NCG050448_Application_20191216

Nc&v SO L
FOR AGENCY USE ONLY
Date Received
Year Month Day
Division of Energy, Mineral and Land Resources Zolol lti tto
Land Quality Section Certificate ofCovera a yA ,nD
National Pollutant Discharge Elimination System N Check Ick I ► I�bact/
g Y C # Amount
Environmental 32'1?1, •100
Quality Permit Assigned to
NCGO50000 5. suwta.--/
NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG050000:
STORMWATER DISCHARGES associated with activities classified as:
SIC*23 Apparel and Other Finished Products Made from Fabrics and Similar Materials
SIC*265 Paperboard Containers and Boxes
SIC*267 Converted Paper and Paperboard Products RECEIVED
SIC*27 Printing, Publishing and Allied Industries DEC 1
SIC*30 Rubber and Miscellaneous Products (except as specified below) 6 2019
SIC*31 Leather and Leather Products (except as specified below) DENR-LAND QUALITY
SIC*39 Miscellaneous Manufacturing Industries STORMWATER PERMITTING
SIC* N/A Like activities deemed by DEMLR to be similar in the process and/or the exposure of raw
materials, products, by-products, or waste materials
The following activities are specifically excluded from coverage under this General Permit:
SIC*301 Tires and Inner Tubes
SIC*311 Leather Tanning and Finishing
*Standard Industrial Classification Code
(Please print or type)
1) Mailing address of owner/operator(address to which all permit correspondence will be mailed):
Name Amesbury Truth
Street Address 125 Amesbury Truth Drive
City Statesville State NC ZIP Code 28677
Telephone No. (704) 924-8586 Fax:
E-mail Address [e-mail]
2) Location of facility producing discharge:
Facility Name Amesbury Truth
Facility Contact Scott Page
Contact E-mail [e-mail]
Street Address 125 Amesbury Truth Drive
City Statesville State NC ZIP Code 28677
County Iredell
Telephone No. (704) 978-2276 Fax:
3) Physical Location Information:
Please provide a narrative description of how to get to the facility(use street names, state road numbers, and
distance and direction from a roadway intersection). Exit W U.S.Route 70,turn right onto Fanjoy Road.Take a right onto
Amesbury Truth Drive and arrive at the facility.
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required with this application)
4) Latitude 35,45,57.18 Longitude 80,49, 13.05 (degrees, minutes, seconds)
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NCG050000 N.O.I.
5) This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility Date operation is to begin
Pi Existing
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: 3 0 8 9
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: The processes at the facility include minor metalwork,extrusion and cloth work(cutting),to produce springs,extruded
foams/plastics,and cloth gaskets.
8) Discharge points:
How many discharge points (ditches, pipes, channels, etc.)convey stormwater from the property? 1
List discharge points (outfalls)that convey discharge from the site (both on-site and off-site)and location
coordinates. Attach additional sheets if necessary, or note that this information is specified on the site plan.
Stormwater Outfall No. 01
Latitude (degrees/minutes/seconds): 35/45/53.49
Longitude(degrees/minutes/seconds): 80/49/8.19 W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude(degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude(degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
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NCG050000 N.O.I.
Stormwater Outfall No.
Latitude(degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
9) Receiving waters:
What is the name of the body or bodies of water(creek, stream, river, lake, etc.)that the facility stormwater
discharges end up in? Unnamed Tributary to Fourth Creek,ends up in Fourth 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). City of Statesville MS4
10) Does this facility have any other NPDES permits?
I No
D Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
I No
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
12) Does this facility employ any best management practices for stormwater control?
❑ No
Pi Yes
If yes, please briefly describe: Spill Prevention Plan,Good Housekeeping Practices
13) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
Pi Yes
If yes, when was it implemented? April 2019
14) Are vehicle maintenance activities occurring at this facility?
• No ❑ Yes
15) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
I No ❑ Yes
b) Is this facility a Small Quantity Generator(less than 1000 kg. of hazardous waste generated per month)of
hazardous waste?
I No ❑ Yes
c) Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste generated per month)of
hazardous waste?
I No ❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:
Type(s)of waste:
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NCG050000 N.O.I.
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport/disposal vendor:
Vendor address:
16) 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($10,000).
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit
will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: Brian Pomerance
Title: Director of Operations
(Sign ure of pplicant) (Date Signed)
Notice of Intent must be accompanied by a check or money order for$100.00 made payable to NCDEQ.
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NCG050000 N.O.I.
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
❑ Check for$100 made payable to NCDEQ
❑ This completed application and all supporting documents
❑ Copy of county map or USGS quad sheet with location of facility clearly marked on map and nearby waters
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
For questions, please contact the DEMLR Central Office or Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office [phone] i
Fayetteville Office [phone] ! Raia'yh
Mooresville Office [phone] — ',!� y • ,'
Raleigh Office [phone]
Washington Office ...[phone] 7a �
Wilmington Office [phone] � � !
Winston-Salem [phone] s` ' " anC
"'"�
Central Office [phone]
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November 25, 2019
DEMLR—Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
RE: Notice of Intent
Amesbury Truth
125 Amesbury Truth Drive
Statesville, NC 28677
To Whom It May Concern:
Please find the enclosed the Notice of Intent(NOI)to apply for coverage under the North Carolina NPDES
General Permit NCG050000 for Stormwater Discharges Associated with Industrial Activities.
If you have any questions, feel free to contact me at your earliest convenience. I can be reached at(952)
567-5625 or by email at [e-mail].
Sincerely,
Sam Anderson
Environmental Specialist
cc: Scott Page—Amesbury Truth
Enclosures
U.S.Compliance Corporation
520 Third Street•Suite 100•Excelsior,MN 55331 •Phone [phone]•Fax [phone]
www.uscompliance.com

North Carolina Secretary of State Search Results Page 1 of 1
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Business Corporation
Legal Name
Amesbury Group, Inc.
Information
Sosld: 0333045
Status: Current-Active
Annual Report Status: Current
Citizenship: Foreign
Date Formed: 10/28/1993
Fiscal Month: December
State of Incorporation:
DE
Registered Agent: Corporation Service Company
Addresses
Reg Office Reg Mailing Mailing Principal Office
2625 Glenwood Avenue Suite 550 2626 Glenwood Ave Ste 550 3600 Minnesota Dr 3600 Minnesota Dr
Raleigh, NC 27608 Raleigh, NC 27608 Edina, MN 55435 Edina, MN 55435
Officers
President Secretary
Jeff Graby Jeff Johnson
3600 Minnesota Dr 3600 Minnesota Dr
Edina MN 55435 Edina MN 55435
Stock
https://www.sosnc.gov/online_services/search/Business_Registration_Results 12/16/2019