NCGNE0973_COMPLETE FILE - HISTORICAL_20131031

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. IV CiGNC—Unj9 3
DOC TYPE 19/HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ ao� i U 3
YYYYMMDD

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM Pat McCrory, Governor
Director John E. Skvarla, ill, Secretary
October 31, 2013
Brad Jones
Jacobson Companies
3811 Dixon Street
Des Moines, IA 50313
Subject: No Exposure Certification NCGNE0973
Jacobson Companies
Guilford County
Dear Mr. Jones:
The Division has reviewed your submittal of the application for No Exposure Certification requesting exclusion from
NPDES stormwater permitting for the Jacobson Companies facility located at 6550 Judge Adams Street in Whitsett, NC.
Based on your submittal of a signed certification of no exposure and on the site visit conducted by Aana Taylor-Smith on
October 31, 2013, the Division is granting conditional exclusion from permitting as provided for under 40 CFR 122.26(g),
which is incorporated by reference in North Carolina regulations.
Please note that by our acceptance of your No Exposure Certification, Jacobson Companies is obligated to maintain no
exposure conditions at this facility. If conditions change such that the facility no longer qualifies for no exposure exclusion,
you are obligated to immediately obtain NPDES permit coverage for any stormwater discharge. Otherwise; the discharge
becomes subject to enforcement as unpermitted discharge.
Jacobson Companies must recertify the no exposure status annually using the included form. Any"yes" answer would
require that you obtain NPDES permit coverage for stormwater discharge from the facility. The annual self-
recertification form does not need to be submitted to DEMLR, unless requested. Please note that this conditional
exclusion from permitting does not affect your facility's legal requirements to obtain environmental permits that may be
required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Aana Taylor-Smith or me at(336) 771-5000.
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosures:
1. Annual Self-Recertification Form
CC: Stormwater Permitting Unit— No Exposure Files
Central Files- DWR
WSRO Files—Land Quality
Winston-Salem Regional Office
'585 Waughtown Street, Winston-Salem, NC 27107 . Phone: [phone] FAX: [phone]

Compliance Inspection Report
Permit: NCGNE0973 Effective: Expiration: Owner: Jacobson Companies
SOC: Effective: Expiration: Facility: Jacobson Companies
County: Guilford 6550 Judge Adams Rd
Region: Winston-Salem
Whitsett NC 27377
Contact Person: Ron Eversole Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 10/31/2013 Entry Time: 09:00 AM Exit Time: 09:30 AM
Primary Inspector: Aana Taylor-Smith Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ■ Compliant Q Not Compliant
Question Areas:
Miscellaneous Questions 0 Misc
(See attachment summary)
Page: 1

Permit: NCGNE0973 Owner-Facility: Jacobson Companies
Inspection Date: 1 D13112013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
OK to issue No Exposure Certification.
Misc Yes No NA NE
Is the facility compliant? ■ ❑ Q
Comment: OK to issue No Exposure Certification.
Page: 2

W-5 Ro
FOR AGENCY USE ONLY IP& Date Received
Division of Water Quality / Surface Water Protection Year Mundy I Day
NCDENR National Pollutant Discharge Elimination System Certificate of Coverage
Nain�c.RouR. PAR7�E %EI'!T OF NO EXPOSURE CERTIFICATION for Exclusion N N E O ry a
ENVIROMME PJIf)Na Re9 RCE9 T'V
NCGNE0000 NR
o� �np t3
NO EXPOSURE CERTIFICATIONmNational Pollutant Discharge Elimination System application for exclusion from_ aPermit.based
on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notification that your facility does not require a
permit for stormwater discharges associated with industrial activity in the State of North Carolina because
it qualifies for a no exposure exclusion. A condition of no exposure at an industrial facility means all
industrial materials and activities are protected by a storm resistant shelter(with some exceptions) to
prevent exposure to rain, snow, snowmelt, and/or runoff.
For permitted facilities in North Carolina, DWQ must approve your application for No
Exposure Certification before this exclusion is effective. Until you are issued a No
Exposure Certification and your NPDES permit is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products.
Material handling activities include the storage, loading and unloading, transportation, or conveyance of
any raw material, intermediate product, final product or waste product. A storm resistant shelter is not
required for the following industrial materials and activities: drums, barrels, tanks, and similar containers
that are tightly sealed,provided those containers are not deteriorated and do not leak. "Sealed"means
banded or otherwise secured and with locked or non-operational taps or valves; adequately maintained
vehicles used in material handling;and final products, other than products that would be mobilized in
stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In
addition, the exclusion from NPDES permitting is available on a facility-wide basis only—not for individual
outfalls. If any industrial activities or materials are, or will be, exposed to precipitation, the facility is not
eligible for the no exposure exclusion. By signing and submitting this No Exposure Certification form, you
certify that a condition of no exposure exists at this facility or site and are obligated to comply with the
terms and conditions of 40 CFR 922.26(g).
You are required to self re-certify your No.Exposure Exclusion annually.
For questions, please contact the DWQ Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of ownerloperator(address to which all certification correspondence will be mailed):
Name Jacobson Companies
Contact Brad Jones
Street Address 3811 Dixon St
City Des Moines State IA ZIP Code 50313
Telephone No. 515-265-6171 Fax: /)Z�_ ­
Email [e-mail]
ocr �
Page 1 of 7 D 1 0 2013
SWU-NE-12Aug2010 finch

r
NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name Jacobson Companies
Facility Contact Ron Eversole
Facility Street Address 6550 Judge Adams Rd
City Whitsett State NC ZIP Code 27377
County Guilford
Telephone No. 614-800-2417 Fax:
Email [e-mail]
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). 1-40185 exit 135 travel south 1.1 miles on Rock Creek
Dairy Rd, turn left onto Judge Adams Rd and travel east for 0.7 miles to the building's entrance.
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands? ❑ Yes X No
5) Is this a Federal facility? ED Yes X No "
6) Latitude 36N 3'4.65278" Longitude -79W 35' 16.47744" (deg., min.,seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
X Existing Date operation began 4/15/13
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes X No
If yes, what is the NPDES. Permit Number?
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 4225
10) Provide a brief description of the types of industrial activities and products produced at this facility:
Warehousing (no production) N t,3 yy\cA kit A kf LhA r i Ins - tnIa ygan F-)LACn K1_
Gtj? !�:eryiL.e d r�—Li-P
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
X No
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
Page 2 of 7
SWU-NE-12Aug2010

i
NCGNE0000 No Exposure Certification
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future?,(Please check either"Yes" or"No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes X No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes X No
c. Materials or products from past industrial activity ❑ Yes X No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes X No
e. Materials or products during loading/unloading or transporting activities ❑ Yes X No
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes X No
use [e.g., new cars)where exposure to stormwater does not result in the discharge
of pollutants)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, ❑ Yes X No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes X No
the discharger
i. Waste material (except waste in covered, non-leaking containers (e.g., dumpsters]) 11 Yes X No
j. Application or disposal of process wastewater(unless otherwise permitted) ❑ Yes X No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes X No
otherwise regulated (Le., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑ Yes X No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes X No
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer"No" to any of the following items, you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or p Yes ❑ No X N/A
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No X NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
5WU-NE-12Aug2010

s
NCGNE0000 No Exposure Certification
14) Secondary Containment: If you answer"No" to any of the following items, you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for all single above ground storage ❑ Yes ❑ No X NIA
containers (including drums, barrels, etc.)with a capacity of more than 660-
gallons?
b. Is secondary containment provided for above ground storage containers stored ❑ Yes ❑ No X NIA
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund ❑ Yes ❑ No X NIA
Amendments and Reauthorization Act (SARA) water priority chemicals*?
d. Is secondary containment provided for hazardous substances" designated in 40 ❑ Yes ❑ No X NIA
CFR §116?
e. Are release valves on all secondary containment structures locked? ❑ Yes ❑ No X NIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? I-] Yes X No
b. Is this facility a Small Quantity Generator (less than 1000 kg, of hazardous waste ❑ Yes X No
generated per month) of hazardous waste?
c. is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste ❑ Yes X No
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored.-
Where is material stored:
How many disposal shipments per year:
Name of transport/disposal vendor:
Vendor address:
Footnotes to Questions 14) c. &d.
*Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFR
§372.38.
*"Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances fisted in 40 CFR §117.3,
Rage 4 of 7
SWU-NE-12Aug2010

NCGNE0000 No Exposure Certification
16) 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.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes X No
b. Does your facility have coal piles on site? © Yes X No
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes X No
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., ❑ Yes X No
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No X NIA
Please specify:
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
SWU-NE-12Aug2010

NCGNE0000 No Exposure Certification
17) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of"no
exposure"and obtaining an exclusion from NPDES stormwater permitting.
certify under penalty of law that 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)).
understand that I am obligated to annually self re-certify No Exposure and, if requested, submit the re-certification to
DWQ or 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 Water Quality, or MS4 operator where the
discharge is into the local MS4, to perform inspections to confirm the condition of no exposure and to make such
inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater from the facility.Additionally, 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 gathered and evaluated 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. 1 am aware
that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
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. /�
e Printed Name of Person Signing: (,f'! I I`� J/te l
Title:
�Z 411 1741,PC r1' tf IPr'sk MA.�A4eI'
(Signature of Applicant) (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at anytime in the future for compliance with the No Exposure Exclusion.
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 mobitoring 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).
There is currently no fee for a No Exposure Exclusion.
Page 6 of 7
SWt1-NE-12Aug2010

NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
X This completed application and all supporting documentation.
X A map with the location of the facility clearly marked.
X If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
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 a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office [phone] is arm
Fayetteville Office ... [phone]P.
at
Mooresville Office ... [phone] �
Raleigh Office ........ [phone] -
�.. a '"'lEis r le
Washington Office ...[phone]
Wilmington Office ... [phone]
Winston-Salem ...... [phone] crilla
Central Office .........[phone]
, W ''r►eson
Page 7 of 7
SVVU-NE-12Aug2010

1\A.'X %_ACCA LJ.all)' i_L !V _tjLjgt; 1AUMIlb 1\U — \JUUViG 1VIUPN
Directions to Judge Adams Rd Goo(71E'! 1.8 mi -about 4 mins
F'M Pp
s wx rJ�C Wtl
sh
. ...a - g, •p S: S�r� h�0[ '?- ' �t�`5 �. - ox+}+ - a aa�,�y V� ">
' S 'rR4
�' f ` • ,�a v�^F". �_y�y....uw �+�w 'ta , 'P`h M �.f ✓al 4 �t�,.- iit ]l
� aAk. _
"�i•R R - .� *. Fi' . � d-,� eri"M.�'lla. xv, �
� - u -x .gip;(z► -.�
7sy.t; hF t,. f of � r 1P� cv a � V z
'�
3»'L
' �j.t-,BSc � rdk3 ��'4"��3�'�•1�'�s F �wm " f `�v ,�++, 1 ,��
,r,�, i u� 1ty q h u
S f L 3k ° s
a c va4v k a s n v --5Lft
4i G Wk.
"IR �� '� �t1 5 r .a ,} # }•,t emu'!#�' '�t,j`i �."
2 , a 'Tr, rl
-
8'1�„� --
'� i+'• ,� � 't'� tr��y"��'�'�� � St'^� s�-�t"�r`"'� a 34`u�� ;,3y; .�P 61
r'r"r.::'"5`" tj5 „� �1 .a 3G.a+• P °s. .¢y-.�.,�'� .' Y `1aym^3� !^a�3 a r 7
� r ' �� ir,• .q� � � s� '�' YET 4
�47aka y }3' �
s ?= a - v�fsa
' e'�
� �� are �7 M'�i
Ole +`y �, a._•� ' �ai.r- t its,. r ,
-nYx ,a r•�r r h. ,,, •x s mr x'i-� r K' ti.r 1 �
ti
,"."-�s� r
r�Z,.�f_ r r' a a� s. 1' -
$:- #ki
a 7 i 3 r s,. c ' "'v '
y� � w !
lU-7
pptl r_ra
y�F ,:,sy�4. ,} ?v.. s
cVf
F
fi'e F{-'�e•�`S '' �: [Y�flw� � .} 3 '�`� ✓ .,,fi 'E +c•�wF 5.�7 �h �',`�
9 f ,xlr
.m •F `Q. - 4•'v ,rr .�:a stif{ t;-i: F`y-.v�9Y3 �hi § r"�' ems- .,M�.'3 a -�"'�' .
- #r4'�kzr •��- M rn x"an.zs''` z^�.' < �v.tx'Iar
SA ' `(r-
Key' W
fir` a}'+�i"�'�I' �i ," ai3 y�,.ITn -
°i .._n;> f +E-`- � �a-.s C � '�ram .# - 4;x '�' �`�" ��� Yx� ",�
14
4+,- b •�'%-^iL 4 -� � +� ,3r'�x 1`��, •' R ` 4x x��• r d°.7y�, -'rSS.k k.a
M"�'•L '. � 't ctF n
eOt� h"4f yr h wfi pap wq § °�>"„
�.' �•v� P � rb a6' vS.-'�¢ qt v^� & �'�q x
3: y
, ... •�'��T 'r , '. " � y,:•' .��e.' iti�-.. �-`tY }�tu ,p g .'. :r 4s. ?+r `t k'e �'
� � a �: i b�'•+`E! w 7 ». _
-
,.Tra'-zFyy,,c � .fig �.'r ,. hw f� •sT'�"',zea f $"'^ }},, F d :�.+d>y�` - ,c�:-
�� Google�-
Rock Creek Dairy.Rd to Judge Adams Rd - Google Maps
Rock Creek Dairy Rd .
1. Head southeast on Rock Creek Dairy Rd toward Millstream Rd go 1.1 mi
About 2 mins total 1.1 mi
2 :,Turn�let onto�Judge Adams'Rd •s j�k ,+��„K: i y 21i� YX to ,y.
r� E .� K4W. ^ xnt.,�>64 -, 3 � ; y+ 's �r ' _� �+ �SQ 7w m
:,t AboutY2 m>tiins w a__ �. A = totall Strtili
,fudge Adams Rd