NC0042251_Renewal (Application)_20160914

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 INCO042251 —71
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
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
Pender County'Schools
Pender High School
925 Penderlea Highway
Burgaw
North Carolina, 28425 RECEIVEDINCDEQURR
910-259-2187 SFP 14 2016
910-259-0132
'Al. -,a- - E1
� �a99$V
Robert-justiceapender.kl2.nc.us Permitting Secliorf
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 5380 NC Highway 53 West
City
State / Zip Code
County
Burgaw
North Carolina, 28425
Pender
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 John Shepard
Mailing Address 925 Penderlea Highway
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
Burgaw
North Carolina, 28425 -%
910-259-2187 d
910-259-0132
John_shepard@pender. k 12. nc. us
1 of 4 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
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff 605
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
school
Number of persons served: 605
5. Type of collection system
xSeparate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 1
Is the outfall equipped with a diffuser? ❑ Yes x No
7. Name of receiving stream(s) (NEW applicants: Provide a snap showing the exact location of each
outfall):
Long Creek
8. Frequency of Discharge: x Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 7 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.
Monitor temp. daily, record flow daily, PH weekly, Dissolved Oxygen weekly, BOD weekly,
fecal weekly. All samples are ( grab samples). Total Chlorine Bi -weekly, NH3as1j _weekly
IF
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 0.02 MGD
Annual Average daily flow 0.006600 MGD (for the previous 3 years)
Maximum daily flow 0.012700 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 nnst .36 months for parameters currentlu in uour permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BODS)
3.9
<2.9
Mg/1
Fecal Coliform
12
<5
Geometric mean
Total Suspended Solids
3.1
<2.9
Mg/1
Temperature (Summer)
26.9
26.3
C
Temperature (Winter)
15.4
12.3
C
pH
8.6
7.6
standard
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES Nc0042251
PSD (CAA)
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (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.
John Shepard ORC
Printed name of Person Signing Title r1�
Signa re of A ca Date
North Carolina General Statute 143-215.6 (b)(2) slates; Any person who knowingly makes any false statemen"(representation, or certification in any
application, record, report, plan, or other document files or required to be maintained under Article 21 or regtions of the Environmental Management
Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate anRecording 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
3 of 4 Form -D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
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.)
4 of 4 Form -D 11/12