NCGNE1590_Application_20230221

N,r, Lb V0 RECEIVED
FFB 212023
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name f le al organ
tional entity:
Legally responsible person (MtBjtl ,signedinttem,7 belg
Jimral
So
Street adsss-
'�
City:
\n
State
N c
Zip Code
Z$0
e
t oLr
C'A S
Telephone number:
11
q' 469
Email address,
�hc�n1�U b5 y
Type of Ownership:
Government
❑ County ❑ Federal ❑ Municipal ❑ State
Non -government
liAusiness (If ownership is business, a copy of NCSOS report must be included with this application)
❑ Individual
2. Industrial Facility (facility requesting exclusion):
3.
Facility name:
Po\ Kemp
Facili environmental contact:
' I
Street a dress:
i
Tele�j hone number,
7 �O
Email address: olrnarl `e— I Kem i ,
City
M�
County
IAs-��
State
N C
Zip Code
2403
Latitude of entrance: 35.7.9` 9
Longitude of entrance: _y I • r 6
Parcel Identification Number (PIN): 01' 9 4 QQ !
Date operation began: ,aoa 2
Standard Industrial Classification (SIC) Code:
Brief description of the types of industrial` activities and products produced at this facility:
�QS i n -E Si
Consultant (if applicable): ND+ C,4)p('i f04,e
Name of consultant: Consulting firm:
Street address: City: State and zip code:
Telephone number: Email address:
4. Exposure Checklists
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future? If you
answer "Yes" to any of these items, you are not eligible for the no exposure exclusion.
Using, storing, or cleaning industrial machinery or equipment, and areas where residuals from
using, storing, or cleaning industrial machinery or equipment remain and are exposed to
stormwater
❑ Yes VNo ❑ N/A
Materials or residuals on the ground or in stormwater inlets from spills/leaks
,�/
❑ Yes pe No ❑ N/A
Materials or products from past industrial activity
❑ Yes No O N/A
Material handling equipment (except adequately maintained vehicles)
❑ Yes VNo ❑ N/A
Page 3 of 6

Materials or products during loadinglunloading or transporting activities
❑ Yes El N/A
Materials or products stored outdoors (except final products intended for outside use [e.g., new
cars] where exposure to stormwater does not result in the discharge of pollutants)
/No
❑ Yes No ❑ N/A
Q'
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks,
and similar containers
❑ Yes No ❑ N/A
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑ Yes VNo ❑ N/A
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
❑ Yes o ❑ N/A
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes Ao ❑ N/A
Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes o ❑ N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise
regulated (i.e. under an air quality control permit) and evident in the stormwater outflow
/
tr!
❑ Yes No ❑ N/A
Empty containers that previously contained materials that are not properly stored (i.e., not closed
and stored upside down to prevent precipitation accumulation)
❑ Yes No ❑ N/A
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has
the facility had any releases in the past three (3) years?
❑ Yes ❑ No YNIA
'Sealed means banded or otherwise secured and with locked or non -operational taps or valves.
Above Ground storage Tanks (ASTs) and Secondary Containment
If you answer "No" to any of the following items, you are not eligible for the no exposure exclusion.
Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or deterioration, or
j0yees; ❑ No N/A
evidence of leaks?
Is secondary containment provided for all exterior ASTs? If so, is it free of any cracks, holes, or
❑ Yes ❑ No N/A
evidence of leaks, and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers (including drums,
❑ Yes ❑ No M NJA
barrels, etc.) with a capacity of more than 660-gallons?
Is secondary containment provided for above ground storage containers stored in close proximity
�/
❑ Yes ❑ No lJ N/A
to each other with a combined capacity of more than 1,320 gallons?
Is secondary containment provided for Title III Section 313 Superfund Amendments and
❑ yes ❑ No N/A
Reauthorization Act (SARA) water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
❑ Yes ❑ No A
Are release valves on all secondary containment structures locked?
❑ Yes ❑ No N/A
Other information
If you answer "Yes" to any of the following items, you might not be eligible for the no exposure exclusion. A more
in-depth evaluation of the site circumstances may be required.
Are vehicles used in material handling in disrepair and/or leaking fluid?
❑ Yes No ❑ N/A
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
Yes ❑ No ❑ N/A
Does this facility have coal piles on site?
❑Yes VN.9 ❑ N/A
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
❑ Yes Oo ❑ N/A
Page 4 of 6

Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, ❑ Yes VNo ❑ N/A
plating, painting, or metal finishing)?
If yes:
Describe the industrial activity:
Are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No
Please specify:
5. Other Facility Conditions (check all that apply and explain accordingly):
❑ This facility has other NPDES permits.
If checked, list the permit numbers for all current NPDES permits:
❑ This facility has Non -Discharge permits (e.g. recycle permit).
If checked, list the permit numbers for all current Non -Discharge permits:
❑ This facility stores hazardous waste in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility is a (mark all that apply)
❑ Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked, indicate:
• Kilograms of waste generated each month:
• Type(s) of waste:
• How material is stored:
• Where material is stored:
• Number of waste shipments per year:
• Name of transport/disposal vendor:
• Transport/disposal vendor EPA ID:
• Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site.
If checked, briefly describe the site conditions:
❑ This facility is located on Native American Lands.
6. Required Items (Application will be returned unless all of the following items have been included):
❑ Copy of most recent Annual Report to the NC Secretary of State (if applicable)
his completed application and any supporting documentation
❑ Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 5 of 6

7. Applicant Certification
North Carolina General Statute 143-215.68 (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($50,000). I hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
R I am the person responsible for the industrial activity, for satisfying the requirements of this exclusion, and for any civil
or criminal penalties incurred due to violations of this exclusion.
I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES stormwater permitting.
Ley There are no discharges of stormwater contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
IP! I understand that I am obligated to maintain no exposure conditions and complete a Self -Recertification form at least
once each year and, if requested, provide this certification to the operator of the local municipal separate storm sewer
system (MS4) into which the facility discharges (where applicable). I understand that I must allow the North Carolina
Division of Energy, Mineral, and Land Resources, or M54 operator where applicable, to perform inspections to confirm
the condition of no exposure and to make such inspection reports publicly available upon request. I understand I must
keep a copy of annual recertifications on file at the facility.
U I understand that in the event that the site no longer qualifies for a No Exposure Exclusion that I must obtain coverage
under an NPDES permit prior to any point source discharge of stormwater from the facility.
Q/ ,The information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, and complete based on
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information.
Printed Name of Person Signing: 3 O`"411 NU9050 n
Title: Cd
02 (K 2�23
Sign of Applican Date Signed
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 6 of 6

LIMITED LIABILITY COMPANY ANNUAL REPORT
■
1/0022
NAME OF LIMITED LIABILITY COMPANY: POlykemi Manufacturing, LLC
SECRETARY OF STATE ID NUMBER: 2191301 STATE OF FORMATION: IL
REPORT FOR THE CALENDAR YEAR: 2022
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Corporation Service Company
2. SIGNATURE OF THE NEW REGISTERED AGENT:
E- Filed Annual Report
2191301
CA202209808142
4MI2022 05:30
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
2626 Glenwood Ave Ste 550
Raleigh, NC 27608 Wake County
SECTION B: PRINCIPAL OFFICE INFORMATION
2626 Glenwood Ave Ste 550
NC 27608
1. DESCRIPTION OF NATURE OF BUSINESS: Production Of plastic Compounds
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
5. PRINCIPAL OFFICE MAILING ADDRESS
2800 Repi Ct. 70 W. Madison St., Suite 5750
Gastonia, IL 28052 CHICAGO, IL 60602-4292
6. Select one of the following if applicable. (Optional see InstruI ctions)
❑ The company is a veteran -owned small business
❑ The company is a service-disobled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Johan Hugoson NAME: Polykemi Holding, Inc. NAME:
TITLE: Manager TITLE: Member
ADDRESS:
ADDRESS:
2800 Repi Ct. 70 W. Madison St., Suite 5750
Gastonia, NC 28052 CHICAGO, IL 60602-4292
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Johan Hugoson
SIGNATURE
Form most be signed by a Company Official fisted under Section C of This form.
4/8/2022
DATE
Johan Hugoson Manager
Print or Type Name of Company Official Print or Type This of Company Official
This Annual Report has been filed electronically.
MAX TO: Secretary of State. Business Registration Division, Post Office Box 29525. Raleigh. NC 2762&0525