NC0040045_Application_20190603

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to: RECEIVED/NCDEA/DWR
NC DEQ / DWR / NPDES
1617 Mail Service Center, Raleigh, NC 27699-1617 JUN 0 3 1019
NPDES Permit NC00 4 00'+$ Water Quality
Permitting Section
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 'o h eX 4 W(L16eir
Facility Name �l I' S � y r
Mailing Address 1'z L v St‘iae- Kites fad
City Li(NIA)43od.
State / Zip Code g . 2 n-q 1
Telephone Number (33‘ )454 4 444
Fax Number (33 G) 4 51► G o 5 7
e-mail Address ru h er-t e wai 5tre t a,h000c4r^
2. Location of facility producing discharge:
Check here if same address as above Et-
Street Address or State Road
City
State / Zip Code
County
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 Ld t, ,(p- k,e O n
Mailing Address �' 0 2. Pio r Sae. A v
City t;e.lungn
State / Zip Code We, 2 '12 45
Telephone Number ( 330 ,23q D g.stZ
Fax Number ( )
e-mail Address Let 1.i,,,kep T,,koo.co M
1 of 3 Form-D 6/2017

�R

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 [vr Number of Employees 3(�
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.):
Number of persons served: 1S0•200
5. Type of collection system
Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) 00 l
Is the outfall equipped with a diffuser? ❑ Yes 2—No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
SOt h 1to s Creed
8. Frequency of Discharge: [r Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 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. _1
a Aue, o pQxa-& C_O e_viS 1ng 0, ©d MQ c� was-itwafer .t-eai mere
P l On} -ghat j,n elkde 5 the, - ,UlOu ing Com ponenvs ,
rt,0. e, a
t (veD iaUUon set is tat- O
Li,Ooo non rec.irt-u-10--444g d©5mS +61-nk- Wi daa. i a 0:5gpmPt-nt 5
tip x 5D ' r Ci rcu 1Qfin 51A-r-Pu.c,-- Sand -1r/4t+
-a,b ChlDrinal-io&. d ,fGchtorina4iv,.�
2 of 3 F loco m ea 5 ikre-ineid C1/EU Form-D 6/2017

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow • 00 f%D MGD
Annual Average daily flow .000.62 MGD (for the previous 3 years)
Maximum daily flow 000 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
El Yes Er 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 past 36 months for parameters currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5). U . 5 ,0 m4)14
Fecal Coliform fit• a 3
Total Suspended Solids 7 1 O ✓j`L
Temperature (Summer) •20 2 Z 5
Temperature (Winter) /0 /3
•
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) /VA NESHAPS (CAA) is/'A
UIC (SDWA) AAA Ocean Dumping(MPRSA) ,/i/A
NPDES 1Ve.v0 i,l0U 41.5/ Dredge or fill (Section 404 or CWA) IIIA
PSD (CAA) • NA Other
Non-attainment program (CAA) 'IY4
14. APPLICANT 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 is true, complete, and accurate. •
£h',rr' Freeman 566re-74auI
Printed namb of Person Signing Title
aka_ 51-24.2019
Signature of pplicant 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.)
3of3
Form-D 6/2017

„./
"0„f , ---4 ..,- -44J.- •t ,,,7.;,14,4,70' i I/ % - v.r.f.-3,A
' � , � ° � �, � A� ,� ';�F10WS'south)» < ti i�'. I \ t" JF:y iTh-i'm,,
1,•r •gin ''-',+e\4'.4',. ,/ �. -.+ j •. , :� %'/1 a
� 4�Y 9%/ �t!1, } j L;;I 5�'t i `”".;t f l\/ V,11 ,r ',H `t;}� y / _r m: r `� 't:,�"��
/' /p` i `�.�, *-4 { 4 l•' �o C11 ���'t f) ; `, \I 1�r7 9 / .'•,? '\ • n1, (
1 f. J, \ r--: 'ew--` /h ` ,-`;,':"- "\ - ,,,• • �/ �„``,,, '.r /`` \ \O
i. .�/ �a:1 �4'3,s"'�Y L �ti,5:}'• ''I t` `ifi.terstate-- •-IW;^,'8`5;�.4;. ;. -]: _ ' tf \ \'�
.� �� �� ,o .`',•� ��z�4'1 `rf .l:: - ,..<4w�;...., z "- ,:�4.�,.,•.:.s�. ,^4:::;i;•.... -.r 1
t' �. , '`fin v ' �" / I tt,..i.71 , �` o ..7 —�'
�`� `r • ,,\' .,,.i'/1,� ; :. --/�i, /▪ /,• :',`:,,',-,off%".,, ( +`•.._w� ? :`, . --..i.,;:;"" ,,- ,. .
�`j`�,/ )y.)\\, \ ,/- : ; '/I I ,-�. fsf �" ; •,, ;Z . ( l�b l I'Y'i" „•fir- d..3
r) `_ %^_ C'�� r 1 � r 7it�'If ` - .'\°; 'm::- ':' -"k-'_`b�.:�1^�?<�..:may'
- �' 7 ', I\_i T f ,-;t f + ^per.-�� }�4" r.^^ .
• ". P t 1. ",„ -, A N' f, Q Gr 4 u, / k 1" �� '3. C'Y!i}s�`P,a
II• �`'` ' �IM:i' / u s t mac' ... '�7,.;: + kb I a, + , l ;:.,,;�.;, �:'41:C. �r� n ,`'
"?:Fj7c ''' '1 '' \ `1/!� r i`,'• {,{ti iy 'Y- . I(I ?'.;:' /� - ..r't�,^�..y�'"�i
.. �.�.j#, IY- �C.,
\?`~'C" '4`y/ F'' O rr•.:; ,.. :>.,- - 4 •.:ti `--:t�':a, l'-'•s•�"
4-111
`�� ;.)r ,`i�f q' , t•4�t.:.^t vr`r 4 if // — :- `f`,'"}')J`\ M S 'Zii??: .;?r" iie !i l 't �-
'1 ',l y, d l"�1'441�4ily&-, P' a f s,,.,ly �---„ / E` 6r ,,i`:. 1 .
• �, lit -, S r Y +,,,,4 / . �• ' ., GG\\•+ 1 `. ;r:'i / -:'•.'X>i.'::t'\' N/y`�, :' l( \�
tLisxir .r, .`l. h_:i a}::"!� { f 'r' l
1 ks. 'z'„ p: •/:1. ra r °` *^ 1 ----- ?.;•+r v�Y ! ,rS,F;.•;;?:-,+tr[/'`f.Y:' f r ;-,,k•;�
,-'4i. �,, �.-'�, -�9�"�3%" `c t: ..r+�it�y,.::1• • ,. ,�' �5.�• y,; a .r._ �` +r, ,' r t;:.>;j_ :r, �%%� :rr'•/
t, , , `,$y :' ;�� w\, T:,, n, L`y,1wood I.- bUlltnont:\Road - t'
G tl'-li�-y�_ .. :.w: Yi+�: _ ':t:.. J'r'�;/'�'-'J-J' �'�;•'l
,r �„ �� is
- ��v� i �,+ `,� ,.Pe'�'-� b',,V,i„ .,.r.�•..-:-�.i`co"`:.""- {':'.. ,'`�".=r.'';•~ tl\ �� 1'�,r1
.. z•.$ -,''^,.'."r^ _ ,,,,, ,,,,,.. H rr;a`r'.; 1.' ;t1,.y .Y•{,,. --,,..,,,, _ 't:.//'�C
iC k7� �ay'f'��•`r,�rs,{p6 ^w«..•r. :`;.. !`rl:'-i ��:.. ,;ti.:f,; ,1 . �:'
• ;1
y 4�,,�ry
"'
AlQ
'.7:i'YC
fir, ..:_ :.-y. +:.5`. >`.f.�3,•x �, `�f. .I {:: m J{
-:F•; ,1C` i`.' i`'`p' �s .,.':(.:;�:!'_ 1.-:•,,} �j. P'td:i:}^..,.�C�;,Y 1
,fr>
'-'r. ▪ z
-l. r.''), \•• ",',1-"c,,V= • ',:"....4'.3•'•.'3" ‘,"•?,, 31.„,„,..4.q,,,, kt\, , 3 .. - , 1 4(116.
ti
�fr:. � " . .,.„...,,,,,,,,.,..,..„, ,,„ ,,,,.
iY. ,,,„,. . ..„::. ... „,,,,,
- :rira:.
..,.......,,, .,.,..„ .
'Q� y
a
4 >r
~� b..it, , .rfs '�.. Y
::1,,,715,f..:'
_s` t may' t • 'It .S ii
..• •$-' �'a3 , `� 7Blt`.� a. 'e,w d f Ya_ v t: ;� .}�' ,,Rrf/ i .i \ ✓ p1 w k' v si r,}' PA;A fr �,,.- r.,Vi "',,./.t ;,'<2.h :r,`;:,
• :� -, y /'�'''i }( ' _\ ff h J,e'd'"'%v'r;" :5 ?i:r: rY. , %;"i..Y.%4;,yjC�:. • -:�-,
- � ,a. ' 'r !.:o' _� 1 I ' t. :r,l,j :w .S,',..-r},w' y
. (--liNs-;:?".'-;ff;V:-1,0%.1'.; :',;'i.1.13'3.4,i';,'1,4• ;.,.tit -',,:*,:-:','..:; ":.! ::.'..• Z;
.1-\',it:\ '`.--\....J.7- . 1 .."---- ,....-z.,,°-,J;47*, fi- _ r.-, \----,,,,.,. ...-, -*- ---‘, QA.t..A*4.;:.*.•,k:,.•A:::.;!::.-„f:41.,e.•,,s.I.;: ,:k.:,:.. .:..i......,.,:. .:::'......--,:',::::;°.,:-.'..-'',1.-: '
. / --, , e,... ,•- - ...- ' tp• '4. 0, ---„---\--)% iiiiiii;,' \ 'A,.:'''4'‘,''',..-;;;.F:.;!':-.',41.•.:,.:K:::',.',4::: :::,§';,.:4°:;:-..:-t.;;;$.•,.:AM:.,4•„:.:';',,:',-...,,,,,:,-,.i.:: :.•;;,;:: t
kc..\- ;. , - $,', , ,- : lil• "'eV '',.<71 S . \ '''''' ,''k. kg,'\‘ i :''4,..t'41;;.:::.,§4!.';',., .';:l.:2'ZiV:Ne''4";';;2'.°4.,!'l i;;'"'':2.•" ':'';,.. ....'•:r..i.:..i. .. ,' I ;
�',r ✓ % ! ( f' a, +tom•; r.y;r..•.,, ...3,':.t I
•
•
NC0040045 - Bill's Truck Stop WWTP' •
; _- {
Facility .. :,.
Latitude: 35°44'59" Longitude: 80°21' 12" = :Yr .. ' -y
Stream Class:CLocation „- _
Subbasin• 03-07,04 [not'to scale] • ?f' „_'': ''h'
Receiving Stream: • South Potts Creek ``
USGS Quad: Southmont,N.C: • •
River Basin: Yadkin--Pee Dee ✓VQ Davidson County