NCS000348_Monitoring Information_20150602

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CPI USA North Carolina LLC
1281 Powerhouse Dr. SE
Southport, NC 28461
T 910-343-6700 F 910-343-6710
February 26, 2015
Division of Water Quality
Surface Water Protection Section
Attention: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Annual Summar 14
Permit No CS000348
Capital Power
Corporation
RECEIVED
0"I
MAR 17 2015
CENTRAL FILE;
DWR SECTION
COD
'0
Stormwater Pollution Prevention Plan Review/Update
The site Stormwater Pollution Prevention Plan (SPPP) was reviewed and modified in November
2014 by RTP Environmental Associates, Inc. from Raleigh, NC. Ted White, PE from RTP signed the
document on 11/24/14 certifying that he had completed a review of the SPPP Plan for the CPI
Southport plant and had amended the plan. Mr. White also acknowledged that CPI Southport had
not experienced a significant spill within the past 12 months from that date.
Best Management Plan (BMP) Summary & Evaluation
Potentially exposed materials at the Southport power plant include coal, wood chips, tire
derived fuel (TDF), petroleum products stored in existing ASTs, water and wastewater
treatment chemicals, and ash.
Coal for the boiler plant is stored outside in the coal pile and coal pile runoff is treated in the low
volume wastewater system prior to discharge (i.e., it is not drained to the stormwater system). Coal is
brought in by rail at the north end of the plant and unloaded through the coal chute and transported via
conveyor belt to the coal pile. The risk of coal dust entering the storm water via fugitive dust exists and
to minimize that risk, coal unloading BMPs are used and, because the drainage adjacent to the rail
bed is through vegetative buffers, the quantity of coal reaching the receiving water is minimal. Water is
sprayed onto the coal, as needed, as it is unloaded from the rail cars in one of the coal unloading
BMPs. Also, coal dust from the edges of the chute where coal is deposited is swept up daily
after unloading operations. These BMPs minimize fugitive dust transport.
The risk of the petroleum products entering the storm system is low due to the use of secondary
containment that conforms to 40 CFR 112.8(c)(2) and non-structural controls (e.g., routine
inspections) to prevent spills. Used oil is stored in a 300-gallon aboveground storage tank (AST)
located at inside the Boiler Building's Oil Storage Room, with full volume secondary containment.

Capital Power-_'
Corporation
Diesel is stored in a 300-gallon AST outside the Pump House, in a 1,000-gallon AST located within
the Rail Car Unloading Area, and in a 300-gallon AST near Truck Dumper 2, all equipped with full
volume secondary containment. Gasoline is stored in a 30-gallon dispenser located in the Gasoline
and Drum Storage Area which is also equipped with full volume secondary containment. Small
tanks of turbine lube oil and hydraulic oil are located on the site, as well as transformers containing
oil. Any spillage from these tanks and transformers would normally be contained by full volume
secondary containment.
Chemical storage and usage is limited to the Wastewater Basin (drums and totes containing
chemicals are stored outside, equipped with full volume secondary containment), the Demineralizer
Building area, the R.O. Building area, and the Cooling Tower Chemical Storage Area. The several
chemical storage units in the Demineralizer Building are all equipped with secondary containment
and, any spills are routed to the Neutralization Tank and then the Wastewater Basin for treatment.
Spill cleanup materials are located inside the Warehouse and the R.O. Building. There is a
dedicated Unloading Bay at the Demineralizer Building. Most of the chemicals used in the R.O.
Building are stored within secondary containment or on a chemical skid on the floor in the building.
The floor is sloping towards a drain that discharges into the chemical sump from the Demineralizer
Building. A temporary tank designed to store bleach for treating well water is located within full
volume containment just outside the R.O. Building. Chemicals stored in the Cooling Tower Chemical
Storage Area are equipped with full volume secondary containment.
The risk of ash or ash residue entering the storm system is low due to the use of dikes and controls
(i.e. Dustmaster). When a truck is loaded with ash, a slurry system is used to minimize fugitive ash
and spillage. The risk of the petroleum products entering the storm system is low due to the use of
secondary containment that conforms to 40 CFR 112.8(c)(2) and non-structural controls (e.g.,
routine inspections) to prevent spills.
Wood chips may spill from trucks on paved or gravel roads, the truck dumpers, conveyors, and
radial stacker. The risk of these materials contaminating stormwater is minimized because
accumulated stormwater flows through a sand filter to remove TSS from the water before it is
discharged off -site. The sand filter is covered by a Sand Filter Operation and Maintenance
Agreement which is incorporated into State Stormwater Management Permit No. SWS 090511.
That permit was issued on 7/19/2013. Trucks are covered, tarped, or enclosed when not being
loaded or unloaded, and paved roads are swept periodically. Spilled materials are promptly
cleaned up.
Page 2 of 5

Capital Power -
Corporation
Outfall Evaluation
All outfalls have been evaluated for non-stormwater discharges, and no non-stormwater
discharges were observed. Appendix B1 of the revised SPPP includes a "Non -Storm Water
Discharge Assessment & Certification" Form that will be used in 2015. The SWPP includes a
procedure for conducting a Non -Storm Water Assessment for all outfalls.
Stormwater Sampling Results (2014)
Permit No. NCS000348 contains analytical monitoring requirements that apply to stormwater
outfalls at the CPI Southport site. Stormwater sampling is required to be conducted at
designated outfalls twice per year during representative storm events. Samples were collected
on April 4, 2014, and on October 28, 2014. Attached please find copies of analytical results from
Environmental Chemists, Inc. for both sampling events.
According to our permit, these results are to be compared to "benchmark" values in Table 3 of
the permit. While these benchmark values are not permit limits, they are to be used as
guidelines for monitoring the effectiveness of the BMP's that are identified in the SPPP.
The outfall sample collected on April 4, 2014 (Outfall 001) showed analytical results that were all
below the benchmark values listed in Table 3 of the permit. The analytical results from samples
collected on October 28, 2014 (from Outfall 001 and Outfall 005) were all below benchmark
values, with the exception of elevated zinc levels in both samples.
Zinc levels in stormwater samples from many industrial sites have a high potential of exceeding
the benchmark zinc value of 0.095 mg/I listed in Table 3. In fact, a paper published by R.K.
Bastian (1997), which can be found on EPA's stormwater guidance website, provides a table
indicating that concentrations of zinc in urban runoff can routinely be as high as 2.90 mg/I.
A more recent study indicates that a common cause of zinc in urban and industrial sites may be
attributed to truck tire wear, especially from tight turning at slow speeds and from areas around
loading docks. Zinc is added to tire tread rubber (mostly as zinc oxide) to facilitate
vulcanization. Tire tread material is released with tire wear as particulate dust containing zinc.
An article entitled "Tire -Wear Particles as a Source of Zinc to the Environment' authored by Terry
B. Councell et al., was published in Environmental Science & Technology in 2004. This article
indicates that tire tread material contains a zinc (Zn) content of about 1 wt % Zn. It should be
noted that there are currently up to 100 trucks per day delivering and dumping various fuels at
the CPI Southport site.
Page 3 of 5

Capital Power
Corporation
At the time permit NCS000348 was originally issued, the plant was not using tire derived fuel
(TDF) as part of the plant's fuel mix. The plant was burning coal that was transported by rail and
stored in an area where drainage discharged to the wastewater treatment ponds. The overall
fuel mix now includes a small percentage of coal (-3-5%), with the majority of the fuel
consumption as wood (-50%) and TDF (-45-49%). The tire derived fuel consists of tires that are
chipped in to small pieces. This material is transported on -site by trucks where it is dumped and
stored on an impervious pad
surrounded by a concrete ditch which flows directly to the wastewater treatment ponds prior to
discharge.
Samples of all fuels used at CPI Southport were collected in September 2014. These samples
were sent to Standard Laboratories, Inc. in Jackson, TN for a comprehensive analysis which
included trace metals. The TDF sample contained 10,600 ug/g Zn using ASTM method D6357.
This value is consistent with the zinc levels (-1 wt % Zn) previously noted in 2004 tire tread
material study.
In an effort to minimize any TDF (and TDF dust) from coming in to contact with stormwater on
roadways and areas that do not drain toward the sand filter and /or the waste treatment ponds,
all TDF trucks are required to be covered, tarped, or enclosed in order to reduce spillage. Since
the October sampling event, special attention has been paid to enforcing this policy. In addition,
the plant has taken a more proactive approach to implementing good housekeeping procedures
around the site dealing with spilled TDF and/or associated dust. Enhanced housekeeping
procedures include weekly inspections of all facility fuel storage areas and other outdoor
equipment locations. An on -site industrial street sweeper was purchased by the plant, and is
routinely used as needed to remove spilled materials and dust from stormwater drainage areas.
Page 4 of 5

y.
Capital Power
Corporation r
Certification
"I certify, under penalty of law, that this document and all attachments were prepared under my
direction or supervision 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 the persons directly responsible for gathering the
information, the information submitted is, to the best of my knowledge and belief, true, accurate
and complete. I am aware there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
David Groves
Plant Manger
CPI USA North Carolina, LLC
Southport Facility
Attachment: Sample Results from April and October 2014
cc: Trentt James, NCDENR Wilmington Regional Office
Date 0 Z 16 -
Page 5 of 5

CPI USA North Carolina LLC
1281 Powerhouse Dr. SE
Southport, NC 28461
' 1 910-343-6 / 00 F 910-343-6 / 10
February 26, 2015
Division of Water Quality
Surface Water Protection Section
Attention: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Annual Summary DMR- 2014
Permit No. NCS000348
Stormwater Pollution Prevention Plan Review/Update
Capital Power
Corporation
11�QEFI2015
V
Rqr? Q �'
The site Stormwater Pollution Prevention Plan (SPPP) was reviewed and modified in November
2014 by RTP Environmental Associates, Inc. from Raleigh, NC. Ted White, PE from RTP signed the
document on 11/24/14 certifying that he had completed a review of the SPPP Plan for the CPI
Southport plant and had amended the plan. Mr. White also acknowledged that CPI Southport had
not experienced a significant spill within the past 12 months from that date.
Best Management Plan (BMP) Summary & Evaluation
Potentially exposed materials at the Southport power plant include coal, wood chips, tire
derived fuel (TDF), petroleum products stored in existing ASTs, water and wastewater
treatment chemicals, and ash.
Coal for the boiler plant is stored outside in the coal pile and coal pile runoff is treated in the low
volume wastewater system prior to discharge (i.e., it is not drained to the stormwater system). Coal is
brought in by rail at the north end of the plant and unloaded through the coal chute and transported via
conveyor belt to the coal pile. The risk of coal dust entering the storm water via fugitive dust exists and
to minimize that risk, coal unloading BMPs are used and, because the drainage adjacent to the rail
bed is through vegetative buffers, the quantity of coal reaching the receiving water is minimal. Water is
sprayed onto the coal, as needed, as it is unloaded from the rail cars in one of the coal unloading
BMPs. Also, coal dust from the edges of the chute where coal is deposited is swept up daily
after unloading operations. These BMPs minimize fugitive dust transport.
The risk of the petroleum products entering the storm system is low due to the use of secondary
containment that conforms to 40 CFR 112.8(c)(2) and non-structural controls (e.g., routine
inspections) to prevent spills. Used oil is stored in a 300-gallon aboveground storage tank (AST)
located at inside the Boiler Building's Oil Storage Room, with full volume secondary containment.

Capital Power
Corporation
Diesel is stored in a 300-gallon AST outside the Pump House, in a 1,000-gallon AST located within
the Rail Car Unloading Area, and in a 300-gallon AST near Truck Dumper 2, all equipped with full
volume secondary containment. Gasoline is stored in a 30-gallon dispenser located in the Gasoline
and Drum Storage Area which is also equipped with full volume secondary containment. Small
tanks of turbine lube oil and hydraulic oil are located on the site, as well as transformers containing
oil. Any spillage from these tanks and transformers would normally be contained by full volume
secondary containment.
Chemical storage and usage is limited to the Wastewater Basin (drums and totes containing
chemicals are stored outside, equipped with full volume secondary containment), the Demineralizer
Building area, the R.O. Building area, and the Cooling Tower Chemical Storage Area. The several
chemical storage units in the Demineralizer Building are all equipped with secondary containment
and, any spills are routed to the Neutralization Tank and then the Wastewater Basin for treatment.
Spill cleanup materials are located inside the Warehouse and the R.O. Building. There is a
dedicated Unloading Bay at the Demineralizer Building. Most of the chemicals used in the R.O.
Building are stored within secondary containment or on a chemical skid on the floor in the building.
The floor is sloping towards a drain that discharges into the chemical sump from the Demineralizer
Building. A temporary tank designed to store bleach for treating well water is located within full
volume containment just outside the R.O. Building. Chemicals stored in the Cooling Tower Chemical
Storage Area are equipped with full volume secondary containment.
The risk of ash or ash residue entering the storm system is low due to the use of dikes and controls
(i.e. Dustmaster). When a truck is loaded with ash, a slurry system is used to minimize fugitive ash
and spillage. The risk of the petroleum products entering the storm system is low due to the use of
secondary containment that conforms to 40 CFR 112.8(c)(2) and non-structural controls (e.g.,
routine inspections) to prevent spills.
Wood chips may spill from trucks on paved or gravel roads, the truck dumpers, conveyors, and
radial stacker. The risk of these materials contaminating stormwater is minimized because
accumulated stormwater flows through a sand filter to remove TSS from the water before it is
discharged off -site. The sand filter is covered by a Sand Filter Operation and Maintenance
Agreement which is incorporated into State Stormwater Management Permit No. SWS 090511.
That permit was issued on 7/19/2013. Trucks are covered, tarped, or enclosed when not being
loaded or unloaded, and paved roads are swept periodically. Spilled materials are promptly
cleaned up.
Page 2of5

Capital Power
Corporation
Outfall Evaluation
All outfalls have been evaluated for non-stormwater discharges, and no non-stormwater
discharges were observed. Appendix B1 of the revised SPPP includes a "Non -Storm Water
Discharge Assessment & Certification" Form that will be used in 2015. The SWPP includes a
procedure for conducting a Non -Storm Water Assessment for all outfalls.
Stormwater Sampling Results (2014)
Permit No. NCS000348 contains analytical monitoring requirements that apply to stormwater
outfalls at the CPI Southport site. Stormwater sampling is required to be conducted at
designated outfalls twice per year during representative storm events. Samples were collected
on April 4, 2014, and on October 28, 2014. Attached please find copies of analytical results from
Environmental Chemists, Inc. for both sampling events.
According to our permit, these results are to be compared to "benchmark" values in Table 3 of
the permit. While these benchmark values are not permit limits, they are to be used as
guidelines for monitoring the effectiveness of the BMP's that are identified in the SPPP.
The outfall sample collected on April 4, 2014 (Outfall 001) showed analytical results that were all
below the benchmark values listed in Table 3 of the permit. The analytical results from samples
collected on October 28, 2014 (from Outfall 001 and Outfall 005) were all below benchmark
values, with the exception of elevated zinc levels in both samples.
Zinc levels in stormwater samples from many industrial sites have a high potential of exceeding
the benchmark zinc value of 0.095 mg/I listed in Table 3. In fact, a paper published by R.K.
Bastian (1997), which can be found on EPA's stormwater guidance website, provides a table
indicating that concentrations of zinc in urban runoff can routinely be as high as 2.90 mg/I.
A more recent study indicates that a common cause of zinc in urban and industrial sites may be
attributed to truck tire wear, especially from tight turning at slow speeds and from areas around
loading docks. Zinc is added to tire tread rubber (mostly as zinc oxide) to facilitate
vulcanization. Tire tread material is released with tire wear as particulate dust containing zinc.
An article entitled "Tire -Wear Particles as a Source of Zinc to the Environment' authored by Terry
B. Councell et al., was published in Environmental Science & Technology in 2004. This article
indicates that tire tread material contains a zinc (Zn) content of about 1 wt % Zn. It should be
noted that there are currently up to 100 trucks per day delivering and dumping various fuels at
the CPI Southport site.
Page 3 of 5

Capital Power
Corporation
At the time permit NCS000348 was originally issued, the plant was not using tire derived fuel
(TDF) as part of the plant's fuel mix. The plant was burning coal that was transported by rail and
stored in an area where drainage discharged to the wastewater treatment ponds. The overall
fuel mix now includes a small percentage of coal (-3-5%), with the majority of the fuel
consumption as wood (-50%) and TDF (-45-49%). The tire derived fuel consists of tires that are
chipped in to small pieces. This material is transported on -site by trucks where it is dumped and
stored on an impervious pad
surrounded by a concrete ditch which flows directly to the wastewater treatment ponds prior to
discharge.
Samples of all fuels used at CPI Southport were collected in September 2014. These samples
were sent to Standard Laboratories, Inc. in Jackson, TN for a comprehensive analysis which
included trace metals. The TDF sample contained 10,600 ug/g Zn using ASTM method D6357.
This value is consistent with the zinc levels (-1 wt % Zn) previously noted in 2004 tire tread
material study.
In an effort to minimize any TDF (and TDF dust) from coming in to contact with stormwater on
roadways and areas that do not drain toward the sand filter and /or the waste treatment ponds,
all TDF trucks are required to be covered, tarped, or enclosed in order to reduce spillage. Since
the October sampling event, special attention has been paid to enforcing this policy. In addition,
the plant has taken a more proactive approach to implementing good housekeeping procedures
around the site dealing with spilled TDF and/or associated dust. Enhanced housekeeping
procedures include weekly inspections of all facility fuel storage areas and other outdoor
equipment locations. An on -site industrial street sweeper was purchased by the plant, and is
routinely used as needed to remove spilled materials and dust from stormwater drainage areas.
Page 4 of 5

Capital Power
Corporation
Certification
"I certify, under penalty of law, that this document and all attachments were prepared under my
direction or supervision 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 the persons directly responsible for gathering the
information, the information submitted is, to the best of my knowledge and belief, true, accurate
and complete. I am aware there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
David Groves
Plant Manger
CPI USA North Carolina, LLC
Southport Facility
Attachment: Sample Results from April and October 2014
cc: Trentt James, NCDENR Wilmington Regional Office
Date 2 2(, Zc / 5
Page 5 of 5

I
1'
SM
ANALYTICAL & CONSULTING
CHEMISTS
Capital Power
1281 Powerhouse Dr.
Southport NC
Attention: Rick Houser
Lab ID Sample ID:
14-10076 Site- 002
Vest
Residue Suspended (TSS)
pH
Lab ID Sample ID:
14-10077 Site:003
Environmental Chemists,
6602 Windmill Way ® Wilmingfon, NC 28403
[phone] (Lab) & [phone] (Fax)
710 Bowsertown Road ® Manteo, NC 27954
[phone]
NCDENR: DWQ CERTMCAT'E #94, DLS CERTIFICATE 937729
Date of Report. Apr 24, 2014
Customer PO #:
28461 Report ff: 2014-04179
Report to: Rick Houser
Project 10:
Method
SM 2W D
SM 4500 H B
Test Method
Oil & Grease (O&G) EPA 1664
Lab ID Sample ID:
14-10078 Site:001
Test Method
Collect DatelTime Matrix
4/8/2014 9:24 AM Water
Results
Sampled by
Kevin Mixon
Date Analyzed
7.8 mg/L
7.79 units
Collect Date/Time Matrix Sampled by
4/8/2014 9:29 AM Water Kevin Mixon
04110/2014
04/16/2014
Results Date Analyzed
<5 mg/L 04/1612014
Collect Dateliime Matrix Sampled by
4/8/2014 9:24 AM Water Kevin Mixon
Results Date Analyzed
Aluminum
EPA200.7
0.175mg[L
04/11/2014
Arsenic
EPA200.7
<0.010mg/L
04111/2014
Beryllium
EPA200.7
<0.010 mg/L
04/11/2014
Boron
EPA200.7
0.036 mg/L
04/21/2014
Cadmium
-EPA200.7
<0.010 mg/L
04/11/2014
Chromium
EPA200.7
<0.010 mgiL
04/11/2014
Copper
EPA 200.7
<0.010 mg/L
04/11/2014
Lead
EPA 200.7
<0.010 mg/L
04/11/2014
.Nickel
EPA200.7
<0.010mg/L
04/1112014
Selenium
EPA200.7
<0.010mg/L
04/11/2014
Silver
EPA200.7
<0.010 mg1L
04/1112014
Thallium
EPA20❑.7
<0.010 mg/L
04/1112014
Zinc
EPA200.7
0.079 mg/L
04111/2014
Antimony
EPA 200,8
<0.010 mg/L
04114/2014
Mercury
EPA246.1
<0.0002 mg/L
04/14/2014
Report#:: 2014-04179 Page 1 of 2

STORM EVENT CHARACTERISTICS
Date �4
Total Event Precipitation (inches) J. Q 44
Event Duration (hours) (only if applicable - see permit.)
Date
Total Event Precipitation (inches)
Event Duration (hours) (only if applicable see permit.) ,
"I 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 the persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am
aware there are significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations."
( Signature of Permittee )
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W i �D
NOV 2 %
9 ~ O� FOR AGENCY USE ONLY
lJ Division of Water Q�2fit / Surface Waer Protection Date Received
Year Month Day
.rrr�r�
NCDENRNational Pollutant Discharge Elirr System
NtYtTI+ CAROB-!µ4 lE?iX1'MEMi' QF
E�� HMU Htv,: REPRESENTATIVE OUTFALL STATUS (ROS)
REQUEST FORM
If a facility is required to sample multiple discharge locations with very similar stormwater discharges, the
=Itete may petition the Directorfor Representative Outfall Status (ROS). DWQ may grant Representative
atus if stormwater discharges from a single outfall are representative of discharges from multiple
outfalls. Approved ROS will reduce the number of outfalls where ana/vtical sampling requirements apply.
If Representative Outfal/ Status is granted, ALL outfalls are still subject to the gual/tative monitoring
requirements of the facility's permit —unless otherwise allowed by the permit (such as NCG020000) and DWQ
approval. The approval letter from DWQ must be kept on site with the facility's Stormwater Pollution
Prevention Plan. The facility must notify DWQ in writing if any changes affect representative status.
For questions, please contact the DWQ Regional Office for your area (see page 3).
(Please print or type)
1) Enter the permit number to which this ROS request applies:
Individual Permit , (or)
cruo 34
2) Facility Information:
Owner/Facility Name
Facility Contact
Street Address
City
County
Telephone No.
f / U S"// %V' L-
Certificate of Coverage
[NI
(.0ij
.1G
State All_ ZIP Code
sip E-mail Address,
Fax: /G' "A's 1 -
3) List the representative outfall(s) information (attach additional sheets if necessary):
Outfall(s) C) 0 ]3 is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
Outfalls' drainage areas contain the same or similar materials?!
Outfalls have similar monitoring results?
Outfall(s) (j fJG S
�,r � is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
Outfalls' drainage areas contain the same or similar materials?
Outfalls have similar monitoring results?
Outfall(s) "A. / C eJ .? is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
Outfalls' drainage areas contain the same or similar materials?
Outfalls have similar monitoring results?
erf
des N No
des ❑ No
❑ Yes ❑ No rvl<o data*
Coe) r
�c
�n
;
dyes ❑ No:
dPes ❑ No
?
❑ Yes ❑ No afClo data*
49
9
iw�-Yes
❑ No
dyes
❑ No
❑ Yes
❑ No Ao data*
*Non-compliance with analytical monitoring prior to this request may prevent ROS approval. Specific
circumstances will be considered by the Regional Office responsible for review.
SW U-ROS-2009
Page 1 of 3
Last revised 12/30/2009

Representative Outfall Status Request
4) Detailed explanation about why the outfalls above should be granted Representative Status:
(Or, attach a letter or narrative to discuss this information.) For example, describe how activities and/or
materials are similar.
urn ekee
51 ----11 .OLJUII.
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 hereby request Representative Outfall Status for my NPDES Permit. I understand that ALL outfalls are still
subject to the qualitative monitoring requirements of the permit, unless otherwise allowed by the permit
and regional office approval. I must notify DWQ in writing if any changes to the facility or its operations
take place after ROS is granted that may affect this status. If ROS no longer applies, I understand I must
resume monitoring of all outfalls as specified in my NPDES permit.
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Pers Signing
Title: I -ZI �<
r0 /
(Signature ofApplic t)
Dat Signed)
Please note: This application for Representative Outfall Status is subject to approval by the
NCDENR Regional Office. The Regional Office may inspect your facility for compliance with the
conditions of the permit prior to that approval,
Final Checklist for ROS Request
This application should include the following items:
❑ This completed form.
❑ Letter or narrative elaborating on the reasons why specified outfalls should be granted representative
status, unless all information can be included in Question 4.
❑ Two (2) copies of a site map of the facility with the location of all outfalls clearly marked, including the
drainage areas, industrial activities, and raw materials/finished products within each drainage area.
❑ Summary of results from monitoring conducted at the outfalls listed in Question 3.
❑ Any other supporting documentation.
S W U-ROS-2009
Page 2 of 3
Last revised 12/30/2009

Representative Outfall Status Request
Mail the entire package to:
NC DENR Division of Water Quality
Surface Water Protection Section
at the appropriate Regional Office (See map and addresses below)
Notes
The submission of this document does not guarantee Representative Outfall Status (ROS) will be granted as
requested. Analytical monitoring as per your current permit must be continued, at all outfalls, until written
approval of this request is granted by DWQ. Non-compliance with analytical monitoring prior to this request
may prevent ROS approval. Specific circumstances will be considered by the Regional Office responsible for
review.
For questions, please contact the ®WQ Regional Office for your area.
Asheville F__�.....�,
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone [phone]
FAX [phone]
Fayetteville Regional Office
Systel Building,
225 Green St., Suite 714
Fayetteville, NC 28301-5094
Phone [phone]
FAX [phone]
Mooresville Regional Office
610 East Center Ave.
Mooresville, NC 28115
Phone [phone]
FAX [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Phone [phone]
FAX [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone [phone]
FAX [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone [phone]
FAX [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone [phone]
Water Quality Main FAX [phone]
Central Office
1617 Mail Service Center
Raleigh, NC 27699-1617
Phone [phone]
FAX [phone]
S W U-ROS-2009
Page 3 of 3
Last revised 12/30/2009