NCG110013 -

�► Permit Coverage hCG��aa 3
MIA Renewal AmAication Form
NCDENR National Pollutant Discharge Elimination System P�:S'
rmit Number
Stormwater Individual Permit 110000
Please provide your permit number in box in the upper right hand corner, complete the information in the space provided
below and return the completed renewal form along with the required supplemental information to the address indicated.
Owner Information * Address to which permit correspondence will be mai/ed
Owner/Organization Name: City of Winston—Salem, Archie Elledge, WWTP
Owner Contact: J. Frank Crump
Mailing Address: 2799 Griffith Road
Winston—Salem, NC 27103
Phone Number: 336-397-7625
Fax Number: 336-659-4320
E-mail address: [e-mail]
Facility Information
Facility Name:
Facility Physical Address:
Archie Elledge. WWTP
2801 G-riffith Road
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Winston—Salem, NC 27103
Facility Contact:
Jon Southern
MAY 012018
Mailing Address:
2801 Griffith Road
Winston—Salem, NC 27103
DENR-LANA UAUTY
Phone Number:
336-397-7600
STORMWATERp RMI'TtNG
Fax Number:
E-mail address:
j nng@ri tynfws _ nrg
Permit Information
Permit Contact: J. Frank Crum
Mailing Address: 2799 Griffith Road
Winstnn—Salem, NC 27103
Phone Number: 336-397-7625
Fax Number: 336-659-4320
E-mail address: [e-mail]
Discharge Information
Receiving Stream: Salem Creek
Stream Class:
Basin: Yadkin River Basin
Sub -Basin:
Number of Outfalls: IQ
Facility/ Activity Changes Please describe below any changes to your facility or activities since issuance of your permit. Attached a
separate sheet if necessary.
Added two Equalization Tanks, 2mg/each for process flows
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 ' true,jcom fete a ccurate.
Signature r Date April 17, 2018
Jon Southern Senior utility Plant SLpervisor
Print or type name of person signing above Title
SW Individual Permit Coverage Renewal
Please return this completed application form Stormwater Permitting Program
and requested supplemental information to: 1612 Mail Service Center
Raleigh, North Carolina 27699-1612

SUPPLEMENTAL INFORMATION REQUIRED FOR RENEWAL OF INDIVIDUAL
NPDES STORMWATER PERMIT
Two copies of each of the following shall accompany this submittal in order for the application
to be considered complete:
(Do not submit the site Stormwater Pollution Prevention Plan)
Initiials
J 1. A current Site Map from the Stormwater Pollution Prevention Plan. The location of
industrial activities (including storage of materials, disposal areas, process areas and
loading and unloading areas), drainage structures, drainage areas for each outfall,
building locations and impervious surfaces should be clearly noted.
N/A . 2.
A summary of Analytical Monitoring results during the term of the existing permit
(if your permit required analytical sampling). Do not submit individual lab reports.
The summary can consist of a table including such items as outfall number,
parameters sampled, lab results, date sampled, and storm event data.
See
Attached 3.
A summary of the Visual Monitoring results. Do not submit individual monitoring
reports. The summary can consist of a table including such items as outfall number,
parameters surveyed, observations, and date monitoring conducted.
See
Attached 4.
A summary of the Best Management Practices utilized at the permitted facility.
Summary should consist of a short narrative description of each BMP's in place at
the facility. If the implementation of any BMP's is planned, please include
information on these BMP's.
See
Attached 5.
A short narrative describing any significant changes in industrial activities at the
permitted facility. Significant changes could include the addition or deletion of
work processes, changes in material handling practices, changes in material storage
practices, and/or changes in the raw materials used by the facility.
/
V/ 6.
Certification of the development and implementation of a Stormwater Pollution
Prevention Plan for the permitted facility (Sign and return attached form).
If the final year analytical monitoring of the existing permit term has not been completed
prior to filing the renewal submittal, then the last years monitoring results should be submitted
within 30 days of receipt of the laboratory reports. (i.e. do not withhold renewal submittal
waiting on lab results)

Question #3- Outfalls are monitored (visual) once per quarter, 2 times during rain events, 2 times during
dry weather. The outfalls are numbered 1-20, #3 outfall was omitted during an upgrade in2008.
Question #4- Outfalls are monitored for erosion and any debris buildup, spill kits are located throughout
plant for spill control.
Question #5- Plant added 2 equalization tanks 2MG each for process flows in 2017.

STORINIWAAR L[7T�OATPI���ENTI(J�1'�1 PLAN
DEVET.OPA'IE1WT AND I�4IPT,E1kIENTATIOt�i
�ERTIFICA I'T()N.
North Carolina Division of Energy, Mineral, and Land Resources - Stormwater Permitting
Facility Name: Archie Elledge, WWTP
Permit Number: NCG 110000
Location Address: 2801 Griffith Road
Winston—Salem, NC 27103
County: Forsyth
"I certify, under penalty of law, that the Stormwater Pollution Prevention Plan (SPPP) document and all
attachments were developed and implemented under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gather and evaluate the information required by the SPPP.
Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
for gathering the information, the information gathered is, to the best of my knowledge and belief, true,
accurate and complete."
And
"I certify that the SPPP has been developed, signed and retained at the named facility location, and the SPPP
has been fully implemented at this facility location in accordance with the terms and conditions of the
stormwater discharge permit."
And
"I am aware that there are significant penalties for falsifying information, including the possibility of fines and
imprisonment for knowing violations."
Sign (according to permit signatory requirements) and return this Certification. DO NOT
SEND STORMWATER POLLUTION PREVENTION PLAN WITH THIS CERTIFICATION.
Signature1 11 , C-) <Y
on Southern
Print or type name of person signing above
Date April 17. 2018
Senior Utility Plant Supervisor
Title
SPPP Certification 10/13

CERTIFICATION OF NON-STORMWATER DISCHARGES
FORM 3
I certify, under penalty of law, that the stormwater outfalls covered by this Permit have been
tested or evaluated for the presence of non-stormwater discharges 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 those persons, to the best
of my knowledge and belief, no non -permitted discharges of non-stormwater enter the
stormwater outfalls covered by this Permit because of activities occurring at this facility [as
specified in Part II, Section A, Paragraph 1(e) of the Permit].
Print Name and Official Title:
Jon Southern
Senior Utility Plant Supervisor
Signat re:
X,P..k�
We Signed:
2-24-2018
Representing:
Archie Elledge WWTP
2799 Griffith Road
Winston-Salem, North Carolina 27103
Methods of Evaluation Used:
l Review of building and site plans.
Visual inspection of storm drainage system components (e.g., catch basins, manholes).
® Observation of outfalls on a dry day that was preceded by at least 72 hours of dry weather.
CR7 Interview with facility personnel.
❑ Flow tests using water, tracers, dyes, or smoke.
The Permittee is aware of the upset or bypass notification procedures as specified in the facility's NPDES Permit and
will act accordingly (See Part III, Sections C and E of the Permit).

Aw
'06
LEGEND
A
SODIUM HYPOCHLORITE
F
GASOLINE
& SODIUM BISULFITE
G
AMMONIUM NITRATE (EFF)
B
CAUSTIC (MAIN TANK)
H
AMMONIUM NITRATE (PTB)
C
CAUSTIC & POLYMER (GBT)
I
POLYMER & FERRIC
D
FUEL OIL (GENERATORS)
J
CAUSTIC & HYPOCHLORITE
E
FUEL OIL (MANSON-MEADS)
K
MISC. CHEMICAL STORAGE
1-19 ARE STORMWATER OUTFALL LOCATIONS
NOTE: 3 WAS REMOVED DURING THE 1992 UPGRADE
18 WAS ADDED FALL 2004 WITH BS CAKE STORAGE
19 WAS ADDED FALL 2007 WITH DRYER FACILITY