NCGNE0480_COMPLETE FILE - HISTORICAL_20081024

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE 0
DOC TYPE
HISTORICAL FILE
DOC DATE
❑ d - `'�
YYYYM M DD

NCGNE0000 No Exposure Certification
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes IN 0
b. is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes M No
generated per month) of hazardous waste?
c, is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes 6'No
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport i disposal vendor:
Vendor address:
16) Certification:
l certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no
exposure" and obtaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every, five (5) years to the North Carolina
Division of Water Quality and, if requested, to the operator of the local municipal separate storm sewer system (MS4) into
which the facility discharges (where applicable). I understand that 1 must allow the North Carolina Division of Water
Quality, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater from the facility. Additionally, I certify under penalty
of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based
on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is to the best of my knowledge and belief true, accurate and complete. I am aware
that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed Name of Person Signing: �OSEPK t>1�1�P��
Title: ' A re-f- Ur/Gfil' 14�?IZir/i�7f1At0�
of Applicant)
11 4L 0- —
(Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at anytime in the future for compliance with the No Exposure Exclusion.
Page 4of5
SWU-NE-060607 Last revised 06/06/07

NCGNE0000 No Exposure Certification
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly
renders inaccurate any recording or 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 (S10,000).
There is currently no fee for a No Exposure Exclusion.
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
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office .....
Fayetteville Office ..
Mooresville Office..
Raleigh Office .......
Washington Office .
Wilmington Office..
Winston-Salem.....
Central Office .......
[phone]
[phone]
[phone]
[phone]
.. [phone]
[phone]
[phone]
.. [phone]
Page 5 of 5
SWU-NE-060607 Last revised 06/06/07

9
pF W A 7E9
o� o� Permit Coverage
r Certificate of Coverage Number
Rescission Request Form
° National Pollutant Discharge Elimination System NCG110056
General Permit NCG110000
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:
Long Creek WWTP
3000 Long Creek Disposal Plant Rd
Dallas, NC 28034
David Vance Morgan
5642 S York Rd
Gastonia, NC 28054
704-854-6655 Ext.
704-866-9405
* Rescission notice will be mailed to the owner address
City of Gastonia
Danny O'Crew LA2.R,l( In> , G uw,ct i �1Sr5
PO Box 1748
Gastonia, NC 280531748
704-866-6896 Ext.
Reason.for rescission request ,(This is required information. Attach separate sheet if necessary):
Cam✓-,,-T;I-VJI11I A, :Or--YVI)sU,2P7_ .• •5F6 .477-A,- l-) !~
REQUEST AND CERTIFICATION
I, as an authorized representative, hereby request rescission of certificate of coverage NCGI10056 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
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