NCGNE0466_COMPLETE RO FILE - HISTORICAL_20090220

n.
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. NCGNE 09 Q
DOC TYPE 1 HISTORICAL FILE
DOC DATE ❑ d O� (� a V
YYYYMMDD

lr
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Joe Hudson
City of Statesville
PO Box 1111
Statesville, NC 28677
Dear Mr. Hudson:
Division of Water Quality
Coleen H. Sullins
Director
February 20, 2009
Dee Freeman
Secretary
Subject: Denial of No -Exposure Certification NCGNE0466
4" Creek VVVVTP
693 Bell Farm Rd., Statesville, NC 28677
Iredell County
The Division has reviewed your submittal of the No Exposure Certification for Exclusion from NPDES Stormwater
Permitting form, which we received on October 25, 2007. The Division is unable to concur with your certification of no
exposure.
Based on an inspection of your facility, Mooresville Regional Office staff found that materials on your site either are
exposed, or have the potential to be exposed. DWQ cannot grant your requested exemption from permit coverage
when materials are exposed or have the potential to be exposed. Please continue to operate under the General Permit
NCG110000.
If you have any questions or need further information, please contact Robert Patterson at [phone], or through
email at [e-mail].
Sincerely,
ORIGINAL SIGNED BY
KEN PICKLE
for Coleen H. Sullins
cc: Mooresville Regional Office -Michael Parker
Stormwater Permitting Unit Files
NCG110112 Permit File
Wetlands and Stortnwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Ralegh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet w .ncwaterquality.org
An Eaual 0000nunity 1 Affnnatve Action EmNover
NorthCarolina
;Vatumllty

FORAGENCy
/ �i Division of Water Quality /Surface W useo nv
� ® Water Da2Rcccivcd
NC EN w�.r. 7 /0 D
National Pollutant Discharge Elimination System o� /o z
NO EXPOS CeroScate or Covaagc
1.u- ="q„, IJItE CERTIFICATION for Exclusion N N b
NCGNE0000
NO EXPOSURE CERTIFICATION
National Pollutant Discharge Elimination System application for exclusion from a Ste water Permit
based on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notice that your facility does not require permit
authorization forits stormwaterdischarges 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.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industria/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 o
shelter /s not required for the following in r waste product. A storm resistant
similar containers that are tightly sealedmaterials and activities: drums, barrels, tanks, and
, provided [hose 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 Tina/ products, other than products that
would be mobilized in stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for eaity qualifying for the no exposure exclusion.
/n addition, the exclusion from NPDES permitting is available on a facility -wide basis only —mot for
individual outfalls. If any industrial activities or materials are, or will be, exposed to e
facility is not eligible for the no exposure eprecipitation,
xclusion. 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 I
obligated to comply with the terms and conditions of 40 CFR 122.26
You am rn ...:� a .- -- (g)• p n
For questions, please contact the DWQ Regional Office for
(Please print or type)
1) Mailing address of ownerloperator (address to wh:�r.-to
Name
Street Address
City
Telephone No.
2) Location of facility
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
8WU-NE-060607
area.
11 ll �
State M(-
ZIP
Fax: 1I -8� $ -
g discharge:
�o U 11!�
State NC -
ZIP Code' Ce
Fax: 76
Page 1 of 5
DWQ-Surface Water u
Last revised 06/06/07
pn_. :N
A`
9W

r NCGNE0000 No Exposure Certification
3) Physical location information:
Please provide a narrative description of haw to
distance and direction from a roadway intersection). 5
get to the facility (use street names,
,��. state road numbers, and
(A copy of a map w th the facility clearly located on it should be included with the
4) Is the facility located on Native American Lands?
5) Is this a Federal facili 7 cert fication application.)
�. ❑Yes o
6 j ty ❑ Yes a,No
Latitude 'LI 36
T) Thls NPDES Longitude �'Q �� )�� �
ES Permit Application applies [o whic�lodeg, min, sec)
New or Proposed Facility
Existing Date operation is to
begin
Date operation began
8) Was this facility or site ever covered under an NPDES Stor
If yes, what is the NPDES Permit Number? rmwater Permit? Cl 13"IQo
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Code
activity at this facility
Classification
q (SIC Code) that describes the Primary industrial
SIC Code: L
10) Provide a brief description of the
j t j 4_� types of industrial activities and
- Sod S �\ products produced at this facility: 11) Does this facili ty have any Non -Discharge permits (ex: recycle
❑ No
2 Yes y permits)?
If Yes, list the permit numbers for all current Non -Discharge permits for this facility:
12) Are any of the followingEx 1 Checklist (12 - 14.J
future? (Please check eitherterials or activities exposed to eligible for the no ex Yes or No.,,) If you answer Precipitation, now or in the foreseeable
exposure exclusion. "Yes an a. Using, storin Y of these items, you are not
residuals from oleaning industrial machinery or equipment, and areas
and are exposed Using, tormwater storing Or cleaning industrial machine Where
ry or equipment remain Yes
b. Materials or residuals on the ground or in stormwater inlets from Spills/leaks
c. Materials or products from past industrial activity
d. Material handling equipment (except adequately maintained vehicles)
e. Materials or products during loading/unloading or transporting activities
f Materials or products stored outdoors (except final products intended for outside
of a g new cars] where exposure Pollutants) to stormwater does not result in the discharge
SWU-NE-060607
Page 2 of 5
❑ Yes p N-
O Yes c7m
❑ Yes p-N—O
❑ Yes e-rq-0
❑ Yes 2-No
Last revised 06/06/07

NCGNE0000 No Exposure Certification
9 Materials contained in open deteriorated
and similar containers
or leaking storage drums, barrels, tanks,
h. Materials or products handled/stored roads
the discharger on Yes p
0
or railways owned or maintained by
i. Waste material (except waste in covered
❑ Yes alro
l- Application , non -leaking containers
or disposal of process wastewater [e.g., dum
psters]) ❑yes
k. Particulate (unless otherwise pefmitted) fd'l o
othe matter or visible deposits of residuals fro
w se regulated i. 0 Yes
stormwater (e., under an m roof stacks a Q.°
outflow air quality control nd/or vents not
Permit) and evident in the Yes
1. Empty containers ErNo
(i.e., not closed and storedPrevmuusly contained
Aside down materials that are not Property
m. For any exterior � to
Prevent precipitation a stored
stored outside ASTs, as well as drumsaccumulation) ❑ Yes p-�
has the facility , barrels, °
ty had any releases in the tanks and similar containers
past three (3) years? 0 Yes ErN-0
73j Above Ground
eligible for the Storage Tanks (ASTs): If
exposure exclusion. You answer "No" to an
a. Are exterior ASTs Y of the folio
Oe leek of rust, wtng items, YOU are n_t
deterioration
or evidencence of leaks? damaged or
weathered coating, pits or
b. Is secondary containment provided for /
cracks, Yes ❑ No
holes, or evidence of leaks, all exterior AST and are drain valves? if SO' is it free of any
maintained locked shut? � Yes ❑ No
14) Secondary Contain
no ex rent: if you answer
pOSure exclusion. No"
to any of the following items
a. Is secondar
y containment provided for ' you are � eligible (including drums, barrels single above 9 ble for the
etc.) with a capacityground stora b. Is secondary of more than 660. ge containers
in close ry containment provided for gallons? a-Ve
proximity above ground stora D No
gallons? h to each other with a combined capacity
ge containers stored ��
c. Are release valves on °f more than 1,320_ Yes ❑ No
all secondary containment structures locked? �
'Yes ❑ No
SWU-NE-o60607
Page 3 of 5
Last revised 06/06/07

NCGNE0000 No Exposure Certification
15) Hazardous Waste:
a. Is this facility a Hazardous
Waste Treatment, Storage, or pis
b. Is this facility a Small Quantity Generator C
Disposal Facility?
generated per month) of hazardous waste?
less than 1000 k O Yes 21 No
9� of hazardous waste /
c. Is this facility a Large QuantityYes NO
generated per month of hazardous waste? g' or more of hazardous
If you answered waste ��
yes to � Yes �No questions b. or c., please
Types) Of waste: Provide the following information:
HOw is material stored:
Where is material stored:
'low many ntsposal shipme
Name f t ants per yea
Vendor address: r:
port / disposal vendor:
16) Certification:
1 certify under Penally
hr of taw that I have read and
and obtaining an exclusion from Np understand
the eligibility requirements for claiming a condition
1 certify under penalty of law QES stormwater permitting_
or materials fromthat there are no dischargesOf 'no
the industrial facility or site identified in of sto
I understand rmwater contaminated by exposure to industrial
rstand that 1 am obligated this document ex22
Division of Water gated to submit a no ex (except as allowed under q activities
certif
Q i f the facili Quality an whet uested, to the operator of the cation fcal orm once eve five 5 earsto
FR 122 26(g)(Z))
ty discharges
exposure y or MSq opeator where the discharge
1 understand that 1 must municipal separate storm sew the North Carolina
P sure make such ' g s into the to the North sewer system (MS4) into
and to are i
In the event that the site u inspection reports Publicly available a upon Perform inspections torconfrm Ina then n Water
In he eve longer qualifies for a No quest. condition of no
Permit prior to any
alPoint sour Exposure
st rmwa a uionI I understand b
of law that this document an source discharge of sto derstand that I system designedassure [h attach p e ared under from the facility. must obtain coverage under
q ry of the person at qualified pers nnel groped and mY direction or su dditionallyI I certify under penalty
on my in inquiry P
information or Persons who Y gathered and evaluated Pervision in accordance
the information sub manage the system, or those aluated the info submitted.with a
that there miffed is nre rmation
knowing violationsased
. false
Penalties for to submitting
falseest �m o knowled belief tr sons directly
uratsPonsible for gathering the
submi 9e and
e and complete JIM
I certifym familiar with the information information, including the possibility of fine and mprisonment ware
that I a
belief such info contained i
information is true, complete n this a
. and accurate, PPLcahon and that to the best of m Printed Name of pefsoJr o Y knowled
ge and
Title: , ,,. Signin
ON
'r=fir � e..r
(Signature of Applicant)
/d
Plea�e( fie r9nedJ
noteAfC: This
olmn p Re ionaf application for the No Ex comp/lance g Drce prior to issuance. Tosure Exclusion is
wnh no exposure conditions he Regional D subject to
inspect your faci/ityatan prior to iceapproval by the
y trnfe in the future for comat a mayRegional
inspect your facili
pprova/. The Regions/ Dfflce h' for
p/iance with the No Exposure may also
SWU-NE-060607 Exclusion,
Page 4 of 5
Last revised 06/06/07

NCGNEO000 No Exposure Certification
North Carolina General Statute 143-215.6 E30) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report,
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly
statement of a material fact in a mlemakin P plan, or other
is
make
con
ested case under this
or
renders inaccurate any recording or monitoring device Orr Methtod required to be operated or,ma maintained ed falsifies,tampers
this Articleorru es of the
[Environmental Management) Commission implementingPers vnUr, or knowingly
not to exceed ten thousand dollars this Article shall be guilty of a Gass 2 mistlemeanor which may include a fine
There is current/y no fee fora No Exp
Final list
This application should include the following items:
This completed application and all supporting documentation.
0 A map with the location of the facility clearly marked.
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.
--- Nrease contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information
Asheville Office ......
Fayetteville Office
[phone]
...
Mooresville Office ...
[phone]
[phone]
Raleigh Office ........
Washington Office
[phone]
...
Wilmington Office ...
[phone]
[phone]
Winston-Salem ......
Central Office
[phone]
.........
[phone]
SWU-NE-060607
Page 5 of 5
Last revised 06/06107

"� "Ons to STATESVILLE, NC
Directions to STATESVILLE; NC
Summary and Notes
—..- --
TART f3 MOORESVILLE, NC
FINISH P� L/6/93 Bell Farm Rd, ST TESVILLE, NC
Total Distance.
K (,(%��
25 nce: 20.5 miles, Total Time:
-- mins (approx.) i
MOORESVILLE, NC
I1. Starting in MOORESVILLE, NC on W IREDELL AVE
2. Turn eon N BROAD ST(NC-115)
3. Turn a on VV MCLELLAND AVE(NC-152 4. Bear )
� on HIGHWAY 150 W(NC-150)
5. Continue to follow NC-150
6. Turn Q to take ramp onto 1-77 N
7. Take exit #49AfG BAGNAL BOULEVARD onto E
BAGNAL BLVD(US-70) toward US-70 E
8. Continue follow GARNER
to ow US-70
9. Bear G on BELL FARM RD
10. Arrive at 693 BELL FARM RD, STATESVILLE
693 BELL FARM RD, STATESVILLE, NC
—�_
lAl400j LOCAL
go < 0.1 mi
go 0.3 mi
90 0.9 mi
90 0.3 mi
90 1.5 mi
90 12.5 mi
90 0.5 mi
90 2.7 mi
go 1.7 mi
< 0.1 mi
0.3 mi
1.2 mi
1.5 mi
3 mi
15.5 mi
16 mi
18.7 mi
20.4 mi
Page I of 1
H5inn driving rlir,-bons pr
'= one. tr l'r i ion Distance: 20. Smiles, les,
and follow all trafn mnP, it's a good ioea is do a rr- - - Time: 25 mins
c saretY Precautions. This is al'(r-herl: ,;
only (p li I'd n�3 i;c SUrP the IL41d c
2 ❑cod ay ,in aid in Pld llning,
tell exists, watch out for
http://mill.maps.yahoo.com/pmt.php?v'=O&mvt=m&q2=69; BELL FARM RD
.

G
STATESVILDISCH
LE-F URARC,
TH CREEK POIIVI ;_
O:.-
REEK \
ANC0031836 TE ATXTNTV FONTPLANTHREEK �
TL
Ir
�j
Latitude: 1 e: � � � � `• , /\
Longitude:
USGS Quad 80E47.n
J5
#: D15SE
River Basin #:
Receivi 0
3-07,06
ng Stream: Fours- e FOUrth Creek
Stream Class: --- W6 - � P
NC003] 836 -
Iredell Conn,,

ATT. B
Non -Discharge permits
Permit # WQ0001759 — Surface DisposaUMonofil
Permit # WQ0006245- N Viro Process Permit # WQ0014543- City of Statesville Land Application

ATT. B
Non -Discharge Permits
• Permit # WQ0001759 — Surface DisposaUMonofil
• Permit # WQ0006245- N Viro Process
• Permit # WQ0014543- City of Statesville Land Application

Date: 917/2007
To: Stormwater Permitting Unit
Cc Files
Front Andy Smith
RE- Attachment C
To whom it may concern.
Upon valuating the Fourth Creek
the "No Expose a Certification". Ireceived � CertificateOfrespectfully ve Coverage this facility on
nd applying r
August 22, 2007. After getting some of the requested information together I realized that
everything that we have regarding chemicals and routine operations is under roof.
If you need more information, Please contact me.

A
jo. 0. Nox 1111 • �hntesuille, Nart4 (>arulina 28587
October 23, 2007
SW General Permit Coverage Rescission
Storm water Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Certificate of Coverage # NCG 110112
Dear Mr. Bennett
Enclosed is the Rescission Request Form along with the required attachments. I had completed
and mailed a No Exposure Certification form on September 10", 2007 explaining the reasons for the no
exposure exclusion.
I eed more inforfnati , please contact me at 704-878-3438.
!Eu
y S ith
Fourth Creek WWTP Supervisor

of Narp9
oa 0
61 Permit Coverage
Rescission Request Form
° National Pollutant Discharge Elimination System
General Permit NCGI10000
Certificate -Coverage Number
NCG110112
Please fill out and return this form only if you no longer need to maintain your NPDES stormwater permit.
The following is the information currently in our database for your facility. Please review this information carefully and
make all corrections as necessary in the space provided to the right of the current information.
Facility Contact Information
Facility Name:
Facility Physical Address:
Facility Contact:
Mailing Address:
Phone Number:
Fax Number
Email Address
Owner Affiliation Information
Owner / Organization Name:
Owner Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
for rescission
Statesville-4th Creek WWTP
693 Bell Farm Rd
Statesville, NC 28625
Andy Smith, �WLKF%0 �afq�t t1;SoT
PO Box 1111
Statesville, NC 286871111
704-878-3438 Ext.
* Rescission notice will he mailed to the owner address
City of Statesville
Robert W Hites, Jr
PO Box 1111
Statesville, NC 286871111
704-878-35SO Ext.
704-873-4167
(This is required information.�Attach separate sheet if
REQUEST AND CERTIFICATION
I, as an authorized representative, hereby request rescission of certificate of coverage NCG110112 under NPDES
Stormwater General Permit NCG110000 for the subject facility. I am familiar with the information contained in this
request and to the best of my knowledge and belief such information is true, complete and accurate.
Signature
Joe uuAsn..,.
Print or type name of person signing above
Date
J,rec� v per QC'1t�C�
Title
Please return this completed rescission request form to: SW General Permit Coverage Rescission
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

Permit
Facility
Number
Name - Facilitl
Address
Facility City
NCGNE0236
Green Fite
rle
en RZ
1007 Amh Or
Charlotte
No -(Dee Browder)
N C National
I � i'; I i ,
T, iK
NCGNE0376
Guard - NC N
Gd. Belmont
CK(
300 N Bth St
Belmont
N C National
NCGNE0389
Guard - NC Nat
Gd- Gastonia
2100 Robinwoo
Gastonia
ok"(�IBG) 0i rj"
City of
NCGNE0511
Statesville
Fourth Creek
WWTP
693 Bell Farm FjStatesville
No-(JL)
Hd Supply - HD
......
'-'v
NCGNE0468
Supply
Plumbing/HVAC
gig P;
t
We
(HG 0910)
1942 Airport Rd
Monroe
The Pepsi
NOGNE0472
Bottling Group
Inc - The Pepsi
Bottling Group,
'f UMW­i­
sto
rg.
Inc.
5047 Hwy 24-2-,
Midland
191� ::x
City of
NCGNE0466
Statesville
Statesville-4th
Creek WWTP
693 Bell Farm F,
Statesville
No-(JL)
Jack 8 Kelley
Inc
A51M15IF'4, lty' ��Mv, "I t "77,f
"T
- Jack B.
NCGNE0467
Kelley-
V, 1,
Charlotte
6108 Old M11 He
Charlotte
K
Terminal
Land 0' Lakes -
NCGNE0476
Land O'Lakes
Purina Feeds,
LLC
173 McNess R
Statesville
No -(Wes Bell)
City of Gastonia
NCGNE0480
- Long Creek
WWTP
3000 Long Cre
Dallas
No -(Wes Bell)
City of Gastonia
NCGNE0481
- Crowders
Creek WWTP
5642 S York Re Gastonia
No -(Wes Bell)

M
Y
�Ai 7-; ^:n.
Division of Water Quality /Surface Water Protection
r CDE R ay
National Pollutant Discharge Elimination System
c
µoN� NO EXPOSURE CERTIFICATION for Exclusion
NCGNE0000
NO EXPOSURE CERTIFICATION
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit
based on NO EXPOSURE:
F
on of this No Exposure Certification constitutes notice that your facility does not require permit
tion for its stormwater discharges associated with industrial activity in the State of North
ecause it qualifies for a no exposure exclusion. A condition of no exposure at an industrial
ans all industrial materials and activities are protected by a storm resistant shelter (with some
s) to prevent exposure to rain, snow, snowmelt, and/or runoff. materials or activities include, but are not limited to: material handling equipment or activities,
ramachinery, 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 etas_ h facili 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,
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 I
obligated to comply with the terms and conditions of 40 CFR 122.26(g).
Ynl i nre .,.,....__�._ - (.0 c
For questions, please contact the DWQ Regional Office for
(Please print or type)
1) Mailing address of owner/operator (address to u i,;,- ii
Name
Street Address
City
Telephone No.
2) Location of facility
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
SWU-NE-060607
\t,
discharge:
C.
area.
State NC ZIP Code
Fax�S-s
\3 kle-
State NC_ ZIP Code
$l$ 3 l3is Fax: 76, S 7K -I(
Page 1 of 5
ml
Last revised 06/06/07

4
t_

NCGNE0000 No Exposure Certification
3) Physical location information:
Please provide a narrative description of how to
distance and direction from a roadway intersection). s ,
get to the facility (use street names, state road numbers, and
(A copy of a map with the facility clead ��
y located on it should be included with the certification a
4) Is the facility located on Native American Lands? ❑ yes
5) Is this a Federal facility? �1 application.)
tY ❑Yes N °
6) Latitude � ��j 3�„ O`No
Longitude o L `) 15
7) This NPDES Permit Application applies to which of the following:
(deg, min, sec)
O New or Proposed Facility
Existing Date operation is to begin
$) Was this facilityDate operation began
or site ever covered under an NPDES `St°fmwater Permit? O Yes
If yes, what is the NPDES Permit Number?
BNo
9) Standard Industrial Classificati
10)
Provide the 4 digit Standard Industrial Classification Code (SIC C�LG I 1 01 1 2 /
ode) that describes the primary industrial
activity at this facility
SIC Code:
idea brief description of the
t S U I �YPes of industrial activities and
-Sol S �\ es s \ products produced at this facility:
11) Does this facility have any Non -Discharge permits (ex: rec cycle ❑ No
0 Yes Y Permits)?
If yes, list the permit numbers for all current Non -Discharge Permits for this facility: �CE
12) Are an �osure�hec (12 _ 14.J
y of the following materials or activities exposed to
future? (Please check either "yes" or "No. If
eligible for the no ex Precipitation to any,
now or in the foreseeable
posure exclusion. ) You answer "Yes" to an
a. Using, storing,Y of these items, you are not
or cleaning industrial machinery or equipment, and areas
residuals from using, storing or cleaning industria[ machine
and are exposed to stormwater where
ry or equipment remain � Yes �o
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks
C. Materials or products from past industrial activity ❑ Yes 9-NO
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes p.vo-
e- Materials or products during loading/unloading or transporting
❑ Yes B_�O
f. Materials or products stored outdoors (except final products intended for outside
use [e.g., new cars � Yes p-�
Of pollutants) ) where exposure to stormwater does not result in the discharge
❑ Yes p-�o
SWU-NE-060607
Page 2 of 5
Last revised 06/06/07

NCGNE0000 No Exposure Certification
9 Materials contained in open, deteriorated or leakin
and similar containers
g storage drums, barrels, tanks,
h Materials or products
the discharger handled/stored on roads or railways a Yes
0
Ys owned or maintained by
i. Waste material (except waste in covered El Yes B-o-
0
J Application . non -leaking containers
or disposal of process waste [e.g., dumpsters))
water (unless otherwise Yes p o
k- Particulate matter or visible de r`�'rse permitted) —/
otherwise regulated i. deposits of residuals from roof stacks 0 Yes P"N
stormwater outflow (e., under an °
air quality control and/or vents not
Permit) and evident in the 0 Yes 1. Empty containers that �O
(i.e., not closed and previously contained materials that are not
stored upside down to prevent precipitation accumulation)
m. For an Propedy stored
Y exterior ASTs, as well as drums, Yes p stored outsitle, has the facility had °
barrels, tanks, and similar containers
y any releases in the past three it years?
13 Yes 2rlqo
73) Above Ground
eligible for the Storage Tanks (gSTs
no exposure )' If You answer "No"
a. Are a exclusion. to any of the following
exterior gSTs or piping free of rust, items, deterioration, or evidence of leaks? damaged You are not
ged or weathered coating, pits or /
b. Is secondary containment provided for � Ye$ No
cracks, holes, or evidence of leaks, all e
and are drain vatves i IfSO,nta is d free of an
maintained locked shut? IT 'Ye ❑ No
exposure 14) Secondary containment: If you answre exclusion. answer "No,, to an
a. Is secondaryY of the following items, containment provided for single above YOU are not eligible (including drums, 9 ble for the
barrels, etc.) with a rapacityground
b. Is secondary °f more than 660-age containers
m close containment provided for above Sailons? �s � No
Proximity to each other ground gallons? with a combined ca storage containers stored
° Are r pacity of more than 1,320_ Yes ❑ No
release valves on all secondary containment structures locked?
✓'�YeS El No
8WU-NE-o60607
Page 3 of 5
Last revised 06/06/07

NCGNE0000 No Exposure Certification
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? facility Small Quantity Generator (less than 1000 k Yes
generated per month) of hazardous waste?
g. of hazardous waste /
c. Is this facility a Quantity Generator (1000
Large Yes e No "
generated g k
Per month) of hazardous waste? g' °r more ❑ of hazardous waste
El Yes
Type(s) of waste:
yes to
If you answered �No
questions b. or c., please Provide the followin
How is material9 information:
stored:
Where is material stored.
How sp°sal shipm
Name f transport ents per year:
/disposal vendor
Vendor address:
16) Certification:
I certify under penalty of law that I
exposure" andmltyhave read and understand
obtaining
an exclusion from NP the eligibility requireme
nts for claiming a condition of "no
certify under penalty of law that there arePermitting.
or materials from the in Of
thal at
orno discharges _
ges of document
r contaminated by exposure
I and Y site identified in this document e
understand that 1 am obligated (except to industrial a
Division of g f to submit a no ex o Pas allowed under 40 activities
Water Quality and, if r sure certification f CFR 122 26(g)(2))
which the facility discharge,equested. to the operator of the form once eve five 5 ears to
Qualit , o (where applicable). I understand a local municipal separate storm the North Carolina
Y or MS4 pemtor where the discharge that I sewer system exposure and to rge is into the I must allow the North Carolina Divisi (MS4) into
make such inspection r ocal M
In the reports public) av S4• to perform inspections to °f Water
event that the Y ailable upon request. COnfirrn the condition
an NPDES site no longer qualifies for a No of no
Permit Prior to any point source discharge
Exclusion I
of law that this document a understand that I mu and all attach 9 of stormwater from the facility, st obtain covers
system designed to menu were prepared and Y Additional) , 9e under
assure that qualified personnel under my direction or Y I certify under penalty
on my inquiry of the person Property gathered suPervision in accordance
information, th °f persons who mans and evaluated submi to with a
e information submitted is ge the system, or thosethe information submitted.
that there are significant to the best of my knowled persons directly responsible for
Based
knowing violations. Penalties for submitting false info ge and belief true, accurate and gathering the
information, including the possibili Complete. I am
ty of fine aware
certify that I am familiar with and imprisonment for
belief such info the information contained in
information is true, complete, and this aPPhcation and d that to the best of
Printed Nam mY knowledge and
e of Pe so Slgnin
Title:t-kcL, ^, a
�� e p N
rr
(Signature of
Applicant)
( to rgned)
Please note:
NCDENR T/irs application for
Is
O the No Exposure Exclusion /s
comp/lance Office prior to issuance. The
with no exposure Regional Office subject to approval b
inspect your fact// Conditions prior to that a may ins Y the
ty at any time in the future for com pprova/. The peat Your fact/ity for
phance with the o Regional Office may also
posure Exclusion.
SWU-NE-060607
Page 4 of 5
Last revised 06/06/07

NCGNE0000 No Exposure Certification
North Carolina General Statute 143-216.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in an a
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 rvlemakin y application, record, report, plan, or other
11
renders inaccurate any recording or monitoring device or Methtod requiested ared to be Operated se under his Article; or who falsifies, tam
[Environmental Management] Commission implemen0n Pers with. or knowingly
g this Article shall be guilt of a Class 2 misdemeanorwhichmay include a fin,
not to exceed ten thousand dollars mission I
is Curre�l, n=fe-- a No
a No
Final Checklist
This application should include the following items:
❑ This completed application and all supporting documentation.
❑ A map with the location of the facility clearly marked.
Mail the entire package to
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
The submission of this document does not gNote
uarantee 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]
Fayetteville Office ...
Mooresville Office
[phone]
...
Raleigh Office ........
[phone]
(919) 791_4200
Washington Office ...(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
Central Office
[phone]
.........(919)
733-5083
SWU-NE-060607
Page 5 of 5
Last revised 06/06/07

--»ccuuns to STATESVILLE, NC
Directions to STATESVILLE; NC
Summary and Notes
START P MOORESVILLE, NC
FINISH 10 6%,93 Bell Farm Rd, ST TESVILLE, NC
Total Distance; t / , - K w�,
251, iaPProx.)
ns 20.5 miles, Total Time:
_.._...__
MOORESVILLE, NC
1. Starting in MOORESVILLE, NC on W IREDELL AVE
2 Turn 0
on N BROAD ST(NC-115)
3Turn (Don W MCLELLAND
AVE(NC-152)
4, Bear 0 on HIGHWAY 150 W(NC-150)
i
5. Continue to follow NC-150
6. Turn 0 to take ramp onto 1-77 N
7. Take exit #49A/G BAGNAL BOULEVARD onto E GARNER
BAGNAL BLVD(US-70) toward US-70 E
8. Continue to follow US-70
9- Bear ell on BELL FARM RD
10. Arrive at 693 BELL FARM RD, STATESVILLE
JUJ 693 BELL FARM RD, STATESVILLE, NC
Page I of 1
�o LOCAL
Add
Your nGies h -"' ere...
go < 0.1 mi
90 0.3 mi
90 0.9 mi
go 0.3 mi
90 1.5 mi
90 12.5 mi
go 0.5 mi
go 2.7 mi
90 1.7 mi
< 0•I mi
0.3 rni
1.2 mi
1.5 mi
3 mi
I5.5 rni
16 mi
IS.7 mi
20.4 mi
a%)Y driving rlircction5 Distance: 20.Smiles,
` "tr"`ii° and follow or maP, it's a Time: 25 rains
.• all traffic safety Precautions Th, � ie`onlY. to raliDy I,ec l_ _
nl',i..c _.ure the road Still e:<is t5, w
lic used as a❑ aid I ii Pla nninq. aN:h out In,
maps yahoo.com/pmt.php?v;=0&mvt=m&q2=69, BELL FARM p�D, Sta tesvilt

yr
a'�' it .i � �' ��, t✓y. I' �al _ \ - �� �/ j �-� `, i _� i /` 1�> \ ,-
•I
STATES DISC
�I LE -FOURTH C HUGE PO
NCO
\ REEK W
� ASTEW
EK WA 836 ATER TREATNIENT PL f ` FOURTH CREEK ANT
j'IIIf
tirade: IN
\1
ngitude- ^ Di\\ `
80°a7'IS"
GS Quad #: D15SE
/er Basin #: 03-07-06
'eiving Stream: Fourth Creek 9 Fourth Creek WTP
=am Gass: = NC003] 836
Ireded Count

ATT. B
Non -Discharge Permits
Permit # WQ0001759 — Surface Disposal/Monofil
Permit # WQ0006245- N Viro Process
Permit # WQ0014543- City of Statesville Land Application

]� `� F Y •.ram
Date: 9/7/2007
TO. Stormwater Permitting Unit
Cc: Files
Franc Andy Smith
RE Attachment C
To whom it may concem.
Upon re-evaluating the Fourth Creek WWTP, I am respectfully asking and applying for
the "No Exposure Certification". I received the Certificate of Coverage for this facility on
August 22, 2007. After getting some of the requested information together I realized that
everything that we have regarding chemicals and routine operations is under roof.
If you need more information, please contact me.

dL ! akt
!in4
• ili �141� ,` .��
1 1
*tate
i
ti. 0. ti6ax 1111 • itatesuille, ?Nort4 Taralina 20687
October 23, 2007
SW General Permit Coverage Rescission
Storm water Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Certificate of Coverage # NCG 110112
Dear Mr. Bennett
Enclosed is the Rescission Request Form along with the required attachments. I had completed
and mailed a No Exposure Certification form on September I Ot', 2007 explaining the reasons for the no
exposure exclusion.
t ouileed more inforptatign, please contact meat 704-878-3438.
Andy S ith
Fourth Creek W WTP Supervisor

OF NATEq
Or o� Permit Coverage
Rescission Request Form
° National Pollutant Discharge Elimination System
General Permit NCG110000
Certificate of Coverage Number
NCG110112
Please fill out and return this form only if you no longer need to maintain your NPDES stormwater permit.
The following is the information currently in our database for your facility. Please review this information carefully and
make all corrections as necessary in the space provided to the right of the current information.
Facilitv Contact Information
Facility Name:
Statesville-4th Creek WWTP
Facility Physical Address:
693 Bell Farm Rd
Statesville, NC 28625
Facility Contact:
Andy Smith,
Mailing Address:
PO Box 1111
Statesville, NC 286871111
Phone Number:
704-878-3438 Ext.
Fax Number
Email Address
g1AC�wi 5�..�P C.i•SknJ��IPkS
Owner Affiliation Information
* Rescission notice will be mailed to the owner address
Owner / Organization Name:
City of Statesville
Owner Contact:
Robert W Hites, Jr
Mailing Address:
PO Box 1111
Statesville, NC 286871111
Phone Number:
704-878-3550 Ext.
Fax Number:
704-873-4167
E-mail address
REQUEST AND CERTIFICATION
I, as an authorized representative, hereby request rescission of certificate of coverage NCGI10112 under NPDES
Stormwater General Permit NCG110000 for the subject facility. I am familiar with the information contained in this
request and to the best of my knowledge and belief such information is true, complete and accurate.
Signature
Date
�QP_ �t1c�yv �rec�os 1d�ae&jAxz_e,
Print or type name of person signing above Title
Please return this completed rescission request form to: SW General Permit Coverage Rescission
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617