WQ0031030_More Information Requested_20160523

Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
May 23, 2016
MARK STEFANIK — SUPERINTENDENT
CURRITUCK COUNTY BOARD OF EDUCATION
2958 CARATOKE HIGHWAY
CURRITUCK, NORTH CAROLINA 27929
Dear Mr. Stefanik
Subject: Application No. WQ0031030
Additional Information Request
Shawboro Elementary School
Facility
Other Non -Discharge System
Currituck County
Division of Water Resources' Central and Regional staff has reviewed the application package received
March 1, 2016. However, additional information is required before the review may be completed. Please
address the items on the attached pages no later than the close of business on June 22, 2016.
Please be aware that you are responsible for meeting all requirements set forth in North Carolina rules and
regulations. Any oversights that occurred in the review of the subject application package are still the
Applicant's responsibility. In addition, any omissions made in responding to the outstanding items in
Section A, Section B, Section C or Section D, or failure to provide the additional information on or before
the above requested date, may result in your application being returned as incomplete. .
Please reference the subject application number when providing the requested information. All revised
and/or additional documentation shall be signed, sealed and dated (where needed), with three copies
submitted to my attention at the address below.
If you have any questions regarding this request, please do not hesitate to contact me at [phone] or
[e-mail]. Thank you for your cooperation.
Sincerely,
David Goodrich, Hydrogeologist
Division of Water Resources
cc: Washington Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Permit Application File WQ0031030
Stale ol'North Carolina I Environmental Quality I Water Resources I Water Quality Permitting I Non -Discharge Permitting
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919 807 6464

Mr. Mark. Stefanik
May 23, 2016
Page 2 of 2
A. Non -Discharge System Renewal Form NDSR 11-15:
1. The Non -Discharge System Renewal Form NDSR 11-15 submitted on March 1, 2016 had Mark
Stefanik designated as the Permtttee instead of the Currituck County Board of Education.
Please designate the Currituck County Board of Education as the Permtttee, complete and submit
the enclosed Non -Discharge System Renewal Form NDSR 11-15 to the following address:
North Carolina Department of Environmental Quality
Division of Water Resources
Water Quality Permitting Section
Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
B. Operator in Responsible Charge (ORC) Designation Form:
It is our understanding that personnel changes have recently taken place at the subject wastewater
treatment facility at the Shawboro Elementary School. In accordance with the provisions of 15A
NCAC 08G .0200, the Water Pollution Control System Operators Certification Commission is to
be kept informed of the identities of the Operator in Responsible Charge and Backup Operator in
Responsible Charge at all classified treatment facilities. The Permittee, designated Operator in
Responsible Charge and Backup Operator in Responsible Charge must complete, sign and submit
a Water Pollution Control System Operator Designation Form indicating the current status of the
facility.
Please complete and submit the enclosed Water Pollution Control System Operator Designation
Form to the address indicated on the Form.

Division of Water Resources
I. PERMITTEE INFORMATION:
1. Permittee's name:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE SYSTEM RENEWAL
FORM: NDSR 11-15
2. Signature authority's name: per 15A NCAC 02T .0I 06(b) Title:
3. Permittee's mailing address:
City: State: Zip: -
4. Permittee's contact information: Phone number: (_) _- Email Address:
I1. FACILITY INFORMATION:
1. Facility name:
2. Facility's physical address:
City: State: Zip: - County:
III. PERMIT INFORMATION:
1. Existing permit number: WQ00 and most recent issuance date:
2. Existing pennit type: Select
I Has the facility been constructed? ❑ Yes or ❑ No
4. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.613? ❑ Yes or ❑ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ❑ No
d. is non -compliant with an existing non -discharge pen -nit, settlement agreement or order? ❑ Yes or ❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or ❑ No
Applicant's Certification per ISA NCAC 02T .0106(b):
attest that this application for
(Signature Authority's name & title from Application Item 12.)
(Facility name from Application Item I1.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. i understand that any discharge of wastewater
from this non -discharge system to surface waters or the land will result in an immediate enforcement action that may include civil
penalties, injunctive relief; and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition
of this permit be violated. I also understand that if all required parts of this application package are not completed and that if all required
supporting information and attachments are not included, this application package will be returned to me as incomplete. i further certify
that the Applicant or any affiliate has not been convicted of an environmental crime. has not abandoned a wastewater facility without
proper closure. does not have an outstanding civil penalty where all appeals have been exhausted or abandoned. are compliant with any
active compliance schedule, and do not have any overdue annual fees per 15A NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement.
representation. or certification in any application package shall be guilty of a Class 2 misdemeanor. which may include a fine not to
exceed S 10,000 as well as civil penalties up to S25.000 per violation.
Signature:
FORM: NDSR 1 1-15
Date:
Page i of 1

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address:
City:
Email address:
Signature:
Facility Name:
County:
State: Zip:
Phone #:
Date:
Permit #:
SUBMIT. ,FORMFOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
..................................................................................................................................................
Mail, fax or mail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
on inal to: Email: certadmin(a nedetingov
Mail or fax a cope, to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Ylooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phonc:919.791.4200
Revised 05-2015

6i,'PCSOCC Operator Designation Form, cont.
Facility Name:
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Permit #:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Email:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015