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Home My WebLink AboutNCG210248_Outfall Location Form_20180705Division of Energy, Mineral, and Land Resources / �Land Quality Section – Stormwater Program OUTFALL LOCATION FORM Energy, Mineral and Land Resources ENVIRONMENTAL QUALITY 1) Individual Permit or Certificate of Coverage (COC) Number (begins with `NCG' or `NCS') 11yG FN_ I Fal � N M O W [ 4 1 F -F] 2) Location of facility producing discharge: Facility Name Facility Street Add Facility City Facility County Facility Contact Telephone No. Contact E-mail Discharge Points and Receiving Waters: 3) List each discharge point (outfall) that conveys stormwater associated with industrial activities (and/or wastewater, if applicable under certain General Permits). If stormwater and wastewater commingle, the outfall is considered a wastewater outfall. To find waterbody information, go to DWR's Website https://deg.nc.gov/about/divisions/water- resources/water-resources-science-data and use the "NC Surface Water Classifications" Map Viewer to search your location and/or waterbody. Outfall No. F-1 I—D] I -ol FI (Must be 34 numbers or characters only, for example: 001 or 001S) Type of Discharge: Vstormwater ❑ Wastewater Description (OPTIONAL) – Use this to denote a I nger outfall name used by the facility, or to briefly describe the outfall or drainage area. c�rti 1 r c.�– sots , h"t-- a-. e- I ie��nc + � 10 N Latitude (degrees /minutes /seconds or decimal degrees): Longitude (degrees / minutes / seconds or decimal degrees): 2'�/ a.4 W What is the name of the body of water (crSek, stream, river, lake, etc.) that this outfall eventually discharges to? ��_n o i-ee, �Gi,� ;Ayl�� Crt v^ ler Ue,r _S 1 kj Does this outfall discharge to an unnamed tributary (UT) first? Waterbody index number (see DWR's Map Viewer above): _ If this outfall discharges to a separate storm sewer system, name the operator of the separate storm sewer system (e.g. City of Raleigh municipal storm sewer): /.iv Does this outfall have Representative Outfall Status (ROS)? ).to If yes, what other outfalls does it represent? »»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»> Page 1 of 3 SWLI-Outfall-Location-Form Last revised 7/18/17 Outfall Location Form Outfall No. E] F-1 F] F-1 (Must be 3-4 numbers or characters only, for example: 001 or 001S) Type of Discharge: ❑ Stormwater ❑ Wastewater Description (OPTIONAL) — Use this to denote a longer outfall name used by the facility, or to briefly describe the outfall or drainage area: Latitude (degrees / minutes / seconds or decimal degrees): Longitude (degrees / minutes / seconds or decimal degrees): N W - What is the name of the body of water (creek, stream, river, lake, etc.) that this outfall eventually discharges to? Does this outfall discharge to an unnamed tributary (UT) first? Waterbody index number (see DWR's Map Viewer above): If this outfall discharges to a separate storm sewer system, name the operator of the separate storm sewer system (e.g. City of Raleigh municipal storm sewer): Does this outfall have Representative Outfall Status (ROS)? If yes, what other outfalls does it represent? »»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»> Outfall No. F-1 F-1 1-1 F-1 (Must be 3-4 numbers or characters only, for example: 001 or 001S) Type of Discharge: ❑ Stormwater ❑ Wastewater Description (OPTIONAL) — Use this to denote a longer outfall name used by the facility, or to briefly describe the outfall or drainage area: Latitude (degrees / minutes / seconds or decimal degrees): Longitude (degrees / minutes / seconds or decimal degrees): N W What is the name of the body of water (creek, stream, river, lake, etc.) that this outfall eventually discharges to? Does this outfall discharge to an unnamed tributary (UT) first? Waterbody index number (see DWR's Map Viewer above): If this outfall discharges to a separate storm sewer system, name the operator of the separate storm sewer system (e.g. City of Raleigh municipal storm sewer): Does this outfall have Representative Outfall Status (ROS)? If yes, what other outfalls does it represent? »»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»> Page 2 of 3 — Attach Additional Sheets if Necessary SM-Outfall-FormLast revised 7/5/17 Outfall Location Form Outfall No. F] F-1 F1 F-1 (Must be 3-4 numbers or characters only, for example: 001 or 001S) Type of Discharge: ❑ Stormwater ❑ Wastewater Description (OPTIONAL) — Use this to denote a longer outfall name used by the facility, or to briefly describe the outfall or drainage area: Latitude (degrees / minutes / seconds or decimal degrees): Longitude (degrees / minutes / seconds or decimal degrees): N W What is the name of the body of water (creek, stream, river, lake, etc.) that this outfall eventually discharges to? Does this outfall discharge to an unnamed tributary (UT) first? Waterbody index number (see DWR's Map Viewer above): If this outfall discharges to a separate storm sewer system, name the operator of the separate storm sewer system (e.g. City of Raleigh municipal storm sewer): Does this outfall have Representative Outfall Status (ROS)? If yes, what other outfalls does it represent? »»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»> Certification: North Carolina General Statute 143-215.6 b (i) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). I certify that I am familiar with the information contained in this form and that to the best of my knowledge and belief, such information is true, complete, and accurate. Printed Name of Person Signing: Wa4l a. &AX'7'd�j Title: tj_aM4 . hA^ , K � (Signature of Submittor) Mail this form back to: Stormwater Program Division of Energy, Mineral, and Land Resources 512 N. Salisbury Street 1612 Mail Service Center Raleigh, North Carolina 27699-1612 6-2-q 4? (Date Signed) Page 3 of 3 — Attach Additional Sheets if Necessary SWU-Outfall-Form Last revised 7/5/17