NCS000570_Application2F_20140122

Please print or type in the unshaded areas only
EPA tD Number (copy from nem f of Form 1)
.t'u FormApp►oved•
AAppprrov�alexpires 31-98.
Form
2F
NPDI:s
United States Inviforimontal Protection Agency
Washington, DC 44W
application for Permit To Discharge Stormwater
Dischar es Associated with in u t i l Agtiyl
Paperwork Reduction Act Notice
Public reporting burden for this application is estimated to average?8.6 hours per application, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate, any other aspebt of this collection of information. or suggestions: for Improving this form, Including
suggestions which may increase or reduce this burden to: Chief, Information Policy Brandt, PM-223, US. Environmental Protection Agency,
401 M St., SW, Washington, DC 20460, or Director, Office of Information and Regulatory Affairs. Office of Management and Budget,
Washington. DC 20503.
J. Outfall Location
For each outfall. list the latitude and longitude of its iocati n t2 the nearest 15 see nds and the narnj gf thl t1glIvina water.
A. Outfali Number
list
B. Latitude
C. Lan c ituda
D. Receiving Water
name
A,62 1-.
94 >
, e
i1.Improve ment
A. Are you now required by any Federal, Staw or local authority to most any implementation schedule for the construction, u reeling or
operation of wastewater treatment equipment or practices or any niher environmental programs which may affect the discharges
described its this application? This includes, but is not limited to, permit conditions, administrative or enforcement orders, enforcement
compliance schedule letters. stipulations. court orders, and grant or loan conditions.
1. Identification of Conditions.
A~rcoments. Etc.
2. Affected Outfalls
3. Brief Description of Project
4. Final
Compliance Date
number
source of discharge
a. req.
b. raj.
B. You may attach additional sheets describing any additional water pollution (or other environmental projects which may affect your
discharges) you now have under way or which you plan, Indicate whether each program is now under way or planned, and indicate your
actual or planned schedules for construction.
Ill. Site Drains a Ms
Attach a site map showing topography (or Indicating the outline of drainage areas served by the outfall(s) covered In the application d a
topographic map is unavailable) depicting the facility including: each of its intake and discharge structures; the drainage area of each storm
water outfall; paved &teas and buildings within the drainage area of each storm water outiall, each known past or present areas used for
outdoor storage or disposal of significant materials, each existing structural control measure to reduce pollutants in storm water runoff,
materials loading and access areas, areas where pesticides, herbicides, sell conditioners and fertilizers are applied; each of its hazardous
waste treatment, storage or disposal units (including each area not required to have a RCRA permit which is used for accumulating hazardous
waste under 40 CFR 262.34); each well where fluids from the facility are injected underground; springs, and other surface water bodies which
receive storm water discharges from the facili .
EPA Form 3510.2E (11.90) Page 1 of 3 continue an Pa" 2

C-eintinnAd from tha Frnnt
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A. For each outfall, provide an estimate of the area (include units) im rvious su (including paved areas and building roofs drainjq
to the outfall, and an estimate of the total sumacs area drained by the ours) .
Outfall
Area of impervious Surface
Total Area Drained
Outfail
Area of impervious Surface
Total Area Drained
B. Provide a narrative description of significant materials that are currently or in the past three years have been treated, stored or disposed in
a manner to allow exposure to storm water; method of treatment, storage, or disposal; past and present materials management practices
employed. in the last three years. to minimize contact by these materials with storm water runoff; materials loading and access areas; and
the location, manner, and frequency in which pesticides. herbicides, soil conditioners, and fertilizers are applied.
C For each "r',di! provide tree location and a description of existing structural and nonstructural control measures to reduce pollutants in
storm water runoff and a description of the treatment the storm water receives, including the schedule and type of maintenance for control
r
Outfatt List Codes from
Number Ireatment
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V. Nonstormwater Discharges
A. I certify under penalty of law that the ou ali(s) covered by this application have been tested or evaluated for the presence of
nonstormwater discharges, and that all nonstormwater discharges from these outfail(s) are identified in either an accompanying Form 2C
r F rm 2E aQplication
Name and Official Title (type or print)
Signature
Date Signed
E. Provide a description of the method used, the date any testing and the onsite drainage points that were di ctly observed during a Lest.
V1. Significant or Soills
Provide existing information regarding the history of significant leaks or spills of toxic or hazardous pollutants at the facility in the fast three
years, including the approximate date and location of the split or leak, and the type and amount of material released,
EPA Form 5510.2F (11.90) Pape 2 of 3 Continue on Page 3

EPA ID Number (copy from Item 1 of form 1)
continued trorn P& 4 a
V11, Discharge In windiall
A.B.C, & D: See instructions before pr OWIng, Complete one set of tables for each outfall, Annotate the cutfall number in the space provided,
Tables \&k Yib6 and Ni1-C are included on separate sheets numbered WI-1 and W-2.
E. jPotenual discharp�jrtof **voted by analysis • Is any pollutant listed in Table 2F.2 a substance or a component of a substance which you
O'le r nufacture as an lnlermediatefb r final product or byproduct
Yes !' st all such poIlufants below) No (o to Section Vtll)
Yes !.isr res::'ts belc.til'
No (Soto SeG'ian iX)
IX. Contract Anal�sis Information
FYes
1TV1 ,No (go ro Section X)
A Name
S. Address
C. Atea e.& Phone No. ! D Pollutants Ana', ed
on
A Name & Official Title (rype or pant)
B. Area Code and Phone No
W3 - o06�3
C. Signature
D. Date Signed
EP Fwrn 3510.2E (11.00) gage 3 of 3

EPA ID Number (copy from item r of Form t)
Vll. Disc hard a lnfa tlon ant need from a e 3 or Form 2E
Para, A - You must provide the results of at least one analysis for every pollutant in this table. Complete one table for eacn outfali. See
instructions 1w additional details.
Pollutant
and
CA..$ Number
fitauadaa!e)
Maximum Values
(include units)
Average Values
(Include units)
Number
of
Storm
Events
Sampled
Sources of Pollutants
Grab Sample
Taken During
First 30
Minutes
Flow -weighted
Composite
Grab Sample
Taken During
First 30
Minutes
Flow -weighted
Composite
Oil and Grease
5,mogical Oxygen
Demand 80051
Cnemical Oxygen
Demand (COD)
Total Suspended
Solias (TSS)
'-
To -at KJeldaht
Nitrogen
Nitrate plus
'vivite Nitrooen
Max-r^um Minimum Maximum
Part 8 - -is* each po .utart ;rat is :+mites in an effluent guioeirne which the tacility is subject to or any ooliutant i,sted in the facility s N POES
permit for its process wastewater fit the facility is operating under an existing NODES permit). Complete one table for each outfah.
--Sag itip r Ri►,�itttatl JtlloCtill�...ilfd
Maximum Values Average Values ( Number
Pcuuta^t (include units) (include units) of
Grab Sample Grab Sample l Storrs•,
Taker, During Taken During Flow -wet heed Events
" c r • ;, te- . Fiow•wei hted $
-" First »C g Firs. 30
r� a•.a !a: e. t: mutes Comoosite i Minutes Composite Sampled Sources of Pollutants
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EPA Form 3510.2F (11-90) rage vial

t'-f"i intmel frAnt tha. V-rnni.
Part C - List each pollutant shown in Tables 2F-2, 2F-3, and 2F-4 that you know or have reason to believe is present, See the instructions for
additional details and requirements. Complete one table for each outfali.
Pollutant
and
CAS Number
(if available)
Maximum Values
PClude units)
Average Values
(include units)
Number
of
Storm
Events
Sampled!
Sources of Pollutants
i;rab Sample
Talon wring
Minutes
Flow -weighted
Composite
Grab Sample
TakenFDul ng
Minutes
Flow -weighted
Composite
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Part D . provide data forth* storm events which resulted in the maximum values for the flout weighted com osits sample.
t.
Date of
Storm
Event
2.
Duration
of Storm
(in Minutes)
3.
Total rainfall
during storm event
On inches
4,
Number of hours between
beginning of storm mess-
ured and end of previous
measurable rain event
Maximum floe rate
during rain event
(gallons/minute or
s units
Total flow from
rain event
(gallons or
AREA units
Season
cam le was
p
taken
Form of
Precipitation
(rainfall,
snowrnelt
9. Provide a description of the method of flow
measurement or estimate,
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