NCG070224_Application_20200527

Division of Energy, Mineral and Land Resources
Land Quality Section
National Pollutant Discharge Elimination System
Environmental
Quality NCG070000
NOTICE OF INTENT
Year
I Certificate of Coveraue I
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG070000:
STORMWATER DISCHARGES associated with activities classified as:
SIC' 32 Stone, Clay, Glass, and Concrete Products (except as specified below)
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 3273 Ready -Mixed Concrete * Standard Industrial Classification Code ' R `ttj_�LD
t , GMAV 27
(Please print or type) UEN I !j*Ll I Y
1) Mailing address of owner/operator (address to which all perm� Wailed):
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.
170 'Z 21--6 I '70 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). q.1 S6,0±6 too l�D 7� n� �� �csSt sake[
(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 �4, Q_ _U, Longitude-11. 11-1.5"Ii!' 1 (degrees, minutes, seconds)
5) This NPDES Permit Application applies to which of the following
❑ New or Proposed Facility Date operation is to begin
0` Existing
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SWU-222-071408 Last Revised 6/24114

Ii 1 1 1 `1 r
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: 0 0
7) Provide a brief
this facility:
8) Discharge points / Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? I —
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.
Latitude (degrees/minutes/seconds): 3 t> 0 q Y6 N
Longitude (degrees/minutes/seconds): " 77, 11'Y2 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
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? cz�3 joe_ Aggr Rover
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SWU-222-071408 Last Revised 6/24/14

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).
10) Does this facility have any other NPDES permits?
[�(No
❑ 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)?
eNo
❑ 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
C''Yes
If yes, please briefly describe: TV 4 r7 ee55 .0-F j2yf�iit� .1"V T>)O )
13) Does this facility have a Stormwater Pollution Prevention Plan?
9 / No
❑ Yes _
If yes, when was it implemented? Id 121-eC6055
14) Are vehicle maintenance activities occurring at this facility?
M'No ❑ Yes
15) Hazardous Waste:
a) IIss this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
93hiNo ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
2 No ❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
L�J" No ❑ 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 / disposal vendor: _
Vendor address:
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SWU-222-071408 Last Revised 6/24/14

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NCG070000 N.O.I.
16) Certification:
North Carolina General Statute 143-215.6 b (1) 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 PMe
on Si ning: �. (.t ad e &riffs.
Title: �'_ ! 1Z /:% T
'j -�. - .5" -�--)®-- 0
(Signature ofApplican (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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SWU-222-071408 Last Revised 6124114