NCG180104_COMPLETE FILE - HISTORICAL_20160815

STORMWATER DIVISION CODING SHEET
NCG PERMITS-.
PERMIT NO.
iv o D
c.�
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ 'AN Lo d�
YYYYM M DD

q0r0-t*IqR
I
miWre�corinpany
August 15, 2016
NCDEQ — Division of Energy, Mineral, and Land Resources
Attn: Stormwater Billing
1612 Mail Service Center
Raleigh, NC 27699-1612
RE: Permit Number NCG180104
Please find enclosed our check for the annual stormwater permit fee.
300 E. Grayson Street
Galax. VA 24333
[phone]
(276) 23 8-811 1 fax
Also enclosed is a copy of the "Permit Owner Affiliation Designation Form", showing a
change in the "legally responsible individual". I included a copy of this form with our check
last year, but records did not get changed. Please see that this is taken care of, as William
Glover is no longer affiliated with our company. Thank you for your help.
Sincerely,
Vaughan -Bassett Furniture Co., Inc.
l�
Barry Branscome
Vice President & Director of Environmental Compliance

ti
r�
NCDENR
al�.
No i.� CFn- Devww E- of
EHVIAOWN�MT — NR - ti[ .C[
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 ONLY
Date Received
Year
Month Day
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:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N :•C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address: Physical
?nailing
(or) Certificate of Coverage
'K 'Y 30 :�•�•
.N tC E G 1 1 8 1 0 1 0 4
Vaughan -Bassett furniture Co. -- Elkin Plant
Vaughan -Bassett Furniture Co., Inc.
501 East Main Street, Elkin, NC
300 East Grayson, Street
Galax VA 24333
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.nedenr.orc/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: William D Glover
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Rodn+
First
M1 Last
Poe
MI Last
Page I of 2
SWU-0WNEPAFF1L-25Ju1y2o14

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Vice President / Plant Manager
Title
300 East Grayson Street
Mailing Address
Galax VA 24333
City State Zip
[phone] [e-mail]
Telephone E-mail Address
[phone]
Fax Number
5) Reason for this change:
A result of: Z Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERT]FICATION:
1, BarryA. Branscome, attest that this application for this change in Owner Affiliation (person Iegally
responsible for the permit) 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.
j2 j
�•�-�- September 25, 2014
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
I612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call 919-707-9220 or visit the website at:
http://portaI.nedenr.oreJweb/ir/stormwater
Page 2 of 2
SWU-OWNERAFFIL-25July2014

Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
WDENRNational Pollutant Discharge Elimination System (NPDI S)
�i�,var.. f1wa_.w� OFPMrrwEwO
Enhwc...rr+.„o N.r�k.,Flesouwces PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
Use this form if there has been:
--FOR AGENCY USE ONLY
Date Received
Year
Monde Day
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 rill 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:
• the responsible corporate officer (fora corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
2) Facility Information:
Facility name:
Company/Owner Organization;
Facility address: Physical
ia;lin
(or) Certificate of Coverage
Vaughan -Bassett Furniture Co. — Elkin Plant
Vaughan -Bassett Furniture Co., Inc.
501 Last Main Street, Elkin, NC
300 f as: Grayson Streci
Galax VA 24333
City State "Lip
To find the current legally responsible person associated with your permit, go to this website:
http://Mortal.ncdenr.grg/(zb/lr/sw-pcnnit-cotttacls and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous le mliv responsible individual: WilliaEn . D Glover
First Mt fast
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Rodnev Poe
First , M1 fast
SM-OWNERAFFIL-25July2414
Page 1 of 2

A.
NPDES Stormwater Permit OWNER AFFII_ATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Vice President / Plant Manajer
Title
300 East Grayson Street
Mailing Address
Galax VA 24333
City State `Lip
_ 276 236-6161 bbranscome;vaughanbassett.com
Telephone E-mail Address
_(276) 236-0385
Fax Number
5) Reason for this change:
® Employee or management change
A result of [] Inappropriate or incorrect designation before
❑ Other
Cf othet- please explain:
The certification below must be completed and signed by the permit holder.
PERM.ITTEE CERTIFICATION:
1, B4r Aj�ranscome, attest that this application for this change in Owner Affiliation (person legally
responsible for the permit) has been reviewed and is accurate and complete to the hest of my knowledge.
understand that if all required parts of this form are not completed, this change may not be processed.
Signature
f
September 25, 2014
Date
PLEASE SEND THE COMPUTED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater 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:
littlt //porta1,ncdemror,Z eb/lr/stor mwater
SWU-OWNERAFFIL-25July2014
Page 2 of 2

W ATF9Q
DWal�
r
March 12, 2008
Mr. Barry A. Branscome
Vaughan -Bassett Furniture Company
300 East Grayson Street
Galax, VA 24333
Subject: General Stormwater Permit Inspection
Vaughan -Bassett Furniture Company
Certificate of Coverage # NCG180104
Surry County
Dear Mr. Branscome:
Michael F. Easley, Governor
wtmarn u. moss ur., :5ecretar
Nonh Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Director
Division of Water Quality
On March 11, 2008, Gary Hudson of this office met with Ros Folger and yourself to
perform a General Stormwater Permit Inspection at the Vaughan -Bassett facility located on
Highway 268 in Elkin. This inspection evaluated the areas designated on the attached
inspection form. Observations from each area are addressed below:
1. Permit
Vaughan -Bassett holds Certificate of Coverage # NCG180104 -for the discharge of
stormwater from the facility. The General Permit became effective September 1, 2004 and
expires August 31, 2009.
2. Records/Reports
Part II, Section A of -the permit requires the development of a Stormwater Pollution
Prevention Plan (SPPP). A copy of the SPPP was available for review. The plan contained
all of the items required by the stormwater permit. Please note that the permit requires the
plan to be reviewed and updated on an annual basis.
3. Facility Site Review
The site appeared clean and well managed. No concerns or problems were noted.
4. Effluent/Receiving Waters
Stormwater runoff from the facility reaches the Yadkin River, Class "C" waters in the
Yadkin/Pee-Dee River Basin.
ore
NhCa:olina
Nalrrrall jl
North Carolina Division of Water' Quality 585 Waughtown Strcet Winston Salem, NC 27107 Phone [phone] Customer Service
Inlemetwww.ncwaierguality.org FAX [phone]
An Equal OpportunitylAtfirmative Action Employer — 50% Recycledli 0% Post Consumer Paper

Mr..Barry.Bransceme—_—
Page #2
March 12, 2008
5. Monitoring Proqram
Part II, Section B of the permit requires that semi-annual qualitative (visual) monitoring be
performed and documented once in the spring (April - June) and once in the fall (September
— November). A review of the facility files found that the qualitative monitoring has been
conducted as required.
The analytical monitoring for on -site vehicle maintenance listed in Section C of the permit is
not required since Vaughan -Bassett uses less than 55 gallons of new motor oil per month
when averaged over the calendar year.
Should you have any questions concerning this letter, please contact Gary Hudson or
me at [phone].
Sincerely,
'Sleve W. Tedder
Water Quality Regional Supervisor
cc: NPS Assistance and Compliance Oversight Unit
Central Files SWP.
WSRO

t,
Compliance Inspection Report
Permit: NCG1801C4 Effective: 09/01/04 Expiration: 08/31/09 Owner: Vaughan Bassett Furniture Co
SOC: Effective: Expiration: Facility: Vaughan Bassett Furniture Co
County: Surry PO Box 230
Region: Winston-Salem
Elkin NC 28621
Contact Person: Wlliam D Glover Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 03111/2008
Primary Inspector: Gary Hudson
Secondary Inspector(s):
Certification: Phone:
Entry Time: 11:00 AM Exit Time: 12:30 P{v1
Phone:
Reason for Inspection: Routine Inspection Type: Stormwater
Permit Inspection Type: Furniture and Fixtures Stormwater Discharge COC
Facility Status: ® Compliant r1 Not Compliant
Question Areas:
® Storm Water
(See attachment summary)
Page: 1

Permit: NCGI80104 Owner - Facility: Vaughan Bassett Furniture Co
Inspection Date: 03I1112008 Inspection Type: Stormwater
Reason for Visit: Routine
Stormwater Pollution Prevention Plan
Yes
No
NA
NE
Does the site have a Stormwater Pollution Prevention Plan?
®
n
n
n
# Does the Plan include a General Location (USGS) map?
®
n
n
n
# Does the Plan include a "Narrative Description of Practices"?
®
n
n
n
# Does the Plan include a detailed site map including outfall locations and drainage areas?
®
In
n
n
# Does the Plan include a list of significant spills occurring during the past 3 years?
®
n
n
n
# Has the facility evaluated feasible alternatives to current practices?
®
n
n
n
# Does the facility provide all necessary secondary containment?
®
n
n
n
# Does the Plan include a t3MP summary?
®
n
n
n
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
®
n
n
n
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
®
n
n
n
# Does the facility provide and document Employee Training?
n
n
n
# Does the Plan include a list of Responsible Party(s)?
®
n
n
# Is the Plan reviewed and updated annually?
n
n
n
# Does the Plan include a Stormwater Facility Inspection Program?
Has the Stormwater Pollution Prevention Plan been implemented?
®n
n
n
Comment:
Qualitative Monitoring
Yes
No
NA
NE
Has the facility conducted its Qualitative Monitoring semi-annually?
®
n
n
In
Comment:
Analytical Monitoring
Yes
No
NA
NE
Has the facility conducted its Analytical monitoring?
n
n
®
n
# Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas?
n
n
n
Comment:
Permit and Outfalls
Yes
No
NA
NE
# Is a copy of the Permit and the Certificate of Coverage available at the site?
®
n
n
n
# Were all outfalis observed during the inspection?
®
n
n
# If the facility has representative outfall status, is it properly documented by the Division?
n
n
®
n
# Has the facility evaluated all illicit (non stormwater) discharges?
®
n
n
n
Comment: .
Page: 3

i% -
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
Kerr T. Stevens, Director
August 27, 1999
1 • •
AWWAft
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RE50URCES
WILLIAM D. GLOVER
VAUGHAN-BASSETT FURNITURE CO. INC. ELKIN FURNITURE CO
P.O. BOX 1549
GALAX. VA 24333
Subject: Reissue - NPDES Stormwater Permit
Vaughan -Bassett Furniture Co. Inc. Elkin Furniture Co
COC Number NCG 180104
Surry County
Dear Permittee:
In response to your renewal application for continued coverage under general permit NCG 180000, the Division of
Water Quality (DWQ) is forwarding herewith the reissued stormwater general permit. This permit is reissued
pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between the state of North Carolina and the U.S. Environmental Protection Agency, dated December 6, 1983.
The following information is included with your permit package:
* A copy of general stormwater permit NCG180000
* A Stormwater Pollution Prevention Plan (SPPP) Certification Form. Completion of this form is required to
certify that you have developed and implemented the SPPP as per the conditions of the permit. This form
must be completed and returned to the Division within 30 days of receipt of this letter.
DO NOT SEND the SPPP with the signed form.
* Five copies of the Analytical Monitoring form and five copies of the Qualitative Monitoring form
* A copy of a Technical Bulletin on the Stormwater program which outlines program components and
addresses frequently asked questions
* A corrected Certificate of Coverage if you indicated a name change on the Renewal Application
Your coverage under this general permit is not transferable except after notice to DWQ. 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 DENR or relieve the permittee from responsibility
for compliance with any other applicable federal, state, or local law rule, standard, ordinance, order, judgment, or
decree.
If you have any questions regarding this permit package please contact Aisha Lau of the Central Office Stormwater
and General Permits Unit at [phone], ext. 578
Sincerely,
for Kerr T. Stevens
Director, Division of Water Quality
cc: Central Files
Winston-Salem Regional Office
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG180000
CERTIFICATE OF COVERAGE No. NCG180104
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,
VAUGHAN-BASSETT FURNITURE CO. INC.
is hereby authorized to discharge stormwater from a facility located at
VAUGHAN-BASSETT FURNITURE CO. INC.
P.O. BOX 230
ELKIN
SURRY COUNTY
to receiving waters designated as the Yadkin River in the Yadkin - Pee Dee River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts 1, 1I, III,
IV, V, and VI of General Permit No. NCGI80000 as attached.
This certificate of coverage shall become effective August 27, 1999,
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day August 27, 1999.
for Kerr T. Steven , Director
Division of Water Quality
By Authority of the Environmental Management Commission

Stat6 of North Carolina
Department of Environment,
Health and Natural'Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
June 9, 1995
Terry Stone
Vaughan Bassett Furniture Co
P.Q. Box 1549
Galax, NC 24333
Subject: General Permit No. NCG180000
Vaughan Bassett Furniture Co
COC NCG180104
Surry County
Dear Terry Stone:
In accordance with your application for discharge permit received on March 30, 1995, 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
December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual permit
application. Unless such demand is made, this certificate of coverage shall be final and binding.
Please take notice that this certificate of coverage is not transferable except after notice to the Division
of Environmental Management. The Division of Environmental Management 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 Environmental Management or 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 question concerning this permit, please contact MS. AISHA LAU at telephone number
919/733-5083.
{s ri3ssnal igned 6y
Sincerely, Goleen H. Sullins
A. Preston Howard, Jr. P.E.
cc: Winston-Salem Regional Office
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
QENERAL PERMIT NO. NCG180000
CERTIFICATE OF COVERAGE No. N G180104
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,
Vaughan -Bassett Furniture Co. Inc.
is hereby authorized to discharge stormwater from a facility located at
Elkin Furniture Company
N.C. Route 268
Elkin
Surry County
to receiving waters designated as the Yadkin River in the Yadkin -Pee Dee River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I,11, III
and IV of General Permit No. NCG180000 as attached.
This Certificate of Coverage shall become effective June 9, 1995.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day June 9, 1995.
m. Sullins
A. Preston Howard, Jr., P.E., Director
Division of Environmental Management
By Authority of the Environmental Management Commission

wT L`, �.: as I4 •=• IKin 11 1
��''•� '�f� • vh �.i `�':11ii h {� ���� •t� �* ti� � 1 ���1 �•� � ��� - a�i'y !1 �.�` } �\
• ~"��•'! .`*0-11; \1���8��:�+�4•' � .�. ail +g5
ti ,-qi• -S M.- =''" P. -Se
_ "� -Sew
��rl_��/t ,i,. J•, '`'` �' •'':1�'� 1`'- °"� �Gagi
I \ • r��c _~99~ !�� /• lg �'I t V' \ �' 9re.. i
'�%i��- /�1L ---, ��: ti •`` ti1••}'1• ; ^S �• ••'�1 T�hCaf '\ i ��(� .%moo
900
�� �� --\1 � �-- ji�� -^ �-;.�1� -_ •� _ \G I' ''{1' �.•• 1 ;�7 .•�.• i��.C�� �--%'�'��`RerMe: '. � � �.,
� �
fp jL' �`41 1�./FeltPfent�--� r• �.�\.J.•} 'l .3 ��•. _�Q��`P f ,• ` ':( r
ram- \�•� �(/ %14:. ,L'`�••. 1����
. �� r '�) r�-1 �,\ ,` - \rJ_ �f` •S✓enl. $II:` � � . •.. ' � l' I `,\ � �O� ! 1 _ \, � -.\\1`!'► --- --
�_ (�^! r � \\ � I r � ��--- �• iVJ • �' • � 7 •I .1 : fl l�: ) r' �� \-1 411 }� � � _ _
/' /' # � r \%�i.— - � (�:' ^' •..+ 'High's `'I I,•l ��� '', •� f l r�_` �• ,, - � , ���1
� r 1 '��f`��\"•i.r.:' �1��' I�Sch ♦ /�: '\�'• 1( �� l�. '`� ���'�� O i� �
- '�_ >/1 1�i:�/•ICeh� J$ I i� 'n'_ � 1 .o -r�;'� ,1: 5 % �' � r� �'," r i35- r
1j. � ti ` �� � � _ . li }} 1• i '1._�" �ii'�LI3�AI1 � ` i� , i
/ -. 54 - ! � i f_\_;��'' r
cr /.. -Greek r� �� �' I
~I �, � '/f - •II .1 ^_�� '�•-- `✓ � I .�-\ � 1,� i l �.w•• \i �Ji o!/i =- r_�l� _ I
-taro'
((f � �r r' r'��- - ��%i� � �' •' i366_lJ �,� ( � � : r � 7 �� I �.r _'. •\: ': jl''.���:{ 1,-- ti - \ I
\.-%;- U �/ - �`-,•~ /II � c - r \\ -_ � Fs i_ i y �� mot. � :�� � �
3 i . ,�1 =._ i t�l / 'Hl i ��iJ�`{ /� l��v, '.., �'•i' `�' '•� �7S station
• '\ - �� -� ���� -� / ' l� � -� rT31k- r 1�, -,f /.�� r': (/ �' ' 2�.� � �-= J � / r4ro.`�
1092
.ice
r1135�?:F I Elkin ;�;� �-- %� `J�.-� `1 �u: `�, /� ` _ _ . II� / } 1�.} � •=��\���/";i�
{r
_ - - �I• -� .'i1w , � , �� ������I� ¢ � � %��_ ���� � � -: ,fir. ` `� ,i�'
-` �_ \ rr '•x �// �Z� - iJj�-/ �� 600 -,>,
_ �� • t� <, �� ill � � _��� ' �" _� �� � rT~ - � � � � _`- ./ ��, , _�+_L, ))1 �

FACILITY
Elkin Furniture Company
COUNTY
Surry
NPDES
NCG180104
MAP#
C 15NE
DSN FLOW
NA
SUB BASIN
03-07-02
LATTITUDE
360 14' 52"
LONGITUDE
800 30' 19"
RECEIVING STREAM
Yadkin River
STREAM CLASS
WSIV CA
DISCHARGE CLASS
Stormwater
EXPIRATION DATE
8/31/99