information on ❑ w/Table B ❑ w/Table E
Effluent Discharges
E ❑ wl Table C ❑ w/additional attachments
rts Section 4: Industrial ❑ w/SIU and NSCIU attachments ❑ w/Table F
cn ❑ Discharges and Hazardous
Wastes ❑ w/additional attachments
❑ w/CSO map ❑ w/additional attachments
❑ Section 5:Combined Sewer
'C Overflows
❑ w/CSO system diagram
= Section 6: Checklist and
❑ Certification Statement ❑ wl attachments
N
�e 6.2 Certification Statement
1 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
Plemmons Enterprises,Inc t/a Hilltop Living Center by Tisha Tuttle President
Signa ure I Date signed
-t 11/13/2024
EPA Form 3510-2A(Revised 3-19) Page 12