NCG100247_COMPLETE FILE - HISTORICAL_20190411

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. �VCCoIOda�-I
DOC TYPE 1 ❑ HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ ;��I I 0 �I (i
YYYYM M DD

w
Permit Number ' NCGl00247
Central Files: APS _ SWP
4/11 /2019
Permit Tracking Slip
Program Category
Status Project Type
NPOES SW
Active New Project
Permit Type
Version Permit Classification
Used Motor Vehicle Parts Stormwater Discharge COG
1.00 COG
Primary Reviewer
alaina.morman
Permit Contact Affiliation
RECEIVED.Marty Robbins
Coastal SWRule
President
APR 2019
1815 Harris -Henrietta Rd
CENTRAL FILES Mooresboro NC 28114
Permitted Flow
DWR SECT0,"
Facility
Facility Name
Major/Minor Region
Robbins Auto Parts
Minor Asheville
Location Address
County
1815 Harris -Henrietta Rd
Rutherford
Facility Contact Affiliation
Mooresboro NC 28114
Marty Robbins
President
1815 Harris -Henrietta Rd
Owner
Mooresboro NC 28114
Owner Name
Owner Type
T & M Auto Sales
Non -Government
Owner Affiliation
Marty Robbins
President
1815 Harris -Henrietta Rd
Dates/Events
Mooresboro NC L 28114
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
419/2019 11/2912018 4/912019 4/912019 5131 /2021
Regulated Activities Requested (Received Events
Dismantling automobiles for scrap RO staff report received 2/7/19
RO staff report requested 12/18/18
Outtall 001
Waterbody Name Streamindex Number Current Class Subbasin
Second Broad River 9-41-(21.5) WS-IV 03-08-02

,i
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
lnrerim Alrecror
Mr. Marty Robbins
President "I"&M Auto Sales
1815 Harris -Henrietta Road
Mooresboro, NC 28114
Dear Mr. Robbins:
NORTH CAROLINA
Environmental Quality
April 9, 2019
Subject:
General Permit No. NCG 100000
Robbins Auto Parts
COC No. NCG100247
Rutherford County
In accordance with your application for a discharge permit received on November 29, 2018, 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 October 15, 2007 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except upon approval of the Division
of Energy, Mineral and Land Resources (Division). The Division 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 Resources, the Coastal Area Management Act, or any other federal or local
government permit that may be required.
If you have any questions concerning this permit, please contact Shane Strickland at telephone number
[phone] or by email shane.strickland ct,ncdenr.gau.
Sincerely,
for S. Danie ith, interim ctor
Division of Energy, Mineral and Land Resources
cc: Asheville Regional Office / Isaiah Reed
Stormwater Program Files
Central Files
D_E Q�� North Carolina Department of Environmental Quality 11]ivislon of Energy, Mineral and Land Resources
512 North Salisbury Street 1 1612 Mall Service Center I Raleigh. North Carolina 27699-1612
9 91N /"� 919.707.9200

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCGl00000
CERTIFICATE OF COVERAGE No. NCGIO0247
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,
T&M Auto Sales
is hereby authorized to discharge stormwater from a facility located at
Robbins Auto Parts
1815 Harris -Henrietta Road
Moorseboro
Rutherford County
to receiving waters designated as Second Broad River, class WS-IV waters in the Broad
River Basin, in accordance with the effluent limitations, monitoring requirements, and
other conditions set forth in Parts 1, II, III, and IV of General Permit No. NCG100000 as
attached.
This certificate of coverage shall become effective April 9, 2019.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this 91h day of April Ml q
for,S. Daniel Smith
Interim Director, Division of Energy, Mineral and Land Resources
By the Authority of the Environmental Management Commission

3/612D19
Permit Facility Location Map
Search location or permit numt Q Q
-81.804 35.264 Degrees
0.2mi
https://nr-denr.maps.arcgis.com/appstwebappviewer/index.html?id=3r-da38498aa344d3a9O5aO437bc2al47 1I1

Reed, Isaiah L
From: Reed, Isaiah L
Sent: Monday, February 11, 2019 2:30 PM
To: McCoy, Suzanne
Subject: NCG100247
I visited the T&M Auto Sales (NCG100247) Facility in Rutherford County on February 7, 2019.1 recommend coverage be
granted to the facility as proposed in the NOI.
Jr1rtM {"./1 Rrll llJA
eVnens nt Enwonnx,nlal OuaSlly
Isaiah L. Reed, BSe.11S.ICEC1. CEPSCI
F.n►•ironmenial Specialist
Division of Eneroc. Mineral and land Resources
North Carolina Ueparinieul of En►•irounienlal QuAl►•
land Qualile Sectial. Asheville Be=iowil Office
Phone: [phone] Email: 2090 US Rwy 70, Swannanoa, North Carolina 28778
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

_\ . ^.
Division of Energy, Mineral and Land Resources
Land Quality Section
National Pollutant Discharge Elimination System
Environmental NCG 100000
Quality
NOTICE OF INTENT
I FOP, AGENCY USE ONLY
Date Received
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG100000: REC171V ED
STORMWATER DISCHARGES associated with activities classified as: t
SIC (Standard Industrial Classification) 5015 Used Motor Vehicle Parts NOV 29 2013
SIC 5093 Automobile Wrecking for Scrap, (except as specified below) DENR-LAND QUALITY
The following activities are specifically excluded from coverage under this General PiTRAN.`WVATER HWITTING
• Establishments primarily engaged in the wholesale trade of metal waste and scrap, iron and steel scrap, and
nonferrous metal scrap (hereafter referred to as the metal waste recycling industry)
For questions, please contact the DEMLR Regional Office for your area. See page 4.
(Please print or type)
1) Mailing address of owner/operator (address to which all permit correspondence will be mailed}:
Name T&MAuto sales
Street Address 1315 Harris -Henrietta Road
City Mooresboro State NC ZIP Code 28114
Telephone No. [phone] Fax: [phone]
2) Location of facility producing discharge:
Facility Namo
Facility Contact
Street Address
City
County
Telephone No.
Email
Robbins Auto Parts
Marty Robbins
1815 Harris -Henrietta Road
Morresboro State NC ZIP Code 28114
Rutherford County
[phone] Fax: [phone]
[e-mail]
3) Physical Location Information:
Please provide a narrative description of Flow to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). Facility is located approximately 0.3miles east
of the intersection of Ferry Road and Harris-Hennrietta Road (FM 2125)
(A copy of a county map or i1SGS quad sheet with facility clearly located must be submitted with this application.)
4) Latitude 35.1502.1'N Longitude 81.48'06-8'w (deg, min, sec)
5) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility
N Existing
Date operation is to begin
S W i1-226-071408
Page 1 of 4
Last revised 6124M 4

NCG100000 N.O.I.
6) Standard Industrial Classification:
Provide the 4-digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 5 0 1 5
T) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: Facility has industrial operations and processes pertaining to the dismantling of End of Life Vehicles for the sale of used parts
6) Discharge points I Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? one
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? Unnamed Tributary to Second 9road River
Receiving water classification: vvs-iv
Is this a 303(d) listed stream? No Has a TMDL been approved for this watershed? No
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer). NIA
List discharge points (outfalls) that convey discharge from the site (both on -site and off -site) and location
coordinates. Attach additional sheets if necessary, or note that this information is specified on the site plan.
Stormwater Outfall No. 001
Latitude (degrees/minutes/seconds): 30'15'11.02"
N
Longitude (degrees/minutes/seconds): 81°49'8.98"
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degreestminutestseconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degreeslminutes/seconds):
N
Longitude (degrees/minutestseconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutestseconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Page 2 of 4
SWU-225-071408 Last revised 6124/14

NCG900000 N.Q.I.
9) Does this facility have any other NPDES permits?
9 No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
10) Does this facility have any Non -Discharge permits (ex: recycle permit)?
4 No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
11) Does this facility employ any best management practices for stormwater control?
❑ No
Yes (Show structural BMPs on the site diagram.)
If yes, please briefly describe: Ditch which directs water to outfall; culverts; catch basins to direct surface water run off to ditch
which Rows to outfall
12) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
R Yes
If yes, when was it implemented? 11/151201B
13) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
I No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
11 No ❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
® No ❑ Yes
d) Is hazardous waste stored in the 100-year flood plain?
11 No ❑ Yes If yes, include information to demonstrate protection from flooding.
e) 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:
Page 3 of 4
SWU-225-071408 Lost revised 6/24114

NCGI OOOUQ N.O.I.
14) Certification:
North Carolina General Statute 143-215.6B(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 rutemaking proceeding or contested case under this Article; or
who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under this Article or rules of the Commission ImptemenUng this Article shall be guilty of a Class
2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit
wili constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual perrnil.
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 of Pers Signing: ^ 1 + Q ,(� `/ �b i N 5
Title: QT%S j n N�
(Signature of
_!!_L1 �
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to-
NCDEQ
RECEIVED
DENR-LAND QUALITY
STORMNATER PERMIT T .rhC
Page 4 of 4
SWU-225-071408 Last revised 6/24/14

NCGl00000 N.O.I.
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
❑ Check for $100 made payable to NCDEQ
❑ This completed application and all supporting documents
❑ A site diagram showing, at a minimum, (existing or proposed):
(a) outline of drainage areas, (b) stormwater management structures, (c) location of stormwater outfalls
corresponding to the drainage areas, (d) runoff conveyance features, (e) areas where materials are stored,
(f) impervious areas, (g) site property lines.
❑ Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The Submission of this document does not guarantee coverage under the NPDES General Permit.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office
... [phone]
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
Page 5 of 4
SWU-225-071408 Last revised 6124114

LEGEND
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AREA
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VEGETATED
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OUTFALL DO1
SAMPLE POINT
SIC CODE 501S I SOY!
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LONG: di-43 a %A'W
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t NaNEa s _
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James Environmental k
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600 Round Rock West Drive. Salts 201
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SITE PLAN N.T.S. 20268
ROBBINS AUTO PARTS JWC FIG 2
MOORESBORO, NORTH CAROLINA 11116

., SECOND
• "" BROAD RIVER' �• Z- ` C • '•�
oil
+ 4 r
UNNAMED ,� f l��� \ , •:*
TRIBUTARY TO "*, •�,, .i iz 3 ! ;� .•
•� -.�=- ems— —,^...---_ ' ;
SECOND BROAD RIVER � • � . i , • , ---��, •' . ,. fJ � + - � t�
1
• •• •�1 ;. .�;�.i "�^ � ••f .n+�". .�`�1I • .Yr,.a. �Met
C• ./.� �"! 'Y;� t; f,�/• 'sue'•:
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• r �., ,
�� -.• ROBBINs ' . � :�. ' �' A lis" AUTO PARTS:
F�, _ - =fity ''�'"�•- ~ �� �! -�!` ' ' �1 ` �' � � �� � � � � { � � �'- � rr��+
/ft�n iz Fi`ar1 t _ a rt� f 4ioaGi • 00;: ' i E
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•• T 1 r 1 •• u Z E � ! ,, j r"ti, ! i �\ � ,--'Siiij 1"�"'a��'' l , � �-•- �� ; •--�.
SITE LOCATION MAP 20268
James USGS Topographic Map FIGURE 1
Environmental
Management, Inc. DATE 11/18
JWC
Round Rock, TX ROBBINS AUTO PARTS
SCALE: 1 "=2000'
MOORESBORO, NORTH CAROLINA

November 19, 2018
Mr. Stanley E. Aiken, PE
Regional Engineer, Land Quality Section
North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources (DMELR)
Asheville Regional Office
2090 U.S. Highway
Swannanoa, North Carolina 28778
Re: Notice of Violation (NOV-2018-PC-0400)
Site Number: WT002590
T&M Auto Sales facility
Rutherford County
Dear Mr. Aiken,
James Environmental
management, inc.
Received
NOV 2 6 2018
Land Quality Section
Asheville
On behalf of T & M Auto Sales dba Robbins Auto Parts, James Environmental Management, Inc.,
(JEM), has prepared the following response to the Notice of Violation issued by the NC
Department of Environmental Quality — Division of Energy Mineral, and Land Resources
(DEM LR) for the site visit and file review conducted by Mr. Isaiah Reed of the Asheville Regional
Office on October 18, 2018. Please note inspector OBSERVATIONS and
RECOMMENDATIONS below in bold and our subsequent Responses in italics.
1.) OBSERVATION:
An NPDES Permit is required to discharge stormwater to waters of the state in accordance
with G.S. 143-215.](a) and Title 15A North Carolina Administrative Code (hereby known
as NCAC) 2H .0126. Enclosed with the inspection report is a copy of the Notice of Intent
(NOI) that shall be filled out and submitted to the Department of Environmental Quality
within 30 calendar days of receipt of this Notice. Submission information can be found in
the NO1.
Response: T & MAuto Sales dba Robbins Auto Parts and James Environmental Management
have been working together to develop a Stormwater Pollution Prevention Plan (SPPP) on site.
The facility has implemented the Plan and appropriate BMPs to prevent contaminants from
entering surface waters via stormwater. This implementation includes documentation of all
monitoring, measurements, inspections, maintenance activities, and training provided to
employees, included the log of the sampling data and of actions taken to implement BMPs
associated with the industrial activities, including vehicle maintenance activities. As of the date
of this response, the facility has submitted a Notice of Intent to the Department in order to obtain
coverage under the NPDES General Permit No. NCGI00000 for stormwater discharges from the
site.
600 Round Rock West Drive, Suite 201 • Round Rock, Texas 78681 • [phone] • Fax: [phone]

Page 2
1875 Harris -Henrietta Road
11/19/2018
We appreciate the opportunity to prepare this response for the Department. Should you have any
questions or request additional information, please feel free to contact the James Environmental
Management office.
Sincerely,
Michael James
President/GEO
James Environmental Management
[e-mail]
cc: Marty Robbins, T & M. Auto Sales dba Robbins Auto Parts
cc. Isaiah Reed, DEMLR — Ashville Regional Office

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r3 $VeeiarMApL No., i Ancozion Mari} Robbins
r - 1875 I lar, is -I lenriclla Road
City. Sta3e, ZiP+4� Ht!ortctij \0,—'Jj Carolina . 8076
Postme�O
Here

■ Complete items 1, 2, and 3.
s Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the malipiece,
or on the front if space permits.
Article Addressed to:
T k na Auto sales
Attention Mary RUilbinS
F 1875 Harris -Henrietta head
llenri,ma North Camlina -'%76
© Agent
C. Date of Deli
D. Is delivery address different from Item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
Nov 1 2W
Land Quality Section
3. Service Type
13 Priority
Adult
Restricted Delivery
keifed
�nature
0 Registered Mag Restiided
9590 9402 1846 6104 5500 99
a cemfw Ma FleswW D&Ary
W Raceipt for
❑ collect on Delivery
Merchandise
2. Article Number (Transfer from service label)
❑ Cotlect on Delivery Restricted Delivery
CI Insured Mail
❑ Signature Confirmation'"'
❑ Signature Confirmation
1 7016 13 7 Q b❑ b 1 6 5 71 6 313
7 S M Restrktea Delivery
Restricted Delivery
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First -Class Mail
Postage&.Fees Paid
� LISPS
Permit No. G-10
9590 9402 1846 6104 5500 99
United Stags
Postal Service
Please print your name, address, and ZIP+40 in this box•
\(_ Dept. nI E VIWIU111131 Quality
t:nem. mineral and Lund HrwnrLYs
{�{ r Land Quality' Seciinn
Asheville RegWmal Office
2IP99 U1 70lli-�h�Na}
ti.cannanua. \'C ZK778-8211
Site Npmber; W1002591f
II,I11t11E111-1111111,11Id111t11111t1j11„W) 1111111'0111llt

ROY COOPER NORTH CAROLINA
Governor Environmental quality
MICHAEL S. REGAN
Secretary
WILLIAM E. (TOBY) VINSON, JR.
interim Director
October 25, 2018
CERTIFIED MAIL: 7016 1370 0001 6571 6313
RETURN RECEIPT REOUESTED
T&M Auto Sales
Attention: Marty Robbins
1875 Harris -Henrietta Road
Henrietta, North Carolina 28076
Subject: NOTICE OF VIOLATION (NOV-2018-PC-0400)
Site Number: WT002590
T&M Auto Sales facility
Rutherford County
Dear Mr. Robbins:
On October 18, 2018, Isaiah Reed from the Asheville Regional Office of the Division of Energy, Mineral
and Land Resources (DEMLR), visited the subject site located at 1875 Harris -Henrietta Road in
Henrietta, Rutherford County, North Carolina. The site visit and file review revealed that T&M Auto
Sales has neither applied for, nor obtained coverage under, an NPDES General Permit No. NCG 100000
(Used Motor Vehicle Parts and Automobile Wrecking for Scrap) for stormwater discharges from the site.
The site currently discharges stormwater affected by processes on site to an unnamed tributary of the
Second Broad River (WS-IV).
An NPDES permit is required to discharge stormwater to waters of the state in accordance with G.S. 143-
215.1(a) and Title 15A North Carolina Administrative Code (hereby known as NCAC) 2H .0126.
Enclosed with the inspection report is a copy of Notice of Intent (NOI) that shall be filled out and
submitted to the Department of Environmental Quality within 30 calendar days of receipt of this Notice.
Submission information can be found in the NOI.
Thank you for your attention to this matter. This office requires that the violations, as detailed above,
be properly resolved. These violations and any future violations are subject to a civil penalty
assessment of up to $25,000 per day for each violation. Your efforts to undertake activities to bring the
subject site into compliance are not an admission, rather they are actions that must be taken in order to
begin to resolve ongoing environmental issues. The timeliness with which you submit an NOI, the degree
and extent of harm to the environment, and the duration and gravity of the violation(s) will be considered
in any civil penalty assessment process that may occur. Should you have any questions regarding these
matters, please contact Isaiah Reed or myself at [phone].
North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
Asheville Regional Office 1 2090 U.S. Highway 70 1 Swannanoa, North Carolina 28778
828.296.4500

Sincerely,
Stanley E. Aik,61, PEoA
Regional Engineer
Land Quality Section
Enclosure:
Notice -of -Intent— - ---- — -- - - --
Inspection Report
ec: Alaina Morman, Environmental Specialist [e-mail]
Stanley E. Aiken- Regional Engineer [e-mail]
u�prn�ml[ o, rm+r�nm� o-miry�
North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
Asheville Regional Office 12090 U.S. Highway 70 1 Swannanoa, North Carolina 28776
$28.296,4500

FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate ofCovera e
N G 1 I 0
Check #
Amount
Permit Assigned to
NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG100000:
STORMWATER DISCHARGES associated with activities classified as:
SIC (Standard Industrial Classification) 5015 Used Motor Vehicle Parts
SIC 5093 Automobile Wrecking for Scrap, (except as specified below)
The following activities are specifically excluded from coverage under this General Permit:
• Establishments primarily engaged in the wholesale trade of metal waste and scrap, iron and steel scrap, and
nonferrous metal scrap (hereafter referred to as the metal waste recycling industry)
For questions, please contact the DEMLR Regional Office for your area. See page 4.
(Please print or type)
1) Mailing address of ownerloperator (address to which all permit correspondence will be mailed):
Name
Street Address
C ify
Telephone No.
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
Email
3) Physical Location Information:
State ZIP Code
Fax:
State ZIP Code
Fax:
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).
(A copy of a county map or USGS quad sheet with facility clearly located must be submitted with this application.)
4) Latitude Longitude (deg, min, sec)
5) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility
❑ Existing
Date operation is to begin
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6) Standard Industrial Classification:
Provide the 4-digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code:
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility:
8) 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 of water (creek, stream, river, lake, etc.) that the facility Stormwater
discharges end up in?
Receiving water classification:
Is this a 303(d) listed stream? Has a TMOL been approved for this watershed?
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer).
List discharge points (outfalls) that convey discharge from the site (both, on -site and off -site) and location
coordinates. Attach additional sheets if necessary, or note that this information is specified on the site plan.
Stormwater Outfall No
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds)-
W
Stormwater Outfall No.
Latitude (degreesfminutesfseconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds):
N
Longitude (degrees/minutes/seconds):
W
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NCG1O000O N.Q.I.
9) Does this facility have any other NPDES permits?
❑ No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
10) Does this facility have any Non -Discharge permits (ex: recycle permit)?
❑ No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
11) Does this facility employ any best management practices for stormwater control?
❑ No
❑ Yes (Show structural BMPs on the site diagram.)
If yes, please briefly describe:
12) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
❑ Yes
If yes, when was it implemented?
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
hazardous waste?
❑ No ❑ Yes
C) Ic this facility a Large Ouentity Generator M 000 ka, or more of hazardous waste aenerated per month) of
hazardous waste?
❑ No ❑ Yes
d) Is hazardous waste stored in the 100-year flood plain?
❑ No ❑ Yes If yes, include information to demonstrate protection from flooding.
e) 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 1 disposal vendor:
Vendor address:
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NCGI00000 N.Q.I.
14) Certification:
North Carolina General Statute 143-215.613(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 monitoring device or method required to be
operated or maintained under this Article or rules,of the Commission implementing this Article shall be guilty of a Class
�2 misdemeanor which may include a fine not t eexceed ten thousand dollars ($10,000).
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 of Person Signing:
Title:
(Signature of Applicant)
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDEQ
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NCG100000 N.O.I.
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
❑ Check for $100 made payable to NCDEQ
❑ This completed application and all supporting documents
❑ A site diagram showing, at a minimum, (existing or proposed):
(a) outline of drainage areas, (b) stormwater management structures, (c) location of stormwater outfalls
corresponding to the drainage areas, (d) runoff conveyance features, (e) areas where materials are stored,
(f) impervious areas, (g) site property lines.
❑ Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee coverage under the NPDES General Permit.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office ._.... [phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleiah Office ........
(9191791A200
Washington Office .__(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........
[phone]
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