NCG180232_COMPLETE FILE - HISTORICAL_20140930

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV U& ) D 0 a3
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
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❑ 3( �`i U � ,
YYYYM M DD

0
Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONL1'
D::Ir RD«6,�d
\'c;u
N1 n1I1
Da Y
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual' mean?
The person is either:
JZ-
• the responsible corporate officer (for a corporation); ,�,��F ^ `^D
• the principle eXecutive officer or ranking elected official (for a municipality, stai�Ped1(1l2f j#her public
agency); DfNR to
ore heleral duly aartnei or uthorizedlrepresentative of oner a eof the above. proprictorship)STORMbygT RPERALITy
MIT NG
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation')
applies:
Individual Permit
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(o)) Certificate of Coverage
N I C I G I 18 U 3
RSZ R0Me I`"rojytx
Address
Lin ca t) 1Q, /9
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http:Hl)oi-tal.iicdenr.orWweb/Ir/sw-permit-contacts and nut the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed: I
Previous legally responsible individual: ROb e— + L H U n+er
First MI Last
4) NEW OWNER AFFILIATION (legally responsible
1� lr1(1y" for tthe permitt)' ):^ I
Person legally responsible for this permit �J Ran eI `
First MI Last '
Page I oft
SW U-OWNERAFFIL-25Ju1y2014

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Direc+or OPn 1-gcAr;r J
ralo .l
838 L_ ncol� vn(\ / To rkbUay
il (Mailing Ad(Ir�sp ?a0��
�..inca 1{��7 N/lam
GINState Zip
(8116) wig -19 0
'lelepltone 1 mail Address
(9,l S) 41on - 5 2 G
Fax Number
5) Reason for this change:
Enlploycc or management change
A result of: Inappropriate or incorrect designation before
❑ Other
ljolher please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
attest that this application for this change in Owner Affiliation
(person legally responsible for the permil) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
�^ q I z'-� 1.20t4
Signillare Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stonnwater Permitting program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call 919-707-9220 or visit the website at:
littp://portal.iicdenr.oraweb/Ir/stormwater
Page 2 of 2
SW U-OWN ERAFF IL-25Ju1y2014

.i
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
May 21, 2004
Mr. Bruce Stubblefield
RSI Home Products
838 Lincoln County Parkway
Lincolmon, NC 28092
Subject: General Permit No. NCG 180000
RSI Home Products
COC NCG 180232
Lincoln County
Dear Mr. Stubblefield:
Alan W. Klimek, P.E.
Director
Division of Water Quality
In accordance with your application for a discharge permit received on May 18, 2004 we are forwarding
herewith the subject certificate of coverage 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).
Please take notice that this certificate of coverage is not transferable except after notice to the Division
of Water Quality. 'fhe Division of Water Quality may require modification or revocation and rcissuance 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 of permits required by the Division of Land Resources, Coastal Area Management
Act or any other Federal or Local governmental permit that may be required.
If you have any questions concerning this permit, please contact.lonathan Diggs to telephone number
[phone] ext. 537.
Sincerely,
ORIGINAL SIGNED BY
WILLIAM C. MILLS
Alan W. Klimek, P.E.
cc: Mooresville Regional Office
Central Files
Stormwater and General Permits Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 [phone]
�Rin
7d DNit
Customer Service
1 800 623-7748

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG180000
CER,rn,"ICATE OF COVERAGE No. NCG180232
STORMWATER DISCHARGES
NATIONAL POLLUTAN'C 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,
RSI Home Products
is hereby authorized to discharge stormwater from a facility located at
RS1 Home Products
838 Lincoln County Parkway
Lincolnion
Lincoln County
to receiving waters designated as UP to Larkard Creek, a class C water in the Catawba River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts 1, If. 111,
1V, V, and VI of General Permit No. NCGt80000 as auached.
This certificate of coverage shall become effective May 21, 2004.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
ORIGINAL SIGNED BY
Signed this day May 21, 2004. WILLIAM C. MILLS
Alan W. Klimek, Director
Division of Water Quality
By Authority of the Environmental Management Commission

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RSI Home
Products
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MaDtech. Inc.

Markers
Name: RSI Home Products NCG180232
Short Name: RSHmPr
Coordinates: 0350 32' 48.7" N, 0810 13' 30.0" W
Comment: RSI Home Products subbasin (03-08-35), Catawba River Basin, Lincoln County,
UT to Larkard Creek, Class C, USGS quad E14SW