NC0029190_Renewal (Application)_20231102

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Jamie Wood, 11 Div Engineer Roadside
NC DOT Division it
PO Box 250
North Wilkesboro, NC 28659-0250
Subject: Permit Renewal
Application No. NCO029190
Surry County Rest Area
Surry County
Dear Permittee:
NORTH CAROLINA
Environmental Quality
November 01, 2023
The Water Quality Permitting Section acknowledges the November 1, 2023 receipt of your permit renewal application
and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deg.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
cc: Central Files w/application
ec: WQPS Laserfiche File w/application
Sincerely,
Cynthia Demery
Administrative Assistant
Water Quality Permitting Section
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes MRI Road Suite 300 1 Winston-Salem. North Carolina 27105
336.776.9800

North Carolina
Department of Environmental Quality
Division of Water Resources
p riui ru ragc�
1 Print Form Only
Modified Application Form 2A
Revised March 2021
Modified Application
Form 2A
Minor Sewage Facilities < 0.1 MGD
and No Pretreatment Program
NPDES Permitting Program
RECEIVED
NOV 01 2023
NCDEQ/DWR/NPDES
Note: Complete this form if your facility is a MINOR new or existing publicly owned treatment works.

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029190
177 rest areatwelcome center SBL at
Modified March 2021
Virginia line
Form
NC Department of Environmental Quality • Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read th fo
NPDES
the instructions may result in denial of the application.)
D
SECTION•N
INFORMATION FOR r
Facility name NOV 01 2023
1.1
177 rest area/welcome center SBL at Virginia line
Mailing address (street or P.O. box)
PO Box 250 NCDEWWRINME
City or town
State
ZIP code
o
North Wilkesboro
NC
28659
Contact name (first and last)
Title
Phone number
Email address
Jamie Wood
DREE
336-903-9243
[e-mail]
Location address (street, route number, or other specific identifier) ❑ Same as mailing address
158 177 SB
City or town
State
ZIP code
Lowgap
NC
27024
1.2
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission No ❑
requirements for new dischargers.
1.3
Is applicant different from entity listed under Item 1.1 above?
❑ Yes ❑ No 4 SKIP to Item 1.4.
Applicant name
NC DOT
Applicant address (street or P.O. box)
PO Box 250
E
City or town
State
ZIP code
North Wilkesboro
INC
28659
Contact name (first and last)
Title
Phone number
Email address
o
Jamie Wood
DREE
336-903-9243
[e-mail]
CL
a
1.4
Is the applicant the facility's owner, operator, or both? (Check only one response.)
❑ Owner ❑ Operator ❑ X Both
1.5
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
❑ Facility X Applicant ❑ Facility and applicant
(they are one and the same)
1.6
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.
E
d
Existing Environmental Permits
R
►I NPDES (discharges to surface
( 9
❑ RCRA (hazardous waste)
UIC (underground injection
❑ ( g i
water)
control)
E
c
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
c
w
a�
y
E]Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
❑ Other (specify)
Ln
Page 1

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029190
177 rest areatwelcome center
7SBL
Modified March 2021
at Virginia line
1.7
Provide the collection system information
requested below for the treatment works.
Municipality
Population
Collection System Type
Ownership Status
Served
Served
(indicate percentage)
100 % separate sanitary sewer
❑ Own ❑ Maintain
2,600
% combined storm and sanitary sewer
❑ Own ❑ Maintain
Z
d
❑ Unknown
❑ Own ❑ Maintain
% separate sanitary sewer
❑ Own ❑ Maintain
y
% combined storm and sanitary sewer
❑ Own ❑ Maintain
cc
❑ Unknown
❑ Own ❑ Maintain
a%
separate sanitary sewer
❑ Own ❑ Maintain
% combined storm and sanitary sewer
❑ Own ❑ Maintain
R
❑ Unknown
❑ Own ❑ Maintain
d%
separate sanitary sewer ❑ Own ❑ Maintain
% combined storm and sanitary sewer ❑ Own ❑ Maintain
C
❑ Unknown ❑ Own ❑ Maintain
Total
°f
Population
U
Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
100%
z'
1.8
Is the treatment works located in Indian Country?
c
3
0
U
ElYes No
1.9
Does the facility discharge to a receiving water that flows through Indian Country?
❑ Yes No
1.10
Provide design and actual flow rates in the designated spaces.
Design Flow Rate
0.030 mgd
Y y
Annual Average Flow Rates (Actual)
a
Two Years Ago
Last Year
This Year
c
ca c
0.005 mgd
0.005 mgd
0.005 mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.016 mgd
0.016 mgd
0.016 mgd
a
1.11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
=
Total Number of Effluent Discharge Points by Type
a, �
Combined Sewer
Constructed
Treated Effluent
Untreated Effluent
Overflows
Bypasses
Oveerfliow�s
0
RECEIVED
NOV 01 2023
NCDEQIDWR/NPDES
Page 2

NPDES Permit Number
Facility Name
Modified Application Form 2A
NC0029190
177 rest area/welcome center SBL at
Modified March 2021
Virginia line
Outf ails Other Than to Waters of the State of North Carolina
1.12
Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
❑ Yes ►B No 4 SKIP to Item 1.14.
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
❑ Continuous
gpd
❑ Intermittent
❑ Continuous
gpd
❑ Intermittent
gpd
Cl Continuous
❑ Intermittent
1.14
Is wastewater applied to land?
.r
❑ Yes No 4 SKIP to Item 1.16.
y
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
o
0
Average Daily Volume
Continuous or
rn
Location
Size
Applied
Intermittent
(chi one)
acres
gPd
❑ Continuous
Q
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
acres
gpd
❑ Continuous
❑ Intermittent
M1.16
Is effluent transported to another facility for treatment prior to discharge?
o
ElYes ►El No 4 SKIP to Item 1.21.
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent transported by a party other than the applicant?
❑ Yes ❑ No -+ SKIP to Item 1.20.
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

NPDES Permit Number
Facility Name
Modified Application Form 2A
NCO029190
177 rest area/welcome center SBL at
Modified March 2021
Virginia line
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
a
d
City or town
State
ZIP code
0
Contact name (first and last)
Title
0
m
Phone number
Email address
QNPDES
number of receiving facility (if any) ❑ None
Average daily flow rate mgd
N
0
1.21
Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
not have outlets to waters of the State of North Carolina (e.g., underground percolation, underground injection)?
❑ Yes No -* SKIP to Item 1.23.
0
1.22
Provide information in the table below on these other disposal methods.
Information on Other Disposal
Methods
o
Disposal
Location of
Size of
Annual Average
Continuous or Intermittent
r
R
Method
Description
Disposal Site
Disposal Site
Daily Discharge
Volume
(check one)
❑ Continuous
0
acres
gp d
❑ Intermittent
0
❑ Continuous
acres
gpd
❑ Intermittent
acres
gp d
ElContinuous
❑ Intermittent
1.23
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
d
❑ Discharges into marine waters (CWA ❑ Water quality related effluent limitation (CWA Section
Section 301(h)) 302(b)(2))
X Not applicable
1.24
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
❑ Yes No 4SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
c
Contractor name
R
(company name
E
Mailing address
street or P.O. box)
0
City, state, and ZIP
R
code
c
Contact name (first and
v
last
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modifie Application Form 2A
NCO029190 177 rest area/welcome center SBL at Modified March 2021
Virginia line
SECTION 2. ADDITIONAL OR1
g Outfalls to Waters of the State of North Carolina
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
as
a
❑ Yes ►P No -+ SKIP to Section 3.
c
2.2
Provide the treatment works' current average daily volume of inflow
Average Daily Volume of Inflow and Infiltration
gpd
V
and infiltration.
c
Indicate the steps the facility is taking to minimize inflow and infiltration.
cc
a
c
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
CL a
specific requirements.)
co
a�
o
❑ Yes ❑ No
E
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
0
0 0,
(See instructions for specific requirements.)
o
❑ Yes ❑ No
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
c
0
70
1.
c
d
E
d
fl.
2.
E
0
3.
3
'a
m
v
4.
2.6
Provide scheduled or actual dates of completion for improvements.
U)
Scheduled or Actual Dates of Completion for Improvements
0
>
Scheduled
Affected
Outfalls
Begin
End
Begin
Attainment of
Operational
o
CL
Improvement
(list l
Construction
Construction
Discharge
Level
E
(from above)
numberber))
(MM/DDNYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
-o
d
a
d
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029190 177 rest area/welcome center SBL at Modified March 2021
Vi inia line
SECTION•' • ON 1 to
3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number I
Outfall Number
Outfall Number
State
NC
County
Surry
O
0
City or town
Lowgap
0
Distance from shore
ft.
ft.
ft.
Q
Depth below surface
0
Average daily flow rate
0.005 mgd
mgd
mgd
Latitude
36° 33' 39.8"
1°
Longitude
80° 44' 45.1"
"
3.2
Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?
R
o
❑ Yes 1�14 No 4 SKIP to Item 3.4.
d
R
3.3
If so, provide the following information for each applicable outfall.
s
Outfall Number
Outfall Number
Outfall Number
0
Number of times per year
o
discharge occurs
a
Average duration of each
o
discharge (specify units
oAverage
flow of each
mgd
mgd
mgd
a,
discharge
Mo
0
ths in which discharge
Fonclu
rs
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes ►Zr No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser type at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
0
0
3 6
Does the treatment works discharge or plan to discharge wastewater to waters of the State of North Carolina from
1
one or more discharge points?
3 w
❑ X Yes No 4SKIP to Section 6,
Page 6

NPDES Permit Number
Facility Name
Modified Application Form 2A
Modified March 2021
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall Number 1_
Outfall Number
Outfall Number
Receiving water name
Naked Run
Name of watershed, river,
or stream system
Yadkin
0
U.S. Soil Conservation
H
Service 14-digit watershed
HUC 12-030-40101804
o
code
Name of state
cc
3
management/river basin
Pee Dee
U.S. Geological Survey
8-digit hydrologic
03040101
cataloging unit code
Critical low flow (acute)
N/A c is
cfs
cfs
Critical low flow (chronic)
N/A cfs
Cfs
cfs
Total hardness at critical
mg/L of
mg/L of
mg/L of
low flow
CaCO3
CaCO3
CaCO3
3.8
Provide the following information
describing the treatment provided for discharges from each outfall.
Outfall Number 1
Outfall Number
Outfall Number
Highest Level of
X Primary
❑ Primary
❑ Primary
Treatment (check all that
❑ Equivalent to
❑ Equivalent to
❑ Equivalent to
apply per outfall)
secondary
secondary
secondary
X Secondary
❑ Secondary
❑ Secondary
X Advanced
❑ Advanced
❑ Advanced
❑ Other (specify)
❑ Other (specify)
❑ Other (specify)
c
Design Removal Rates by
Outfall
BOD5 or CBOD5
30 mg/L
%
%
c
m
E
TSS
30 mg/L
%
X Not applicable
❑ Not applicable
❑ Not applicable
Phosphorus
%
%
%
X Not applicable
❑ Not applicable
❑ Not applicable
Nitrogen
%
%
%
Other (specify)
X Not applicable
❑ Not applicable
❑ Not applicable
Page 7

NPDES Permit Number
Facility Name
Modified Application Form 2A
Modified March 2021
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below. Chemical
d
3
C
i+
C
O
a
Outfall Number 1
Outfall Number
Outfall Number
o
Disinfection type
Chemical
CD
0
Seasons used
m
E
4
d
Dechlorination used?
❑ Not applicable
❑ Not applicable
❑ Not applicable
X Yes
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
X Yes ❑ No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
X Yes ❑ No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number 1
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
3
rn
water
Number of tests of receiving
water
d
W
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
X Yes -* Complete Table B, including chlorine. ❑ No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
X Yes ❑ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results to this application package?
❑ Yes X No additional sampling required by NPDES
permitting authority.
Page 8

NPDES Permit Number
Facility Name
Modred Application Form 2A
Modified March 2021
3.19
Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
X Yes ❑ No 4 Complete tests and Table E and SKIP to
Item 3.26.
3.20
Have you previously submitted the results of the above tests to your NPDES permitting authority?
X Yes ❑ No -* Provide results in Table E and SKIP to
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results
(MhNDDffM)
02/22/2023
PASSED
05/17/2023
08/30/2023
2
c
w
c
0
w3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
o
toxicity?
CD
U)
❑ Yes ►% No 4 SKIP to Item 3.26.
0
3.23
Describe the cause(s) of the toxicity:
c
d
LU
W
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes 1`14 No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls and attached the results to the application package?
❑ Yes OP. Not applicable because previously submitted
i1mil
information to the NPDES permitting authority.
Page 9

NPDES Permit Number Facility Name Modified Application Form 2A
NCO029190 177 rest area/welcome center SBL at Modified March 2021
Virginia line
SECTION. CHECKLIST AND CERTIFICATION1
6.1 In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
X ction l: B si A pli atio
n ormation orcAll �pplicanIs
❑ w/ variance request(s) ❑ w/ additional attachments
Sr ction 2: Additional
El neformatlon
El w/ topographic map El w/ process flow diagram
❑ wl additional attachments
X w/ Table A ❑ w/ Table D
X Ectior : Ir�ormation on
uen isc arges
X w/Table B ❑ w/ additional attachments
❑ w/ Table C
E
d
"'
c
Section 4: Not Applicable
0
ea
Section 5: Not Applicable
d
U
X Ci�cnam�deafiokn
❑ w/ attachments
.r
6.2
Certification Statement
1 certify under penalty of law that this document and all attachments were prepared 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 the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. l am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Jamie Wood
Division Roadside Engineer
Signature
Date signed
t o �30 �z3
Page 10

NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
NCO029190 177 rest 001 Modified March 2021
areatwelcome
.;I WINZIM-11THO-
•�
Maximum Daily Discharge
Average Daily Discharge
Analytical ML or MDL
Value
Units
Pollutant
Value Units Number of Method' (include units)
Samples
Biochemical oxygen demand
❑ BODsor ❑ CBOD5
39
MGL
El ML
❑ MDL
(report one)
Fecal coliform
1500
Geometric mean
El ML
❑ MDL
Design flow rate
0.030
MGD
pH (minimum)
6.0
pH (maximum)
9.0
N/A
Temperature (winter)
Temperature (summer)
N/A
Total suspended solids JSS)
46
MGL
❑ MDL
Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters of
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
NCO029190 177 rest area/welcome center 1
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Value
Units
Number of
NumberUnits
Pollutant
Method' (include units)
Sam les
0.10
Mg/I
4500-nh3g-201 1
ML
Ammonia (as N)
Q MIDL
Chlorine
28
Ug/l
❑ ML
(total residual, TRC)2
❑ MDL
Dissolved oxygen
<2.0
Mg/1
❑ ML
❑ MDL
Nitrate/nitrite
❑ ML
❑ MDL
75.9
Mg/1
Epa-351.2
0 ML
Kjeldahl nitrogen
❑ MDL
Oil and grease
g
N/A
N/A
❑ ML
❑ MDL
21.0
Mg/I
4500-pe-201 1
❑ ML
Phosphorus
P
❑ MDL
45
Mg/I
2540d-2015
❑ ML
T
Total dissolved solids
❑ MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.
EPA Form 3510-2A (Revised 3-19) Page 12

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant
Methods (include units)
---
N umber of
Value
Units Value
Units
Samples
Metals, Cyanide, and Total Phenols
Hardness (as CaCO3)
ML
o MDL
Antimony, total recoverable
❑p MpL
Arsenic, total recoverable
o MoL
Beryllium, total recoverable
ML
o MDL
Cadmium, total recoverable
❑ ML
❑ MDL
Chromium, total recoverable
❑ ML
❑ MDL
Copper, total recoverable
ML
o MDL
Lead, total recoverable
❑ ML
❑ MDL
Mercury, total recoverable
o MoL
Nickel, total recoverable
❑ ML
❑ MDL
Selenium, total recoverable
❑ ML
❑ MDL
Silver, total recoverable
❑ ML
❑ MDL
Thallium, total recoverable
❑ ML
❑ MDL
Zinc, total recoverable
❑ ML
❑ MDL
Cyanide
0 ML
❑ MDF-I
Total phenolic compounds
ML
o MDL
Volatile Organic Compounds
Acrolein
❑ ML
❑ MDL
Acrylonitrile
El ML
❑ MDL
Benzene
❑ ML
❑ MDL
Bromoform
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 13

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant
Method' (include units)
--- --
Number of
Value
Units
Value
Units
Samples
Carbon tetrachloride
❑ ML
❑ MDL
Chlorobenzene
p MpL
Chlorodibromomethane
❑ ML
❑ MDL
Chloroethane
0 MDL
2-chloroethylvinyl ether
ML
o MDL
Chloroform
11
o IVIDL
Dichlorobromomethane
❑ ML
❑ MDL
1,1-dichloroethane
o MoL
1,2-dichloroethane
❑ ML
❑ MDL
trans-1,2-dichloroethylene
o MDL
1,1-dichloroethylene
o MoL
1,2-dichloropropane
❑ MDL
1,3-dichloropropylene
0 ML
❑ MDL
Ethylbenzene
11 ML
❑ MDL
Methyl bromide
o MDL
Methyl chloride
o ML
Methylene chloride
p MDL
1,1,2,2-tetrachloroethane
❑ ML
❑ MDL
Tetrachloroethylene
❑❑ MDL
Toluene
❑ ML
❑ MDL
1,1,1-bichloroethane
❑ ML
❑ MDL
1,1,2-bichloroethane
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 14

EPA Identification Number
NPDES Permit Number Facility Name Ouifall Number
Modified Applicabon Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant
Method' (include units)
Number of
Value
Units
Value
Units
Sam les
Trichloroethylene
❑ ML
❑ MDL
Vinyl chloride
❑❑ MDL
Acid -Extractable Compounds
p-chloro-m-cresol
ML
o MD
2-chlorophenol
ML
o MDL
2,4-dichlorophenol
ML
°❑ MDL
2,4-dimethylphenol
ML
o MDL
4,6-dinitro-o-cresol
El ML
❑ MDL
2,4-dinitrophenol
❑❑ MDL
2-nitrophenol
ML
o MDL
4-nitrophenol
❑ MDL
Pentachlorophenol
0 ML
❑ MDL
Phenol
❑ ML
❑ MDL
2,4,6-trichlorophenol
0 ML
p MIX
Base-Neutral Compounds
Acenaphthene
ML
o MDL
Acenaphthylene
0 ML
❑ MDL
Anthracene
El ML
❑ MDL
Benzidine
❑ ML
❑ MDL
Benzo(a)anthracene
ML
o MDL
Benzo(a)pyrene
ML
o MDL
3,4-benzofluoranthene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 15

EPA Identification Number
NPDES Permit Number
Facility Name Outfall Number
Modified
Application Form 2A
Modified March 21
Maximum Daily Discharge
Average Daily Discharge
Analytical
ML or MDL
Pollutant
Method' !
(include units)
Number of
Value
Units
Value
Units
Samples
Benzo(ghi)perylene
- -. --
_
o MDL
ML
o MDL
ML
o MDL
ML
o MDL
Benzo(k)fluoranthene
Bis (2-chloroethoxy) methane
Bis (2-chloroethyl) ether
Bis (2-chloroisopropyl) ether
El ML
o MDL
Bis (2-ethylhexyl) phthalate
El o
MDL
ML
o MDL
4-bromophenyl phenyl ether
Butyl benzyl phthalate
0 ML
r o MDL
241oronaphthalene
0 ML
❑ MDL
ML
o MDL
o MDL
4-chlorophenyl phenyl ether
Chrysene
di-n-butyl phthalate
o MDL
di-n-octyl phthalate
ML
o MDL
Dibenzo(a,h)anthracene
ML
o MDL
1,2-dichlorobenzene
❑ ML
❑ MDL
1,3-dichlorobenzene
❑ ML
❑ MDL
1,4-dichlorobenzene
❑ ML
❑ MDL
3,3-dichlorobenzidine
❑ ML
❑ MDL
Diethyl phthalate
ML
o MDL
Dimethyl phthalate
0 ML
❑ MDL
2,4-dinitrotoluene
❑ MI
❑ MDL
2,6-dinitrotoluene
❑ ML
❑ MDL
EPA Form 3510-2A (Revised 3-19) Page 16

EPA Identification Number
NPDES Permit Number Facility Name Outfall Number
Modified Application Form 2A
Modified March 2021
1OR&I0 ••
Maximum Daily Discharge Average Daily Discharge
Analytical ML or MDL
Pollutant
—
Number of
Method' (include units)
Value Units Value Units
Samples
ML
1,2-diphenylhydrazine
o MDL
❑ ML
Fluoranthene
❑ MDL
0 ML
Fluorene
o MDL
❑ ML
Hexachlorobenzene
4-❑
----
MDL
❑ ML
Hexachlorobutadiene
❑ MDL
Hexachlorocyclo-pentadiene
ML
o MDL
ML
Hexachloroethane
o MoL
ML
o MIDL
Indeno(1,2,3-cd)pyrene
Isophorone
❑❑ MDL
ML
Naphthalene
o MDL
Nitrobenzene
❑ MI
❑ MDL
N-nitrosodi-n-propylamine
❑p MDL
N-nitrosodimethylamine
ML
o MDL
N-nitrosodiphenylamine
ML
o MDL
Phenanthrene
❑ ML
❑ MDL
Pyrene
ML
❑❑ MDL
1,2,4-trichlorobenzene
❑ MI
❑ MDL
' Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2A (Revised 3-19) Page 17

NPDES Permit Number Facility Name Outfall Number Modified Application Form 2A
Modified March 2021
Maximum Daily Discharge Average Daily Discharge
Pollutant Number Analytical ML or MDL
—T—Units
of ytMethod'
(list) Value Value Units (include units)
Samples
❑ No additional sampling is required by NPDES permitting authority.
-
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
❑ ML
❑ MDL
l Samnlinn shallha (,.nnrii irtpd arcnrdinn to cuffiriPntly sensitive test nrnredures ti e _ methods) annroved under 40 CFR 136
for the analvsis of pollutants
or pollutant Darameters or reauired
under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 18

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No.16S
Contact: NCDOT
Report Date:
9•/14/2023
Client: PO Box 150
NPDES #:
2.9190
N. Wilkesboro. NC
28659'
Project: Surry
Rest -Area.
Date Sample. Rcvd=
9/6./2023
Meritech Work order # 09062319; Sample: Effluent Composite
9./5-6/23
Pig ors
Resups Analysis Date
Reporting LimiLimit
A 9004
BQD, 5 day
9.4 mg/L 9/7/23
2.0 mg/L
SM 5210 9
Total Suspended Solids
<Z7 mg/L 9/7/23
2.7 mg/L
SM 2540 D Y
Ammonia, Nitrogen
4A mg/L 9/1.1/23
0..1 mg/L
EPA350.1
Meritech Work Order # 09062320 ! Sample: Effluent Grab 9/6/23
Parameters Results Analygis Date Reporting Lim Method Qualifle�;
Fecal Coliform 12 CFU/100 ml 9/6/23 1 CFU/100 ml SM 9222 D
Y Elevated PQL* due: to insufftientsample size.
1 hereby certify that I have reviewed and approve these data. t"t t W
Laboratory Repr�_esetf active
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

..............
.. .....
ch6tn of custody R-ecord. (C0Q.
Client: NC DOT
NPOESM—
Phone:._-_,........
29190
__ 336=903--9240
MERITECHp INCO
Addeass:­­­ PO Box 250
ENVIRONMENTAL LAB()RATORIES
N.wiNotboro, NC 286S9
Email: —Iw-ShuinaL-
-- --— LZO—v
642 Tarneo Rd. Phone: [phone]
Project;__
Surry Rest Arpa
Reidsville NC 27320 Fax: [phone]
Town Around Time*
Emaik. 1nf0@raerfte-chIibs4com
Attent.ii3h-,_ Waylan Shumate
qqusowor eels Prior approval.
k
Howwould you like your report sent?
W com
Circle all %that apply-tmail(preferwri), Fax, Mail
std. 10 1
Sampling Dates & Times
Person T#klng.�arnple (Sign/Print):
Lab Use Only
Sample Locitionsand/or ID # —Start^'
comov 0.6f
Test(s)
on ice? pH 00
Required Y94- No cl or'?
,Date T11 m# D;�te Time
Grab?� CoM..
1 FECAL COLIFORM
0
EFFULENT
Ca
1-6
4�400
c I ANWaNIA
EFFULENT
C I BOD
1- 6
ovo
EFFULENT
C
5
EFr-(JLENT
-11TSS
Method of
--- **sV -Dephlorin;atio n I
-
Comments:
Shipment:
UPS
Fed Ex
Are these results for
Hand Deffwry
MOM
-Aovj'rl Z�
0 ier
7 Yes L�' NO
Pec
'me7 Fec 'i by
--
Time: ed rffo,
to
In:
Compositor #
JULY #
rng/L ug/L U
Time!
T*7—y
Dot": Tfme:

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No.165
i
i
I
Contact: NCDOT Report Date: 9/20/2023
Client: PO Box 250 NPBES #: 2919G
N. Wilkesboro, NC 28659 Project: Surry Rest Area j
Date Sample. Rcvd: 9/13/2023
Meritech Work Order # 09132391 Sample: Effluent Composite 9/12-13/23
ramgters Results Analysis Qjft
Reporting Limit Qd:
901),.5 day 2.8 mg/L 9/14/23
2.0 mg/L SM 5210 B
Total Suspended Solids 3 mg/L 9/14/23
2.5. mg/L SM 2540 D
Ammonia, Nitrogen <0..1 mg/L 9/I8/23
0.1 mg/L ERA 350.1
Meritech Work Order # 091-32392 Sample: Effluent Grab
9/13/23
Pairaw Resufts Analys- #s Bare
Reporting Liitnit Method
Fecal Coliform <1 CFU/100 rnl 9/13/23 1 CFU/100 ml Shr19222 D
i
I hereby certify that I have reviewed and approve these data.
La oratory.Representative
642 Tamco Road, Reidsville, North Carolina 27320
tei.[phone] fax.[phone]

Chain & Custody Record (CQ
NPDFS#.- 29190
Client NCDOT Phone-- 336-903-9240
Address: P0 Brix 250 Fax:-.
MERITECH, INC.
ENVIRONMENTAL LABORATORIES
. . ....... N.Wilkesboro, NC 28659 EmaW— Jlwshumate00)nW—Q—tKQ—v
642 TaMtcl Rd; Phone; 316-342-4748
Project:_ Surry Rest Area
Reidsville NC 27920 Fax., 336-342-1522
Turn Around Time*
tirnall, InfoOmeritechlabs.corn
www.meritechfalis.com-
Attention:_ Wayloh Shumate *RUSH work needs prior OPPrOV81.
How would you like your report sent? —
aretiq all that apply: Email (profitered), Fak, Mail Std Days 24 - 48 H . v;
Sample Location and/or ID#
SamplinDates & Times
g
..Start
Prtrsdil Tliking sarnple (Sign/Print!:
Comp? 11 of
(34b? cant. Test(s) Required___
Lab Use Only
on ice? PH 0K7
/--No Cl 0K7
bate
time
Date
Time
EFFULENT
G
I
FECAL COLIFORM
EFFULENT
q cc
C/ I
Oqco
c
I
L AMMONIA
OC10
C
i
BOO
EFFULENT
0qT'-6H--,
'S
EFFULENT
C
1
TSS
T.-Pt., Upon
L
Dechlarinatibn (<Q.15.:pprh) of Ammonia, Cyanide, must be done in the field prior to Breservarlon,
Method of
compositor 4
Shipment: corntwents:
ri UPS
—
Jug #
13 Fed Ex
-0 Hand aellvery.
13 Other
-SU tory purposes Yes D No
—'\Are these re 1!� fqe �gLuia
Re a TiM
L
edb - Tirn
. by.
ulslied
results MOIL M91kg J , ug,(L
Report results in
T
ite Date Time:
Date: Time-
Y: Dattr Time:
RgSwd by Lab:
Delfin
74M

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No. 165
Contact: NCDOT Report Date: 9/27/2023
Client: PO Box:250 NPDES #: 29190
N. Wilkesboro; NC 28659 Project. Surry Rest Airea
Date Sample Rcvd: 9/20/2023
Meritech Work Order # 09202310 Sample: Effluent Composite 9/19-20/23
BOD, 5 day 3.9 mg/L 9121/23 2.0 mg/L_ SM 5210 B
Total Suspended Solids <2.6 mg/L 9/21/23 2.6 mg/L. SM 2S40 D Y
Ammonia, Nitrogen <4.1 mg/L 9/25/23 0.1 mg/L EPA 350.1
Meritech. Wore Order # 09202311 Sample: Effluent Grab 9/20/23
Farameters results Analysis pate RellorUng Lima Method Q11ajjf
Fecal Colifarm 1 CFU/100 ml 9/20/23 1 CFU/100 ml SM 9222 D
Y Elevated PQL* due to insufficient sample size.
I hereby eer* that I have reviewed and approve these data. OL-til —h
Laboratory Representative
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fim(336)342-1522

Chain of custady Record (COC)
Phone:
Address:__ PO Box: 7-50
N.Wilk
Pmject_
Attefitiofj-._ Woylon Shumate
ditcle all that appl'y: Trriail (prelpryed), Fax, Mail
336-903-9240
@n�dot
Surry Rest Area
Turn Around r
*RUSH work ne prior appm. val.
.
MERITECH, INC.
ENVIRONMENTAL LABORATORIES
Ertiaik ltv.f0@merjte&ljbsxum
www.meritechlabs.com
Sample Location and/or ID Start End
-
comp? # of
Test(s)
tab Use only
Required Y ir4 Cl OK?
:`0
AMMONIA
EFFULENT
upon
the field P
Report results In: mg/l.

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No.165
Contact: NCDOT Report Hate: 10/4/2023
Client: PO Sax 250 NPDES #: 29190
N. Wilkesboro; NC 28659 Project:: Surcy Rest Area
Date Sample Revd: 9/27/2023
Meritech Work Order # 09272344 Sample: Effluent Composite. 9/26-27123
BOD, 5 day 3.9 mg/L 9/28/23 2.0 mg/L SM 5210 B
Total Suspended Solids <2.6 mg/L 9/28/23 2.6 mg/L SM 2540 D Y
Ammonia, Nitrogen 2.7 mg/L 9/28/23 0.1 mg/L EPA 350.1
Meritech Work Order # 0:9272345 Sample: Effluent Crab 9/27/23
Parameters Results Analysis Date RepArting Limit Method Qualifier
Fecal Col.iform 70 CFU/100 ml 9/27/23 1 CFU/100 ml SM 9222 D
Y Elevated PQL* due to insufficient sample size.
f
I hereby certify that 1 have reviewed and approve these data.
Laboratory Representative
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

Kin D FS#
29190
C}
Chain of Custody Record {CO .
^_-- Client NCDOT phone: [phone]o
M E R ITEC H, INC. Address:,,_,, PO Box 250 Fax: .. ---
ENVIRONMENTAL LABORATORIES N.Wiikesboro, NC 286.59 Elnall:_,1wshvmate ..ncdot•Rov
_ `T Project:_ Surry Rest Area
647 Tamco Rd. Phone! 336-342-4748 .._.___ _—_..._.�
Reidsville NC 27320 Fax: [phone] _._......
Turn Around dime'
Email: infooa meritechlabs.com Attent!On,. Waylon Shumate *PUSH work needs prior approval.
How would you like your report scant?
5t SO da EYE:
J." I :
VI/VVW. m rite -h ia.bs.cvm Circle all that apply: Ernail (preferred) , Fax, Mail
"— person Taking Sample {Sign/Print.l-- Lab Use Only
Sampling Dates & Times
Sample Location and/or ID ft start EndCamp? °f
on iced phi OK?
Date Time Date Tune Grab? Cont.. Test(s) Required o I No Cl OK?
EFFULENT '" G 1 FECAL COLIFORM
EFFULENT
EFFULENT
EFFULENT
Method of
Shinment:
•"'' Dechlori
Fed. Ex Are
Relinquished '"t
Hand Delive
Other RLnil
AMMONM
-
o p
TSS
I amture upgn
Recelpt: 'ice W
of Ammonia, C anide,'Phenol and TKNsdm les must bs dpne in the field rlor to preservation. cnrrrnosiltor sY
[Jug #—
[ �Ro rest�its in: mg/i. irTig/ ug1l
for regulatory purpiases7 �t�s NoTime
t Tima: R
p '.; TirYlec
Time: / ce d try:
J ry� Date: Time-1Date. Tina: Rft"d by� `�
EFFULENT
EFFULENT
EFFULENT
Method of
Shinment:
•"'' Dechlori
Fed. Ex Are
Relinquished '"t
Hand Delive
Other RLnil
AMMONM
-
o p
TSS
I amture upgn
Recelpt: 'ice W
of Ammonia, C anide,'Phenol and TKNsdm les must bs dpne in the field rlor to preservation. cnrrrnosiltor sY
[Jug #—
[ �Ro rest�its in: mg/i. irTig/ ug1l
for regulatory purpiases7 �t�s NoTime
t Tima: R
p '.; TirYlec
Time: / ce d try:
J ry� Date: Time-1Date. Tina: Rft"d by� `�

Proposal No. 54-Sivi-0440000000 72 SunY County Janitorial
NQRTH CAROLTNA DEPARTMENT OF TRANSPORTATION
Surry County Rest Area on 1-77
WATER USE REPORT
Month: av-OQy t, , 20 3
Date
Read
Meter Reading 9:00 a.m.
Gallons Used
Comments
-Day
2
CC
3
C)
4
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QA�
1i0 4q(3v
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5
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26
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27
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30
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31
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Total: LA 1 1.5zxD Q
Supervisor's Signature_ Date:

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