NCG200514_COMPLETE FILE - HISTORICAL_20170601

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V C& a061LI
DOC TYPE
�, HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ � b� � n (�-„� I
YYYYMMDD

Energy, Min era! &
Land Resources
ENVIRONMENTAL OUALITV
June 1, 2017
Wei Zhao
B1ueSky Solutions, LLC
631 Winterlochen Road
Garner, NC 27603
ROY COOPER
Governor
MICHAEL S. REGAN
secretary
TRACY DAVIS
Director
Subject: NPDES Stormwater Permit NCG200514
BlueSky Solutions, LLC
Formerly Greenteknology Electronics
Recycling Solutions, LLC
Randolph County
Dear Wei Zhao,
Division personnel received your request to revise your stormwater permit Certificate of
Coverage to accurately reflect your new company and/or facility name.
Please find enclosed the revised Certificate of Coverage. The terms and conditions contained
in the General Permit remain unchanged and in full effect. This revised Certificate of
Coverage is issued under the requirements of North Carolina General Statutes 143-215.1 and
the Memorandum of Agreement between North Carolina and the U.S. Environmental
Protection Agency.
If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
Original Signed by
Richard L. Riddle, Jr.
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land
Resources
cc: Mooresville Regional Office
Stormwater Permitting Program Files
Central Files
Nothing Compares,
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
512 N. Salisbury Street 11b12 Mail Service Center I Raleigh, North Carolina 27b99-lb1Z
919 707 9200

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG200000
CERTIFICATE OF COVERAGE No. NCG200514
STORM WATER 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,
BlueSky Solutions, LLC
is hereby authorized to discharge stormwater from a facility located at:
BlueSky Solutions, LLC
5019 Hovis Road, Suite G
Charlotte
Mecklenburg County
to receiving waters designated as Stewart Creek, a class C water in the Catawba River Basin; in
accordance with the effluent limitations, monitoring requirements, and other conditions set forth
in Parts I, I1, III, and 1V of General Permit No. NCG200000 as attached.
This certificate of coverage shall become effective June 1, 2017.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day June 1, 2017.
Original Signed by Richard L. Riddle Jr.
,for Tracy E. Davis, P.E., Director
Division of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission

A
.� Division of Energy, Mineral & Land Resources
I Land Quality Secti on/Storm water Permitting
NCDENR National Pollutant Discharge Elimination System
N � woRe�.o.
EPERMIT NAME/OWNERSHIP CHANGE FORM
wNAowvcNr ...,a mxx- Aesouwces
FOR AGENCY USE ONLY
Date Received
Year
I Month
IDay
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N I G I S 10 1 1 1
LN 10
10 j 2
1 01
0
5
1 4
11. Permit status prior to requested change.
a. Permit issued to (company name):
Greenteknology Electronics Recycling Solutions LLC
b. Person legally responsible for permit:
Ethan S Gilbert
First A11 Last
Director of Business Development
"Title
715 Rollerton Rd Apt 313
Pen -nit Holder Mailing Address
Charlotte NC 28205
Cite Stag Zip
{ 704 )412 3343 ( )
Phone Fax
c. Facility name {discharge):
Greenteknology Electronics Recycling Solutions LLC
d. Facility address:
5919 Hovis,Rd.,S�+i ite G _
Address
Charlotte NC 28208
City State Zip
e. Facility contact person:
Valerie A Gilbert ( 704 )412 3343
First 1 MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
® Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Pertnit issued to (company name):
BlueSky Solutions LLC
c. Person legally responsible for permit:
Wei Zhao
First M1 Last
*** Please send permit copy to facility
President
contact listed below****
; itir
RECEIVED
631 Winterlochen Rd
Permit Holder Mailing Address
MAY 10 2017
Garner NO 27603
b l�€�AXRANO ITY
Cite State Zip
��PERMITTING
( 919 )771 0744 wei.zhao9blueskysolutions.us
Phone E-mail Address
d. Facility name (discharge):
BlueSky Solutions LLC - Charlotte Facility
e. Facility address:
5019 Hovis Rd Suite G
Address
Charlotte NC 28208
CiLv State Zip
f. Facility contact person:
Valerie A Gilbert
First Mi Last
( 704 ) 412 3343 valerie. ilbert bluesk solutions.us
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27. 2014

NPRES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Valerie A Gilbert
First Ml Last
EHS Compliance Manager
Title
5019 Hovis Rd Ste G
Mailing Address
Charlotte NC 28208
Cior, State Zip
( 704 ) 412 3343 [e-mail]
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
This completed application is required for both name change and/or ownership change
requests.
© Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
.....................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, _VG, attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
cornpletef arj that if all required supporting information is not included, this application package will be
returned s i omplete. /�_1
Signature
APPLICANT CERTIFICATION
5/3/17
Date
1. VG , attest that this application: for a name/ov.,nership charge has been revie%ved and is accurate m.d
complete to the best of my knowledge. I understand that if all required parts of this application are not
comple�d atd that if all required supporting information is not included, this application package will be
returne as ncomplete.
Signature
5/3/17
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan. 27, 2014

PURCHASE OF BUSINESS AGREEMENT
THIS PURCHASE OF BUSINESS AGREEMENT (the "Agreement") made and entered into,
this ,S} day of, .� (the "1"xecution C)a(c"),
BETWEEN:
Ethan Gilbert of'715 Rollerton Rd- Charlotte. North Carolina 28208
(dw "Seller")
OF THE FIRST PART
and
Wei 7_.hao of632 Winterlochen Road, Garncr. North Carolina 27603
(tile "Purchaser")
BACKGROUND
OF THE SECOND PART
A. The Seller is the I00".'� member ow•ncr•ofGREENTEKNOLOGY ELECTRONICS
RECYCLING SOLUTIONS. LLC of. 5p19 hovis rd. Charlotte, North Carolina -`8208
Rite "LLC") which carries on the, business of electronics recvcii:tg under the operating
name GREENTEKNOLOGY Eli--c-mONICS RECYCLING SOLUTIONS, LLC. In the
State of Delaware.
B. The Seller desires to sell their ownership to the Purchaser, and the Purchaser desires to
buy the ownership.
IN CONSIDERATION of the provisions contained in this Agreement and for ether goad and
valuable consideration, the receipt and sufficiency of which consideration is acknowledged, the
Parties agree as follows:
Definitions
I . The following definitions apply in the Agreement:
a. "Closing" means the completion of the purchase as described in this Agreement
by the payment of agreed consideration, and the transfer of ownership.

b. "Parties" means both the Seller and the Purchaser and "Party" ineans- any one of
them.
Z. Subject to the temps and conditions of this Agreement, and in reliance on the
representations, warranties, and conditions set out to this Agreement, the Seller agrees to
;ell to the Purchaser and the Purchaser agrees to purchase fironi the Seiler.
Purchase Price
3. The price to be Paid by the Purchaser to the Seller will he r US Dollars (tht
"Total Purchase Price")
4� The Parties agree to co-operate in the filing of elections under the Interned Revenue CmIc=
and under ally other applicable taxation legislation, in order to give the required of"
desired effect to the allocation of the Total Purchase Price,
5. The Closing of the purchase and sale will take place on October 1. 2016 (the "Closing
Date") at the offices of the Seller or at such other tipple and place as the Parties mutually
Liu
0. At Closing, and upon the Purchaser resolving the Total Purchase Price in full to the
Seller. the Seller \,vill:
a. Provide the Purchaser with duly executed lorms and docutttents evidencing
transfer of signing authority and control of thy; bank accounts of the LLC:
b. The Seller will take all steps necessary f«r the LLC io enter the Purchaser. or its
nt111 ince, as the 100% member owner.
pa.Y. Belt[
?. The Total Purchase Price will be paid by the Purchaser in a lump sung payment of
US Dollars and by .a promissory note (the "Promissory Note") ill the form
attached. in the antount of_US Dollars trade out to the Seller.

i\ WITNESS WHEREOF the Parties have ditty affixed their siyistiatures under hand anti seal on
this day Of
Wei Zhao (Purchaser)
Ethan Gllhcrt (Seiierj

NORTH CAROLINA.
Department of the Secretary of State
To all whom these presents shall come, Greetings:
1, Elaine F. Marshall, Secretary of State of the State of North Carolina, do hereby certify
the following and hereto attached to be a true copy of
ARTICLES OF AMENDMENT
OF
BLUESKY TRADING LLC
WHICH CHANGED ITS NAME TO
BLUESKY SOLUTIONS LLC
the original of which was filed in this office on the 27th day of March, 2017.
19~ IN WITNESS WHEREOF, I have hereunto set
my hand and affixed my official seal at the City
of Raleigh, this 27th day of March, 2017.
Scan to verify online.
Document Id: C201708302981 Secretary of State
Verify this certificate online at http://www.sosnc.gov/verification

December 30, 2016
RECEIVED
JAN 1 0 Ztlil
Wastewater Branch CENTRA, S
FILE Water Quality Permitting Section B�` SI<CTILE
Division of Water Resources
ON
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
GREENTEKNOLOGV ELECTRONICS, RECYCLING SOLUTIONS, LLC
NPDES Permit Number'NCG200514
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506.
Individual #1 Individual #2 (if applicable)
Name:
Sharon Bass
Title:
Senior Engineer
Mailing Address:
Environmental Process Solutions, Pllc
624 Matthews -Mint Hill Rd, #115
Matthews, Nc 28105
Physical Address:
(if different)
Email Address:
[e-mail]
Office Phone:
980 - 202 - 2377
- -
Mobile Phone:
704 - 451 - 5354
- -
If you have any questions regarding this letter, please feel free to contact me at
[e-mail]
Sincerely,
V6��C��
Valerie Gilbert
Environmental Health And Safety Compliance Manager
5019 Hovis Rd., Suite G
[e-mail]
704-412-3343
617-680-2936
cc: Mooresville Regional Office, Water Quality Permitting Section

► Certificate of Coverage No. NCG20 OD El
CERTIFICATION
"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 quatifed 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 fines and imprisonment for knowing violations."
[Required by 40 CFR §122.221
Mail Annual Summary Stormwater DMR to the NCDEQ Central Office:
Note the address is correct -- Central Files is housed in DWR (not DEMLR)
N.C. Department of Environmental Quality (DEQ)
Division of Water Resources
Attn: DWR Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Central Files Telephone [phone]
Questions? Contact DEMLR Stormwater Permitting Staff in the Central Office at:
[phone]
Permit Date 1011/2015 - 9/3012020
Last Revised 10-2-2015

PAT MCCRORY
Got-emor
DONALD R. VAN DER VAART
Energy, Mineral
and Land Resources
ENVIRONMENTAL OVALITY
December 29, 2015
Ethan Gilbert
Greenteknology Electronics Recycling Solutions, LLC.
715 Rollerton Road, Apt 1 l 7
Charlotte, NC 28205
Subject: General Permit No. NCG200000
Greenteknology Electronics Recycling Solutions, LLC
COC NCG200514
Mecklenburg County
Dear Mr. Gilbert:
ecrefart-
TRACY DAVIS
Director
In accordance with your application for a discharge permit received on November 13, 2015, 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 October 15, 2007 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except after notice to the
Division of Energy, Mineral, and Land Resources. 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 Energy, Mining, and Land Resources, or permits required by the Division of
Water Resources, Coastal Area Management Act, or any other federal or local governmental
permit that may be required.
If you have any questions concerning this permit, please contact Richard Riddle at telephone
number [phone].
Sincerely,
ORIGINAL. SIGNED ElY
UICHEAL F RANG
kt
for Tracy E. Davis, P.E., CPM
cc: Mooresville Regional Office
Central Files
Stormwater Permitting Program Files
Charlotte -Mecklenburg Storm Water Service
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Center 1 512 North Salisbury Street I Raleigh, NC 27699-1612
919 707 9200 T

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG200000
CERTIFICATE OF COVERAGE No. NCG200514
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,
Greenteknology Electronics Recycling Solutions, LLC
is hereby authorized to discharge stormwater from a facility located at
Greenteknology Electronics Recycling Solutions, LLC
5019 Hovis Road, Suite G
Charlotte
Mecklenburg
to receiving waters designated as Stewart Creek, a class C water in the Catawba River Basin, in
accordance with the effluent limitations, monitoring requirements, and other conditions set forth
in Parts I, 1I, III, and IV of General Permit No. NCG200000 as attached.
This certificate of coverage shall become effective December 29, 2015.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day December 29, 2015.
ORIGINAL SIGNED a)!
M I C i-NEAL F RAN (?At;
for Tracy E. Davis, F.E., Director
Division of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission

a�wv- I. ',�
f , d
Jl
WOO
Greenteknology..
I
121FLIL

Riddle, Rick L
From: Khan, Zahid
Sent: Thursday, December 17, 2015 10:06 AM
To: Riddle, Rick L
Subject: RE: NCG200514 - Greenteknology -
Bill,
This facility was inspected on December 16, 2015. We do not have any objection for the issuance of this permit.
Inspection report is in RIMS. Thanks and have a great rest of the week.
Zahid
From: Riddle, Rick L
Sent: Tuesday, December 01, 2015 9:08 AM
To: Khan, Zahid <[e-mail]>
Subject: NCG200514 - Greenteknology -
Zahid Khan,
Good afternoon. Hope your Thanksgiving holiday was pleasant.
Please review the attached NOI application and respond to me with any recommendations for the permit. Your
recommendation now to issue the permit serves as your acknowledgement that (1) the facility is located in your region,
(2) that there are no current complaints outstanding about the facility that have not been dealt with, and (3) that the facility
may ultimately be inspected by the regional staff. The latitude and longitude given on the NOI application is incorrect,
the correct latitude 35 16' 09", longitude -80 54' 0.1".
COC # Facility Location City/County
NCG200514 Greenteknology Electronics Recycling Solutions 5019 Hovis Rd, Suite G Charlotte/Meck I en burg
If you need any more info, give me a call. If you could send me a recommendation to issue the permit by around
12/30/2015 or so, I'd appreciate it, so I can issue their COC.
Thank you.
Richard Riddle
Richard L. Riddle, Jr.
Stormwater Engineer
North Carolina Department Enviromental Quality
North Carolina Division Energy Mineral Land Resources
919 803-6375 office
rick. riddle[aD_ncden_r.goy
512 North Salisbury Street

FDivision of Energy, Mineral, and Land Resources
���Land Quality Section
NCDENRNational Pollutant Discharge Elimination System
C. w�
E.1.0..� A.D "�`�"` RE$OVRCE$ NCG200000
NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG200000 for STORMWATER DISCHARGES associated with activities classified as:
SIC 5093 Scrap Metal Recycling (except as specified below)
And, Like activities deemed by DEMLR to be similar in the process, or the exposure of raw
materials, intermediate products, final products, by-products, or waste materials.
The following activities are excluded from coverage under this General Permit:
1)
Automobile Wrecking for Scrap (a portion of SIC 5093)
Non -Metal Scrap Recycling (a portion of SIC 5093)
• Used Motor Vehicle Parts (SIC 5015)
(Please print or type)
Mailing address of the owner/operator (address to which official permit_ correspondence will be mailed):
Name Greenteknology Electronics Recycling Solutions, LLC
Owner Contact Ethan Gilbert
Street Address 715 Roilerton Rd, Apt 117
City Charlotte State NC ZIP Code 28205
Telephone No. [phone] Fax:
E-mail Address [e-mail]
2) Location of the facility producing the discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
Email
Greenteknology Electronics Recycling Solutions, LLC
Valerie Gilbert
5019 Hovis Rd, Suite G
Charlotte State NC _
Mecklenburg
[phone]
[e-mail]
3) Physical Location Information:
ZIP Code 28208
Fax:
Please provide a description of how to get to the facility (use street names, state road numbers, and distance
and direction from a roadway intersection). Start by heading north on 1-277. Continue/follow onto NC-16
N. After 4 miles, turn left onto Hovis Road. Our facility is on the right in 0.8 miles.
(A copy of a county map or USGS quad sheet with facility clearly located on the map is a requir part of this application.)
3.�.2- 93q�,sue. q1?(9-3
4) Latitude 35016`18.6"N Longitude 80053'59.9"W (degrees, minutes, seconds)
5) This NPDES Permit Application applies to which of the following:
Cl New or Proposed Facility` Date operation is to begin
. Existing
'If this new or proposed facility is iocated in one of the 20 coastal counties, please contact the appropriate DEMLR Regional
Office (see page 4) to determine if a State Stormwater Permit is required prior to construction.
Page 1 of 4
SWU-235-012815 Last revised 1128/15

NCG200000 N.O.I.
0
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 9 3
7) Services and Activities
a) provide a brief description of the types of industrial activities and products manufactured at this
facility: (Include a site diagram of the process areas and location of activities present at this facility.)
inside our warehouse we sortde-manufacture and pLocess. electronic scrap. Outside of facility in the rear of
the building we have a large metal bin to collect steel, large dumpster for trash, and some used wooden
Pallets.
b) Check all activities conducted at this facility.
X Outdoor stockpiling of materials
X Processing — cutting, grinding,
crushing, baling, separation, etc.
Storage of materials in above-
ground tanks
X Material loading and unloading
8) Discharge points / Receiving waters:
X Transport of materials by a
conveyor or front-end loader
X Vehicle and equipment
maintenance
Vehicle or equipment washing
X Vehicle and equipment fueling
How many discharge points (ditches, pipes, channels, curb and gutter, swales, etc.) convey stormwater from
the property? 5
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? Stewart Creek
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).
Receiving water classification (if known):
9) Does this facility:
a) Have an untreated wastewater discharge? E3 No eYes
b) Have a treated wastewater discharge? ■ No ❑ Yes
If yes, list the permit number.
c) Have a wastewater discharge from a recycle system? ®No ❑ Yes
If yes, list the permit number.
d) Have a non -discharge permit? N No
If yes, list the permit number. 4
Cl Yes
e) Discharge wastewater to a municipal wastewater collection system? ❑ No ® Yes
If yes, list the municipality and permit number: Charlotte/Mecklenburg sanitary sewer system
Note: Stormwater discharge permit NCG200000 does not authorize the discharge of any wastewater.
If this site discharges wastewater, you must obtain the appropriate wastewater discharge
permit in addition to coverage for stormwater discharges under NCG200000.
10) Does this facility employ any best management practices for stormwater control?
❑ No . Yes (Show any structural BMP's on the site diagram.)
Page 2of4
SWU-235-012815 Last revised 01/28/15

NCG200000 N.O.I.
If yes, please briefly describe: We keep all of our processes indoors; we do not do processing or dismantling
electronics outside. We have our steel bin and dumpster replaced frequently to avoid unnecessary stormwater
contamination.
11) Does this facility have a Stormwater Pollution Prevention Plan?
. No ❑ Yes
If yes, when was it implemented? We are in the process of writing one and implementing it, and expect to
have a Stormwater Pollution Prevention Plan within one year (by December 2016).
12) Are vehicle/equipment maintenance activities occurring at this facility?
❑ No , Yes
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) 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?
. 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: CRTs; batteries, whole and shredded circuit boards; toner
How is material stored: palletized or in Gaylord boxes
Where is material stored: Inside warehouse
How many disposal shipments per year: varies
Name of transport / disposal vendor: various downstream vendors
Vendor address: various downstream vendors
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 tiled 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
(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).
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.
Page 3 of 4
SWU-235-012815 Last revised 01/28/15

NCG200000 N.0.1.
Printed Name of Person Signing:
Title: V-- Yl V ico fl m_P/ud-oJ
(Signature of Applican
9 4�.�SS,sfGt�t�t;� V�
�1pr
(Date Signed)
This Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDENR
Final Checklist
This application will be returned as incomplete unless all of the following items have been included.
Please do not ask us to "hold" an incomplete application in anticipation of a check under separate cover.
2 Check for $100 made payable to NCDENR
This completed application signed by the applicant along with all supporting documents
Lam' 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 which drainage areas), (d) runoff conveyance structures, (e) areas where materials are
stored, (f) impervious areas, (g) site property lines, (h) vehicle and equipment maintenance, blasting,
painting, and washing areas, and (i) location of activities listed in 7b.
rc/ Copy of county map or USGS quad sheet (preferred) with location of facility clearly marked on map
Please mail the entire package to:
Stormwater Permitting Program
Division of Energy, Mineral, and Land Resources
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Please note:
The submission of this document does not guarantee the issuance of NPDES permit coverage.
For questions, please contact the DEMLR Regional Office for your area.
To visit our website please go to htpJlbortal.ncdenr.orc4web/!r/stormwater
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 .........[phone]
S" 1-235-012815

��N� reenteknolo
/' „ 'gal [ogy
5019 HOVIS ROAD STE G
CHARLOTTE, NC 28208
SANK OF AMERICA
66-191530
11/10/2015
PAY TO THE NCDENR $ xx100.00
ORDER -OF•
One`Hundrid and
NCDENR
Stormwater Permitting. Program
Division of Energy Mineral'& Land RecourceS r'
1612,Wail Service Center �}
MEMO Raleigh, NC 27699-1612 � E t�� V �'� AUTHORIZED SIGNATURE
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