NC0001384_application_20211210

Edward "Cowboy" Naylor
From:
Sent:
Subject:
Attachments:
Importance:
Friday, October 8, 2021 3:15 PM
aazcl_" 9ta@ACISii
FW: transfer of ownership for NPDES permit NC0001384 + renewal application forms
NC0001384_owner name change_20211008.pdf; npdes standard conditions -
20111109.pdf; 2019-NPDES-Form-1.pdf; 2019-NPDES-Form-2E.pdf
High
Sent: Friday, October 8, 2021 3:05 PM
To: '[e-mail]' <[e-mail]>
Cc: Burbage, Jordan <[e-mail]>; Graznak, Jenny <[e-mail]>; Thedford, Wren
<wre n.thedford @ ncde nr.gov>
i111 _,zrpmtirJ (4 a,av0:; r ieltrfoffi"rr
The Division has reviewed and approved your request to transfer ownership of NPDES permit
NCOOO1384. A copy of the revised permit is attached. You may begin using this version
om.,, ..
immediately.
Permit NCOOO1384 expired in May 2021 and must be renewed. Use the attached EPA application
forms to prepare and submit your application package Scan and email the completed forms to me
directly, then mail the original documents to:
Ms. Wren Thedford
NCDEQ/DWR/NPDES,
1617 Mail -Service Center 'F
Raleigh NC 27699-1617
If you have any questions, simply reply to this message.
Charles H. Weaver
Environmental Specialist
N.C. DEQ•/ Division of Water Resources
919-707-3616'
\ [e-mail]
.(mailing address) 1617 Mail Sery
enter, Raleigh, NC 27699-1617
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed
to third parties.

United States
Environmental Protection Agency
Office of Water
Washington, D.C.
EPA Form 3510-1
Revised March 2019
Water Permits Division
.EPA, Application Form 1
General Information
NPDES Permitting Program
Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
"General Instructions" for this form.

EPA Identification Number NPDES Permit Number
AICoco Alf*
Facility Name
sede- t
Form Approved 03/05/19
OMB No. 2040-0004
FORM
2E
NPDES
.EPA
U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater
MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURAL FACILITIES WHICH
DISCHARGE ONLY NONPROCESS WASTEWATER
SECTIO 41. OUTFALL LOCATION (40 CFR 122.21(h)(1))
1.1 Provide information on each of the facilit 's outfalls in the table below.
Outfall
Number
Receiving Water Name
Latitude
Longitude.
PI
SECTIO 4 2. DISCHARGE DATE (40 CFR 122.21(h)(2))
2.1 Are you a new or existing discharger? (Check only one response.)
1111 New discharger ❑ Existing discharger 4 SKIP to Section 3.
2.2 Specify your anticipated discharge date:
SECTIO 4 3. WASTE TYPES (40 CFR 122.21(h)(3))
3.1 What types of wastes are currently being discharged if you are an existing discharger or will be discharged if you are a
new discharger? (Check all that apply.)
S Sanitary wastes
❑ Restaurant or cafeteria waste
❑ Non -contact cooling water
3.2 Does the facility use cooling water additives?
❑ Yes
❑ Other nonprocess wastewater (describelexplain
directly below)
1111 No 4 SKIP to Section 4.
3.3 List the cooling water additives used and describe their composition.
Cooling WaterAdditives,
Gist)
SECTION 4. EFFLUENT CHARACTERISTICS (40 CFR 122.21(h)(4))
Composition of Additives
(d available to you)
4.1 Have you completed monitoring for all parameters in the table below at each of your outfalls and attached the results to
this application package?
❑ Yes
If
No; a waiver has been requested from my NPDES permitting authority
(attach waiver request and additional information) 40 SKIP to Section 5.
4.2 Provide data as requested in the table below.t (See instructions for specifics.)
Maximum Daily
Parameter or Pollutant Discharge
(specs) units)1
Number of
Analyses
(f actual data
Biochemical oxygen demand (BODs)
Total suspended solids (TSS)
Oil and grease
pH (report as range)
Temperature (winter)
Temperature (summer)
+Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under40 CFR 136 for the analysis of pollutants or pollutant
parameters or required under40 CFR chapter t, subchapter N or0. See instructions and 40 CFR 12 .21(e)(3).
Mass
Conc.
Average Daily
Discharge,
(specs units)
Mass
Conc.
Source
(use codes
per
instructions)
EPA Form 3510-2E (revised 3-19)
Page 1

EPA IdenG'ficalion Number
NA
4.3
4.4
NPDES Permit Number
A G2Umb
�J FacilFacilityName�
Is fecal coliform believed present or is sa Ita ry waste discharged (or will it be discharged)?
❑ Yes ❑ No 4 SKIP to Item 4.5.
Provide data as requested In the table below.1 (See instructions for specifics.)
Numberiof
Analyses
pf actual data
Maximum Daily
Discharge
(specif units)!
Form Approved 03105/19
OMB No. 2040-0004
Average Daily
Discharge
Mass
Conc.
Source
(use codes
per
Instructions)
Fecal coliform
E. coli
Enterococci
4,5
4.6
Is chlorine used (or will it be used)?
❑ Yes ❑ No 4 SKIP to Item 4.7.
Provide data as requested in the table below.1 (See instructions for specifics.)
Total Residual Chlorine
Number of
Analyses
(d actual data
reported)
Maximum Daily
Discharge
(specit units)
Mass
Average Daily
Discharge
(sped units)
Mass,
Conc.
Source
(use codes
instructions)
4.7
Is non -contact cooling water discharged (or will it be discharged)?
❑ Yes ❑ No . SKIP to Section 5.
4.8
Provide data as requested in the table below.1 (See instructions for specifics.)
Number of
Ana yses
(if actual data
reported)
Maximum Daily
Discharge
(specif units)
Conc.
Average Daily
Discharge
(sp€air unfls)
Source
(use codes
per
instructions)
Chemical oxygen demand (COD)
Total organic carbon (TOC)
SECTION 5. FLCW (40 CFR 122.21(h)(5))
5.1
Except for stormwater water runoff, leaks, or spills, are any of the discharges you desc ibed in Sections 1 and 3 of this
application intermittent or seasonal?
❑ Yes 4 Complete this section. ® No 4 SKIP to Section 6.
5.2
Briefly describe the frequency and duration of flow.
SECTION 6. TREATMENT SYSTEM (40 CFR 122.21(h)(6))
6.1
Briefly describe any treatment system(s) used (or to be u
idc,,444Ve
e
I Sampling shall be conducted according to suffidently 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 3510-2E (revised 3-19)
Page 2

EPA Iden' m lion
SECTION 7. OTHER
Number NPDES Permit Number
�d 000 /3 pr
INFORMATION (40 CFR 122.21(h)(7))
the above
limitations.
f
Facility Name
.,nA,tp' �/ -J ,.* Gx+'/1tM'FJ
�G,
items. Use this space to provide
Attach additional sheets as
Form Approved 03/05119
bC,�+ ,... OMB No. 2040•0004
any information you believe the
needed.
o =-
46
0
7.1
Use the space below to expand upon any of
reviewer should consider in establishing permit
r
SECTION
8. CHECKLIST
AND CERTIFICATION STATEMENT
(40 CFR 122.22(a) and (d))
2E that you have completed and are submitting with your application.
attachments that you are enclosing to alert the permitting authority. Note that
Checklist and Certification Statement
8.1
In Column 1 below, mark the sections of Form
For each section, specify in Column 2 any
not all applicants are required to provide attachments.
Column 1
Column 2
❑ Section 1: Outfall Location
for additional outfalls)
• wl attachments (e.g., responses
❑ Section 2: Discharge Date
❑ wl attachments
❑ Section 3: Waste Types
❑ w/ attachments
❑ Section 4: Effluent Characteristics
❑ w/ attachments
• Section 5: Flow
• w/ attachments
❑ Section 6: Treatment System
❑ w/ attachments
❑ wl attachments
• Section 7: Other Information
❑ Section 8: Checklist and Certification Statement
0 w/ attachments
8.2
Certification Statement
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 those 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 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)
"r2o
Official title
Su r✓cSO&
Signature
1 &t.C_---
Date signed
/,0O/a
EPA Form 3510-2E (revised 3-19)
Page 3

United States
Environmental Protection Agency
•
Office of Water
Washington, D.C.
EPA Form 3510.2E
Revised March 2019
Water Permits Division
:EPA Application Form 2E
Manufacturing, Commercial,
Mining, and Silvicultural
Facilities Which Discharge
Only Nonprocess Wastewater
NPDES Permitting Program
Note: Complete this form and Form 1 if your facility is a new or existing manufacturing, commercial,
mining, and silvicultural facility that discharges only nonprocess wastewater.

EPA Identifi%/lifon Number NPDES Permit Number
/V rj cYr
Form
1
NPDES
.=.EPA
Facility Name (tide,
a/
U.S. Environhlental Protection Agency
Application for NPDES Permit to Discharge Wastewater
GENERAL INFORMATION
SECTION 1. ACTIVITIES REQUIRING AN NPDES PERMIT (40 CFR 122,21(f) ant (f)(1))
Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned
treatment works?
If yes, STOP. Do NOT complete It No
Form 1. Complete Form 2A.
Applicants Required to Submit Form 1
Is the facility a concentrated animal feeding
operation or a concentrated aquatic animal
production facility?
Yes 4 Complete Form 1 e No
and Form 28.
Is the facility a new manufacturing, commercial,
mining, or silvicultural facility that has not yet
commenced to discharge?
Yes 4 Complete Form 1 J No
and Form 2D.
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
ID Yes 4 Complete Form 1 ® No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15.
Form Approved 03/05/19
OMB No. 2040-0004
1.1.2 Is the facility a new or existing treatment works
treating domestic sewage?
If yes, STOP. Do NOT No
complete Form 1. Complete
Form 28.
1.2.2 Is the facility an existing manufacturing,
commercial, mining, or silvicultural facility that is
currently discharging process wastewater?
Yes 4 Complete Form No
1 and Form 2C.
1.2.4 Is the facility a new or existing manufacturing,
commercial, mining, or silvicultural facility that
discharges only nonprocess wastewater?
ID Yes 4 Complete Form No
1 and Form 2E.
SECTION 2. NAME, MAILING ADDRESS, AND LOCATION (40 CFR 122.21(1)(2))
2.1 Facility Name . i'a r1'i✓1Xt F ' 1akrses
711
c
2
i. 2.4 Facility Mailing Address
Streettr!ox
oorPP.O.b/ox •J Q A
City or town r y� y//
EPA Form 3510-1 (revised 3-19)
2.2 EPA Identification Number
NA-
2.3 Facility Contact
Name (first and lasV Title
E4wA-IZet 41,4044. vitae e e/tile ®e-
Email ta'/SrCAcrtIALute
State
cam
Phone number Lea'
33 itoz--8343
ZIP code
Page 1

EPA Identlfic Number
2 5 <Facility Locat on
NPDES Permit Number
Negao
Street route number, or others ecific entifi r
yore f 8�r �.
County name
(IA& Je(L
City or town
6-/h sranivdie
Facility Name
tile nsrde-;
County code (if known)
7-
State
SECTION 3. SIC AND NAICS CODES (40 CFR 122.21(f)(3))
SIC Code(s)
NAILS Code(s)
Description (optional)
Description (optional)
SECTION 4. OPERATOR INFORMATION (40 CFR 122.21(f)(4))
NameofOperator
Form Approved 03/05/19
OMB No. 2040-0004
/j• e• .
ZIP code
Is the name you listed in Item 4.1 also the owner?
❑ Yes ❑ No
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
❑ Private ❑ Other (specify)
Phone Number of Operator
Operator Address
Street or P.O. Box
City or town
Email address of operator
SECTION 5. INDIAN LAND (40 CFR 122.21(f)(5))
State
Is the facility located on Indian Land?
❑ Yes i No
ZIP code
EPA Form 3510-1 (revised 3-19)
Page 2

EPA
SECTION
identification Number
• A-
6. EXISTING ENVIRONMENTAL
NPDES Permit Number Facility Name
. may - 0 ea / 33 e, i'et /�., 4e1— Yc4,1)
PERMITS (40 CFR 122.21(f)(6)) �
Permits (check all that apply and print or type the corresponding
Form Approved 03/05/19
C,. OMB Na 2040-0004
permit number for each)
co
W
SECTION
6.1
7. MAP
Existing Environmental
• NPDES (discharges
to surface
• RCRA (hazardous wastes)
• UIC (underground injection of
fluids)
water)
❑ PSD (air emissions)
❑ Nonattainment program (CM)
❑ NESHAPs (CAA)
❑ Ocean dumping (MPRSA)
• Dredge or fill (CWA Section 404)
❑
application?
Other (specify)
(40 CFR 122.21(f)(7))
Have you attached a topographic map
specific requirements.)
1111 Yes ❑ No ❑ CAFO—Not
containing all required information to this
Applicable (See requirements in Form 2B.)
(See instructions for
A !
2
7.1
SECTION
8. NA7URE
OF BUSINESS (40 CFR 122.21(0(8))
60
it
0) ;.
`0
m.
8.1
Describe the nature of your business.
--/—a vor tick-e— t3 `to rt ..w
SECTION
9. COOLING
WATER INTAKE STRUCTURES (40 CFR 122.21(f)(9))
Does your facility use cooling water?
0 Yes 1111 No 4 SKIP to Item 10.1.
i
�
,
c y '
9.1
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122,21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)
SECTION
10. VARIANCE
REQUESTS (40 CFR 122.21(0(10))
or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
authority to determine what information needs to be submitted and
(CWA ❑ Water quality related effluent limitations (CWA Section
302(b)(2))
❑ Thermal discharges (CWA Section 316(a))
, y
d
d ,,'
d ;-
0 ;
:,
10.1
Do you intend
apply. Consult
when.)
❑ Fundamentally
Section
to request or renew one
with your NPDES permitting
different factors
301(n))
pollutants (CWA
301(c) and (g))
• Non -conventional
Section
• Not applicable
Page 3
EPA Form 3510-1 (revised 3-19)

EPA Identifi lion
Number
NPDES Permit Number
^ '-,r.�r� ` r1
Facility Name Form Approved 03/05/19
! OMB No. 2040-0004
SECTION
11. CIECKLIST
AND CERTIFICATION STATEMENT (40
CFR 122.22(a) and (d))
you have completed and are submitting with your application.
tha you are enclosing to alert the permitting authority. Note
Checklist and Certification Statement
11.1
In Column 1 below, mark the sections of Form 1 that
For each section, specify in Column 2 any attachments
that not all applicants are required to provide attachments.
Column 1
Column 2
1: Activities Requiring an NPDES Permit
❑ wl attachments
i Section
2: Name, Mailing Address, and Location
❑ w/ attachments
• Section
❑ Section 3: SIC Codes
• w/ attachments
❑ Section 4: Operator Information
❑ w/ attachments
❑ Section 5: Indian Land
• w/ attachments
❑ Section 6: Existing Environmental Permits
❑ wl attachments
7: Map
w/ topographic
❑ map ❑ w/ additional attachments
III Section
8: Nature of Business
❑ wl attachments
• Section
❑ Section 9: Cooling Water Intake Structures
❑ w/ attachments
10: Variance Requests
❑ w/ attachments
• Section
❑ Section 11: Checklist and Certification Statement
❑ w/ attachments
11.2
Certification Statement
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 those 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 that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or
y, �p
IS&4'
type first and last name)
,%,� r
Official title • / I sy
IYO4t+fI�lJ'e'OVn...ilea/�l/?T�-8401.. 2-C.-
,L'l`lari/'G3'o✓�
Date signed/�
AV /a/
4 Yit
Signature
y
11
EPA Form 3510-1 (revised 3-19)
Page 4

State Grid: Williamsburg
Permitted Flow: 0.025 MGD
Drainage Basin: Cape Fear River Basin
L
I 1 r t ..
la I ▪ .NI
•
•
✓ -
r, , •,
a' J a
r • fir1 i
• �
el ~~. .1
1•i
Outfall 003 I.. I.
Outfall 002
ti
▪ .3 Miles to Grays Branch
Stormwater Outfall
Grays Branch
WWTP
Upstream Sampling Point
789nft
1
Riverside friffAitiktrO; C,'bsgi11e Re s&
did Williamsburg Plant WWTP
Outfali 001' Latitude 36' 15' 18' N Longitude 430' 58' W
Outtalk 002, Latitude 36' 15' 19' N Longtude 79'30' 58' W
Ouliall003' Latitude 35° 15' 27" N Longitude 79 31' 00' W
Sub -Basin: 03-06-02 Stream Class: WSII-NSW
Receiving Streams: Outtails 001 1002 UT to Buttermilk Creek Outfall 003 to UT Grays Branch
Facility
Location
not to scale
North
a.
NPDES Permit No. NC0001384
Caswell County
z
•.J
1 •

Se.
FURNITURE
Edward "Cowbalp" Naylor
Maintenance/Warehouse
Supervisor
;www.riverside-fumiture.com
"zit " S/
i® r & ), zje4vL
5928 Hwy 87 N.
Gibsonville, NC 27249
Phone: [phone] X102
Cell: 336-402-8308
[e-mail]
41L� iere CZ ioh Vey... ie--
e4alie
7/�LSitica94 Ltic eL / / L U%4 e ,/
Ck1�A

e
FURNITURE
Edward "Cauboip" Naylor
Maintenance/Warehouse
Supervisor 5928 Hwy 87 N.
Gibsonville, NC 27249
Phone: [phone] x102
Cell: 336-402-8308
[e-mail]
,rww.riverside-furniture.com
/7-40 , /
l kok_ L m C_/VCrie
/eta - a% V �.�
gi,cd dew
ziott-
gyadig Age
�'e_ deit/ oLgie)
e ee Gciam6 v ea -A. ad e/'Cpztd
136- aV ke44-