NC0088803_Renewal Application_20160211

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD q
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit INC00S
If you are completing this form in computer use the TAB keg 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
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road � i1 _� 'LNq {fin- - f�C���l�L•
city
State / Zip Code
County
� r
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), i
Name
Mailing Address 1
City
uK
State / Zip Code L o rs 14
Telephone Number
Fax Number ( )
e-mail Address
1 of 3 Form-D 11112

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
❑
Number of Employees j
Commercial
Number of Employees
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.): I 41 ,l L �)
Number of persons served:.-_L
S. 911SZarate
f collection system
(sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s)
Is the outfall equipped with a diffuser? PYes ❑ No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
S. Frequency of Discharge: ❑ Continuous Intermittent
If intermittent:
Days per week discharge occurs: 1 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.
2of3
re��I, 911iilf H

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information: x,
Treatment Plant Design flowMGD f,' �•a` °
1�
Annual Average daily flows MGD (for the previous 3 years)
Maximum daily flow �9 MGD (for the previous 3 years) ,� \ L�
�k
11. Is this facility located on Ind' n country? .�
❑ Yes No
12. Effluent Data
NEW APPLICANTS: Provide data for the parameters listed. Fecal Colifonn, 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 nnct .16 months fnr nornmeters currenthi in uour nermit. Mark other parameters "NIA".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD;)
Fecal Coliform
Total Suspended Solids
Temperature (Summer)
Temperature (Winter)
pH
4�
� f �z 13. List all permits, construction approvals and/or applications:
�( Type Permit Number Type
�0 Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES Dredge or fill (Section 404 or CWA)
PSD (CAA) Other
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
Permit Number
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.
Printed name of Person Signing/ itle
Signature o 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 3 Form-D 11112

Water Resources
ENVIRONMENTAL QUALITY
February 22, 2016
Mr. William Young, Owner,
Siler Bullet Convenience Store
109 Carriage Drive
Burnsville, NC 28714
PAT MCCRORY
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
Subject: Acknowledgement of Permit Renewal
Application No. NCO088803
Siler Bullet Convenience Store
Yancey County
Dear Permittee:
The Water Quality Permitting Section has received your permit renewal application on February 11,
2016, A member of the NPDES Unit will review your application. They will contact you if additional
information is required to complete your permit renewal. Per G.S. 150B-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. Please respond in a timely manner to
requests for additional information necessary to complete the permit application.
If you have any additional questions concerning renewal of the subject permit, please contact Derek
Denard at 919-807-6307 or [e-mail].
Sincerely,
V/ re w Tln-ed( r&
Wren Thedford
Wastewater Branch
cc: Central Files
NPDES
Asheville Regional Office
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-807-6300

I AffL r2 .
j i�1•—c
N L 4J ��{ � � :� r�{• c. �- — "� , '-s �Itr � PAT MCCRORY
DONALD R. VAN DER VAART
Water Resources '2 Z-T
ENVIRONMEN I AL©UALIr Y. S. JAY ZIMMERMAN
January 28, 2016
Mr. William I Young, Owner
Silver Bullet Convenience Store
109 Carriage Dr.
Burnsville NC 28714
Dear Mr. Young:
RECEIVEDINCDEa1DWR
FEB 11
Sub_lect: Permit Renewal Application
Silver Bullet Convenience Store Wale,
NPDES Permit NCO088803 permitting Section
Yancey County
Please find an attached copy of NPDES Application — Form D.
NPDES Permit NCO088803 will expire on February 29, 2016. The Division has not received a
renewal application for this facility.
In accordance with Permit Condition IL B. 10., any Permittee that has not requested renewal at
least 180 days prior to expiration, or any Permittee that does not have a permit after the
expiration and has not requested renewal at least 180 days prior to expiration, will subject the
Permittee to enforcement procedures as provided in NCGS 143-215.6 and 33 USC 1251 et. seq.
To prevent further action, please submit a copy of the renewal application before the
expiration date of February 29, 2016.
If you have any questions, please contact me at 919-807-6307 or email at
derek.denardn_a ncdenr.ov.
cc: NPDES Files
Central Files
Sincerely,
� .........
Denard, Environmental Specialist
Division of Water Resources
1617 Mail Ser.ice Center, Raleigh, North Carolina 27699-1617
Phone: [phone] \Imernev N%wwv.ncwaterquelity.org
An Equal OpportunilgI. Affirm rn%c Action limploper - Made in part by recycled paper

AS '
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild P E Dee Freeman
Governor Director Secretary
n-I"
May 21, 2012 �hr c� - e ►10 r- -_ ~1•
William 1. Young ►ir�,�'�-�" c.�--
PO Box 250
Micaville NC 28755-0250
SUBJECT: Compliance Evaluation Inspection
Silver Bullet Convenience Store
Permit No: NCO088803
Yancey County
Dear Mr. Young :
Enclosed please find a copy of the Compliance Evaluation Inspection conducted
on April 24, 2012. The facility was found to be in Compliance with permit NC0088803.
Please refer to the enclosed inspection report for additional observations and
comments. If you or your staff have any questions, please call me at 828-296-4500.
Sincerely,
RECEIVEDINCDEWWR
FEB 11 2016 Jeff Menzel
Environmental Specialist
Water Quality
Permitting Section
cc: Juanita Reed James, ORC
Central Files
Asheville Files
SURFACE WATER PROTECTION — ASHEVILLE REGIONAL OFFICE
Location 2090 U S Highway 70 Swannanoa. NC 28778 One
Phone [phone]\FAX: [phone] Noi-thCarollna
1 Internet: www.ncwaterguality orq S:\SWP\Yancey\Wastewater\Minors\Silver Bullet 88803\88803 CEI 2012.docx Naturally

United States Environmental Protection Agency
Form Approved.
Washington, D.C. 20460
EPA
OMB No. 2040-0057
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 INI 2 I S I 31 NCO088803 111 121 12/04/24 117 18I C I 19I S I 20III
Remarks
21IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA --------------------------- Reserved ----------------------
67 I 169 70131 711 I 72 I N I 73I I 174 751 I I I I I Li
W
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
04:05 PM 12/04/24
11/03/01
Silver Bullet Convenience Store
Exit Time/Date
Permit Expiration Date
4075 E US Hwy 19 E
Burnsville NC 28714
04:25 PM 12/04/24
16/02/29
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Juanita Reed James/ORC/828-697-0063/
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
William I Young,PO Box 250 Micaville NC 287550250//828-682-7956/ No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Operations & Maintenance N Facility Site Review r Effluent/Receiving Waters
Section D: Summary of Finding/Comments Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
�r
Jeff Menzel ARO WQ//828-296-4500/ JIj J
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page # 1

NPDES yr/mo/day Inspection Type
3I NCO088803 1
11 12I 12/04/24 117 181 C
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
The facility was not discharging at the time of inspection.
No violations of permit requirements or applicable regulations were observed during this inspection.
Page # 2

Permit: NCO088803
Inspection Date: 04/24/2012
Operations & Maintenance
Owner - Facility: Silver Bullet Convenience Store
Inspection Type: Compliance Evaluation
Is the plant generally clean with acceptable housekeeping? ■ 0 0 D
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge 0 n N 0
Judge, and other that are applicable?
Comment: The facility was not discharging at the time of inspection.
4
Page # 3