NCG110103_COMPLETE FILE - HISTORICAL_20121210

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE
CAI HISTORICAL FILE
0 MONITORING REPORTS
DOC DATE
❑ �/ D I a� a� �
YYYYMMDD

1/
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
.Jeff Dotson
Jeff` Dotson
397 Riverside Dr
Forest City, NC 2804
December 10. 2012
Subject: Permit Renewal Application Fee Return
Permit NCG 11010 3
Forest City�at� �rR clamation Facility
Rutherford County
Your fee, submitted as part of your request for a General'Permit renewal received on November 29. 2012 is
being returned due to:
❑ Check for $100.00 made payable to NCDENR is missing.
U. Application is incomplete.
❑ Application package is missing the supporting documents.
❑ /0t'h
ing copy of county map or USGS quad sheet with facility clearly marked.
er Permit renewal applications for NPDES stormwater permits do not require renewal fees. This fee is
being returned. Your check is enclosed. You will receive additional information from our Division in the next
few weeks associated with the permit renewal process. _
Please return the complete package of information so we can continue processing your request. If you have any
additional questions, please contact Bradley Bennett at 919-807-6378.
cc:
Wetlands and 5toanwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: 9IM07-63001 FAX: 9IM07.6494 l Customer Service: 1.877-623-6748
Internet: www.nMaterquality org
An Equal Opportunity 1 Aff rmatve Action Employer
NorthCarolina
Naturally

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NCDENR
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Ei+..R .ew mo N�Rce .ces
NOTICE OF INTENT
Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NCG110000
FOR AGENCY USE ONLY
Date Received
Year Month Day
Certificate or Covem p
Check n 1Amounl
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG110000:
STORMWATER DISCHARGES associated with activities classified as: i
Treatment Works treating domestic sewage or any other sewage sludge or wastewater treatment
device or system, used in the storage, treatment, recycling, and reclamation of municipal or
domestic sewage, with a design flow of 1.0 million gallons per day or more, or required to have an
approved pretreatment program under Title 40 Code of Federal Regulations (CFR) Part 403,
including lands dedicated to the disposal of sewage sludge that is located within the confines of
the facility; and like activities deemed by DWO to be similar in the process and/or the exposure of
raw materials, products, by-products, or waste materials.
(Please print or type)
1) Mailing address of ownerloperator (address to which all permit correspondence will be mailed):
Name
Street Address
City
Telephone No.
E-mail Address
2) Location of facility producing discharge:
Facility Name
Facility Contact
Contact E-mail
Street Address
City
County
Telephone No.
3) Physical Location Information:
-1626
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). From Asheville NC take 1-26E to exit 67, take US74E to Old Caroleen
Rd. exit 184, left onto Caroleen Rd. to Riverside Drive, right onto Riverside Drive, Site is located on right @ 397 Riverside Drive
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required to be submitted with this application)
4) Latitude E 35deg 19min 36.84sec I Longitude f-81d,eg 50min 25.80sec � (degrees, minutes, seconds)
5) This NPDES Permit Application applies to which of the following :
0 New or Proposed Facility Date operation is to begin
!X I Existing
Page 1 of 4
SWU-226-071408
Last Revised 7/14/2008

NCG110000 N.O.I.
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: 1_4_9_5_2_
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: ,Wastewater Treatment
8) Discharge points ! Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? �, 5_ 1
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?'Second Broad River
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). � NIA I
10) Does this facility have any other NPDES permits?
1❑ No
+X iyes
If yes, list the permit numbers for all current NPDES permits for this facility: NCO025984
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
1❑I No
,X Iyes
If yes, list the permit numbers for all current Non -Discharge permits for this facility: WQ0010926
12) Does this facility employ any best management practices for stormwater control?
�F-11No
IYes
If yes, please briefly describe: !Visually inspect drainage ditches and pipes to make sure they are flowing.
Keep the property maintained by mowing the grass and seeding bare spots when needed. Make sure the site
is free of litter. Make sure that there are no leaks from vehicles. Make sure that storage areas are maintained.
13) Does this facility have a Stormwater Pollution Prevention Plan?
+X I No
❑' Yes
If yes, when was it implemented?
14) Are vehicle maintenance activities occurring at this facility?
!XI No I❑IYes
15) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
!X I No ❑I Yes
Na7t 10 103
7
Few rive
Page 2 of 4
SWU-226-071408 Last Revised 7/14/2008

NCG110000 N.O.I.
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
X I No I❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
�X! No I❑I Yes
d) 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 1 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:
Title: L
��=��
nf)
/4z
(D to rgned)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to NCDENR
Page 3 of 4
S W U-226-071408
Last Revised 7/14/2008

NCG110000 N.0.1.
Final Checklist
Thispplication will be returned as incomplete unless all of the following items have been included:
Check for $100 made payable to NCDENR
This completed application and all supporting documents
Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
Stormwater and General Permits 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 an NPDES permit.
For questions, please contact the DWQ Central Office or Regional Office for your area.
DWQ 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]
Page 4 of 4
SWU-226-071408 Last Revised 7/14/2008

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FOREST CITY WATER RECLAMATION FACILITY
GENERAL STORMWATER DISCHARGE PERMff
JOBNO0to", 2, 2FIGURE
DATE:ADD Y: Ks 2,2012
DFSIGNFD BY: WHs
cESIGN Ks
DESIGN REVIEW:
VICINITY MAP
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TOWN OF FOREST CITY
CON5T. REVIEW;•
ENGINEER.ING-PLASNING- FINANCE"
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RUTHERFORD COUNTY, NORTH CAROLINA

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