NCG050372_COMPLETE FILE - HISTORICAL_20161007

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V
DOC TYPE
L9/HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ 42 01 WD
YYYYMMDD

NK
MR
J.
Energy, Mineral &
Land Resources
ENVIROMMENZAL QUALITY
Bart Stofforis
VP of Laminate Operations
Unilin Flooring
550 Cloniger Drive
Thomasville, NC 27360
02
PAT MCCRORY /
Governor
DONALD R. VAN.DER VAART
Secretary
October 07 2016 TRACY DAVIS
Director
Subject: - Compliance Evaluation Inspection
Permit No. NCG 050372
Unilin Flooring — Denton Road facility
Davidson County
Dear Mr. Stofforis:
On October 4, 2016 Glen White of the North Carolina Department of Environmental Quality;
Department of Energy, Minerals, and Land Resources met with Jennifer Teague; EHS Manger,
at the facility located at 3286 Denton Road in Thomasville, to conduct a compliance inspection
per the Industrial Stormwater Permit requirements. Inspection consists of review of the
Stormwater Pollution Prevention Plan, training, monitoring and spills records as well as
observation of the general condition of the site, the outfalls and any possible exposures to
downstream stormwater. Her assistance with the inspection was greatly appreciated.
Permit:
This facility holds. General. Stormwater Permit NCG050372 to discharge stormwater from
industrial activity associated with Apparel, Printing, Leather, Rubber, & Miscellaneous
Manufacturing under the National Pollutant Discharge Elimination System (NPDES). The
permit became effective ,Tune 1, 2013 and expires on May 31, 2018. A copy of the current
permit is required to be maintained with the Stormwater Pollution Prevention Plan (SPPP)
documents. A current copy of the permit was available for review at the time of inspection.
Records/Reports:
This facility was required to develop and maintain a (Stormwater Pollution Prevention Plan)
SPPP in accordance with Part II, Section A of the permit. The facility has developed a SPPP. It
is maintained at the Cloniger Drive facility in the EHS Managers office. The permit generally
requires that the permit and the SPPP be maintained onsite. This location will be closing when
future construction at the other location.is complete. Documents not maintained at this site are
not viewed as an issue. Documents are complete and maintained at the other facility.
State of North Carolina l Environmental Quality I Energy, Mineral and Land Resources
Winston-Salem Regional Office 1 450 Hanes Mill Road, Suite 300 1 Winston-Salem, NC 27103
336 ?76 9800

Facility Site Review:
Unilin Flooring is a Division under its parent company, Mohawk. This facility is an older plaint
and it has changed ownership over the years. It has been closed and reopened on several
occasions. This plant will be closing again as soon as current construction and improvements at
the Cloniger Drive facility are complete. Production at this plant will move to that location.
Effluent Receivinp Waters:
Effluent from this facility drains to North Hamby Creek, class "C" waters of the Yadkin Pee Dee
River Basin.
Self -Monitoring Program:
Part II, Section C of the permit requires semi=annual qualitative monitoring. No analytical
monitoring is required under current operating procedures and permit requirements. Monitoring
has been performed as required. All industrial processes occur inside and under roof and very
few possible stormwater exposures exist.
Ms. Teague's assistance with this inspection was very much appreciated. The facility was found
to be compliant with requirements of its industrial stormwater permit. If you have questions or
need additional information, please contact Glen White at [phone].
Sincerely,
Matthew E. Gantt, P.E.
Regional Engineer
Land Quality Section
Winston-Salem Regional Office
Enclosures: Inspection Report
cc: . File Copy Division of Energy, Mineral and Land Resources (WSRO)
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
Wlnston-Salem Regidnal Ofttce 1 450.Hanes Mill Road, Suite 300. I Winston-Salem, NC 27103
336 776 9800

Compliance Inspection Report
Permit: NCG050372 Effective: 06/01/13 Expiration: 05/31/18 Owner: Unilin Flooring
SOC: Effective: Expiration: Facility: Unilin Flooring -Denton Road
County: Davidson 3286 Denton Rd
Region: Winston-Salem
'Thomasville NC 27360
Contact Person: Jennifer Teague Title: Phone: [phone]
Directions to Facility:
Take 1-85 toward Thomasville. take exit #115 (Highway 109). Turn left onto 109, then take a right on Cedar Lodge. Approx. 2 miles
ont he right.
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 10/04/2016 EntryTime: 10:OOAM Exit Time: 10:30AM
Primary Inspector: Glen White Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: ApparellPrintinglPapedLeatherlRubber Stormwater Discharge COC
Facility Status: Compliant Not Compliant
Question Areas:
Storm Water
(See attachment summary)
Page: 1

perrnit: NCG050372 Owner - Facility: Unilin Flooring
Inspection Date: 10/04/201 G.. Inspection Type : Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
See Compliance Letter.
Page: 2

Permit: NCG050372 Owner -Facility: Unilin Flooring
Inspection Date: 1010412616 Inspection Type : Compliance Evaivation Reason for Visit: Routine
Analytical Monitoring Yes No NA NE
Has the facility conducted its Analytical monitoring? ❑ ❑ 0 ❑
# Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas? ❑ 110 ❑
Comment: No analytical monitoring is required per the current NCG05 permit. Not required. Facility really_
has no exosures under current operating practices.
Permit and Outfalls
# Is a copy of the Permit and the Certificate of Coverage available at the site?
# Were all outfalls observed during the inspection?
# If the facility has representative outfall status, is it properly documented by the Division?
# Has the facility evaluated all illicit (non stonnwater) discharges?
Comment: Facility is compliant with NCGOS. No issues found.
Qualitative Monitoring
Has the facility conducted its Qualitative Monitoring semi-annually?
Yes No NA NE'
■❑❑❑
® ❑ ❑ ❑
❑ ❑ ® ❑
s❑❑❑
Yes No NA NE
-N 11110
Comment: Facility has three (3) locations observed as outfalls. „Appears that only one of those is an actual
outfall but Ms. Teaque monitors all three locations to keep a record of outside_ sources of
possible contamination that could reach the property and the final outfall. No issues observed.
Stormwater Pollution Prevention Plan
Does the site have a Stormwater Pollution Prevention Plan?
# Does the Plan include a General Location (USGS) map?
# Does the Plan include a "Narrative Description of Practices"?
# Does the Plan include a detailed site map including outfall locations and drainage areas?
# Does the Plan include a list of significant spills occurring during the past 3 years?
# Has the facility evaluated feasible alternatives to current practices?
# Does the facility provide all necessary secondary containment?
# Does the Plan include a BMP summary?
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
# Does the facility provide and document Employee Training?
# Does the Plan include a list of Responsible Party(s)?
# Is the Plan reviewed and updated annually?
# Does the Plan include a Stormwater Facility Inspection Program?
Yes No NA NE
■❑❑❑
E ❑ ❑ ❑
N ❑ 1113
❑ ❑ ❑
■❑❑❑
❑ 1113
❑ ❑ ❑
M ❑ ❑ ❑
❑ ❑ ❑
Page: 3

permit; NCG050372 Owner - Facility: Unilin Flooring
Inspection Date: 10/04/2016 :, Inspection Type : Compliance Evaluation. -. ... Reason for Visit: Routine.
5tormwater Pollution Prevention Plan
Has the Stormwater Pollution Prevention Plan been implemented?
Yes No NA NE
®❑❑❑
Comment: SPPP documents up to date. Documents maintained with SPPP for the Cloni er Drive facility at
that facility, This plant has been closed and reopened several times over the past several years.
It will close again when facilities under construction and/or planned at the, Cloniger Drive plant
are complete. No issues observed.
Page: 4

I Alp" �'
KCDERR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, RE. John E. Skvarla, III
Governor Director Secretary
March 27, 2013
Unilin FIooring NC, LLC
Attn: Ms. Jennifer Teague
550 Cloniger Drive
Thomasville, NC 27360
Subject: Compliance Evaluation Inspection
Certificates of Coverage 4s NCG050371, NCG050372 & NCG500643
Unitin Flooring NC LLC
Davidson County
Dear Ms.Teague:
Jenifer Carter of the Winston-Salem Regional Office"performed compliance Evaluation Inspections at Unilin Flooring
facilities located on Cloniger Drive and Denton Road in Thomasville, North Carolina on February 27, 2013. You were
present for the inspections. The purpose of the inspections was to review compliance with the National Pollutant
Discharge Elimination. System (NPDES) General stormwater, and wastewater permits. The following are the findings
from the subject inspections:
NCGO50371 (Cloniger Rd) & NCG050372 (Denton Rd)
a A Stormwater Pollution Prevention Plan (SPPP) has been developed and implemented. Make sure annual staff
training is properly documented.
a Qualitative monitoring has been conducted and recorded in accordance with permit requirements.
G Analytical monitoring is not required since no vehicle maintenance is performed on either site.
a There were no residuals from spills or leaks observed'on the ground, nor in or near surface waters.
a There was no evidence of use of, or cleaning of industrial machinery or equipment outdoors.
a 6 true stormwater outfalls are monitored as required (4 and 2 respectively). It was noted that the Denton Road facility
has been shut down, though monitoring has continued.
NCG500643 (Denton Rd)
o This facility has the potential to discharge cooling tower blow down and A/C condensate, though the facility is
currently shut down.
o Monitoring reports have been completed as required, with forms indicating `no discharge'.
The Division greatly appreciates your efforts to maintain compliance. Should you have any questions, please contact
Jenifer Carter at [phone].
Sincerely,
1:111-1,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office.
Division of Water Quality
cc: WSRE)Tiles}�
SWP — Central Files
NPS AC0 Urn t
North Carolina Division of Water Quatity, Winston-Salem Regional Office
Location: 585 Waughtown Street, Winston-Salem, NC 27107
Phone: [phone] Fax: [phone] Customer Service: 1-877-623.6748
Internet: http:llportal.ncdenr.org/weh/wq
On
e NCarolina
NIZA 11Y
An Equal Opportunity l Affirmative Action Employer

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
February 9, 2009
Mr. Jennifer Teague,
Environmental Health & Safety Coordinator
Unilin Flooring NC LLC
3286 Denton Road
Thomasville, NC 27360 '
Subject: Compliance Evaluation Inspection.
Certificates of Coverage #s NCC05037I, NCGO50372 &.NCG500643
Unilin Flooring NC LLC
Davidson County
Dear Ms.Teague:
Dee Freeman
Secretary
Jenifer Carter of the Winston-Salem Regional Office performed compliance Evaluation
Inspections at Unilin Flooring facilities located on Denton Road and Cloniger Drive in Thomasville,
North Carolina on January 22, 2009. You and Mr. Marty Zahn were present for present for the
inspections. The purpose of the inspections was to- review compliance with the National Pollutant
Discharge Elimination System (NPDES) General stormwatei- and wastewater permits. The following are
the findings from the subject inspections:
NCG050371 (Cloniger Rd) & NCG050372 (Denton Rd)
• A Stormwater Pollution Prevention Plan (SPPP) has been developed and properly implemented:
• Qualitative monitoring has been conducted and recorded in accordance With 0erin1t°re4uiremeiits.
• Analytical'inonitonng is not required since no vehicle maintenance is performed•on'either site.
• There were no residuals from spills or Ieaks observed on the ground, nor in or near surface waters.
• There was no evidence of use of, or cleaning of industrial machinery or equipment outdoors.
• 10 outfalIs are being monitored (8 and 2 respectively). It was noted that the Denton Road facility has
been shut down, though monitoring has continued.
NCG500643 (Denton Rd)
• This facility has the potential to discharge cooling tower blow down and A/C condensate, though the
facility is currently shut down.
• Monitoring reports have been completed as required, with forms indicating `no discharge'.
continued on reverse...
North Carolina Division of Water Quality, Winston-Salem Regional Office
t.ocatiow 585 Waughtown St. Winston-Salem, North Carolina 27107 One
Phone: [phone] FAX: [phone] L Customer Service: 1-877-623-6748 No]"th Carol111 a:
Internet: www.ncwaterquality.org ARturally
An Equal Opportunity 4 Affarnalive Action Employer

Sincer ly,
M . &SRC` ,i1es,
SWP — Central Files
NPS ACO Unit
The Division greatly appreciates your efforts to maintain compliance. Should you have any questions,
please contact Jenifer Carter at [phone].
Steve W. Tedder
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality.
0

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0 Y
April 11, 2008
Ms. Jennifer Teague
Environmental, Safety & Health Coordinator
Unilin Flooring
550 Cloniger Drive
Thomasville, North Carolina 27360
Michael F, t aslcy, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
RECEIVED
N.C. Dent. of ENR
APR 2 12008
Winstcn-sale,n
Regional office
Subject: General Permit No. NCG050000
Unilin Flooring — Denton Plant
COC No. NCG050372
Davidson County
Dear Ms. Teague:
In accordance with your application for a discharge permit received on March 26, 2008, we are
forwarding herewith the subject certificate of coverage (COC) to discharge under the subject state —
NPDES general permit. This permit is issued pursuant to the requirements of North Carolina General
Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the US
Environmental Protection Agency dated May 9, 1994 (or as subsequently amended).
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, this certificate of coverage shall be final and binding.
Please take notice that this certificate of coverage is not transferable except after notice to the
Division of Water Quality. The Division of Water Quality may require modification or revocation and
reissuance of the certificate of coverage. This permit does not affect the legal requirements to obtain
other permits which may be required by the Division of Water Quality or permits required by the
Division of Land Resources, Coastal Area Management Act or any other federal or local governmental
permit that may be required.
Please note that the attached permit expires on April 30, 2008. Your COC will be automatically
renewed to cover the full 5 year term of the soon to be reissued permit. In the interim you must abide by
the terms of the expiring permit. You can review the proposed general permit changes at
(http://h2o.enr.state.ne.us/su/publicnotice.htm). If you have any questions concerning this permit, please
contact Bill Diuguid at telephone number [phone] ext. 382.
SinceGINAL SIGNED BY
BRADLEY BENNETT
Coleen H. Sullins
cc: Winston-Salem Regional Office
Central Files
Stormwater Permitting Unit Files
Attachments
One
NpohCarolma
Naturally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone (9i9) 733-5083 Customer Service
Internet: www.ncwaterqualitt,ora Location; 512 N. Salisbury St. Raleigh, NC 27604 Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 500% Recycled110% Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG050000
CERTIFICATE OF COVERAGE No. NCG050372
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
Unilin Flooring
is hereby authorized to discharge stormwater from a facility located at
Unilin Flooring Denton Plant
.3286 Denton Road
Denton
Davidson County
to receiving waters designated as Brier Creek, Class C, to Yadkin River Basin, in accordance with the effluent
limitations, monitoring requirements, and other conditions set forth in Parts I, II, III, IV, V and VI of General Permit
No. NCG050000, as attached.
This Certificate of Coverage shall become effective April 11, 2008.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day April 11, 2008. ORIGINAL. SIGNED BY
BRADLEY BENNETT
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

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Latitude: 351148'57"
Longitude: 80105'41" NCG050372 Facility
County: Davidson Unilin Flooring
Location
Stream Class: C Denton
Receiving Stream: Brier Creek
Sub -basin: 03-07-07 (Yadkin -Pee Dee River Basin) P40T ICALED
Stream Index- 12-119-7-4

el,
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
April 11, 2008
Ms. Jennifer Teague
Environmental, Safety & Health Coordinator
Unilin Flooring
550 Cloniger Drive
Thomasville, North Carolina 27360
Subject: General Permit No. NCG050000
Unilin Flooring — Denton Plant
COC No. NCGO50372
Davidson County
Dear Ms. Teague:
In accordance with your application for a discharge permit received on March 26, 2008, we are
forwarding herewith the subject certificate of coverage (COC) to discharge under the subject state —
NPDES general permit. This permit is issued pursuant to the requirements of North Carolina General
Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the US
Environmental Protection Agency dated May 9, 1994 (or as subsequently amended).
If any parts, measurement frequencies, or sampling requirements contained in this permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, this certificate of coverage shall be final and binding.
Please take notice that this certificate of coverage is not transferable except after notice to the
Division of Water Quality. The Division of Water Quality may require modification or revocation and
reissuance of the certificate of coverage. This permit does not affect the legal requirements to obtain
other pen -nits which may be required by the Division of Water Quality or permits required by the
Division of Land Resources, Coastal Area Management Act or any other federal or local governmental
permit that may be required.
Please note that the attached permit expires on April 30, 2008. Your COC will be automatically
renewed to cover the full 5 year term of the soon to be reissued permit. In the interim you must abide by
the terms of the expiring pen -nit. You can review the proposed general permit changes at
(httpalh2o.enr.state.nc.us/su/publicnotice.htm). If you have any questions concerning this permit, please
contact Bill Diuguid at telephone number [phone] ext. 382.
cc: Winston-Salem Regional Office
Central Files
Stormwater Permitting Unit Files
Attachments
SincOR16INAL SIGNED BY
BRADLEY BENNETT
Coleen H. Sullins
Nn`hCarolina
Natura!!il
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: www.ncwaterauality.ore Location: 512 N. Salisbury St, Raleigh, NC 27604 Fax [phone].623-6748
An Equal Opportunily/Affirmative Action Employer — 50% Recycledll T1. Post Consumer Paper

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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG050000
CERTIFICATE OF COVERAGE No. NCG050372
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
Unilin Flooring
is hereby authorized to discharge stormwater from a facility located at
Unilin Flooring Denton Plant
3286 Denton Road
Denton
Davidson County
to receiving waters designated as Brier Creek, Class C, to Yadkin River Basin, in accordance with the effluent
limitations, monitoring requirements, and other conditions set forth in Parts I, II, III, IV, V and VI of General Permit
No. NCG050000, as attached.
This Certificate of Coverage shall become effective April 11, 2008.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day April 11, 2008.
QRt DL Y BFN13ETT
ED By
BRA
Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

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Latitude: 3548'57"
Longitude: 80cO5'41" NCG050372 Facility
County: Davidson Unilin Flooring Location
Stream Class: C Denton
Receiving Stream. Brier Creek
Sub -basin: 03-07-07 (Yadkin -Pee Dee River Basin)
Stream Index: 12-119-7-4 NOT SCALED

Re: NCG050372 Unilin Flooring Denton
Subject: Re: NCG050372 Unilin Flooring Denton
From: "[e-mail]" <[e-mail]>
Date: Tue, 8 Apr 2008 14:33:55 -0400 (EDT)
To: <[e-mail]>
Please proceed with issuing the permit. Thanks again.
----Original Message ----
From: [e-mail]
Date: Apr 7, 2008 17:18
To: "Jenifer Carter"<[e-mail]>
Subj: NCG050372 Unilin Flooring Denton
1 of 1 4/8/2008 3:07 PM

AK;wA
4 *,* Division of Water Quality 1 Water Quality Section
I
NC®EiNR National Pollutant Discharge Elimination System
Na— C gCLlm DE meM Or
F_za«MCKr rno
NCG050000
NOTICE OF INTENT
FOR AGF,NCY USE ONLY
Date Received
Year
I Month
Da
Certificate of Coverage
Nc Ga5 131717,
Check ft W Amount
Permit Assigned to
%u d
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG050000:
STORMWATER DISCHARGES associated with activities classified as:
SIC' 23 Apparel and Other Finished Products Made from Fabrics and Similar Materials
SIC 265 Paperboard Containers and Boxes
SIC 267 Converted Paper and Paperboard Products
SIC 27 Printing, Publishing and Allied Industries
SIC 30 Rubber and Miscellaneous Products (except as specified below)
SIC 31 Leather and Leather Products (except as specified below)
SIC 39 Miscellaneous Manufacturing Industries
The following activities are specifically excluded from coverage under this General Permit:
SIC 301 Tires and Inner Tubes
SIC 311 Leather Tanning and Finishing
Standard Industrial Classification Code
(Please print or type)
1) Mailing address of ownerloperator:
Name
Street Address
City
Telephone No.
Address to which all permit correspondence will be mailed
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
3) Physical Location Information:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). �!� 1-�SS f0 Q r-Cl Srl 11C I WkU -eVi-&
L )a Turn )e& auto 169 &7fa ri eWr i 10
{A copy of a coup y map or USGS quad sheet with iacillty clearly located on the map is required to be submitted with this application} 6n rhq i-t4.-
4) This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility Date operation is to begin
EI < isting
Page 1 of 3
S W U-220-10 t 701

NCG050000 N.O.I.
5) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 3 R 9
G) Provide a brief narrative description of the types of industrial act
1XVes and products manufactured at
this facility: 17U�'i or- a 1">7) ale-6166rin rp frcludes Vw
praSSinQr c
55
7) Discharge points�Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property?
What is the name of the body or bodies f water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? k% 1 tree t A./a. C.r,- c.
If the site stormwater discharges to asearate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer).
8) Does this facility have any other NPDES permits?
I�o
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
9) Does this facility have any Non -Discharge permits (ex: recycle permits)?
9<0
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
10) Does this facility employ any best management practices for stormwater control?
L9 No
❑ Yes
If yes, please briefly describe:
11) Does this facility have a Stormwater Pollution Prevention Plan?
L�l IVo
❑ Yes
If yes, when was it implemented?
12) Are
vehicle maintenance activities occurring at this facility?
Q Na ❑ Yes
13) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
® No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
haz dous waste?
Lh No ❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
haz dous waste?
No ❑ Yes
Page 2 of 3
SW U-220-101701
vP'09

r,
NCG050000 N.O.I.
d) If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
Flow is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport / disposal vendor:
Vendor address:
14) Certification:
North Carolina General Statute 143-215.6 b (1) 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 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
$10,000, 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 $10,000 or imprisonment not more than 5 years, or both, for a similar, offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit
will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual 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 f Person Signing: ,Tenni Per ICCA (.A
Title: EH 1 § Co ordinotiol-
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDENR
,4 Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
l' Check for $100 made payable to NCDENR
12' This completed application and all supporting documents
l Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
SW U-220-101701
Page 3 of 3

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Longitude. 8OT5'41" NCG050372 Facility
County: Davidson Unilin Flooring Location
Stream Class: C De Mon
Receiving Stream: Brier Creek
Sub -basin- 03-07-07 (Yadkin -Pee Dee River Basin) NOT MUD
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