NCG060373_COMPLETE FILE - HISTORICAL_20160609

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STORMWATER DIVISION CODING SHEET
NC6 PERMITS
PERMIT NO.
Iv CC`�p b 3�
DOC TYPE
C\HISTORICALFILE
❑ MONITORING REPORTS
DOC DATE
YYYYMMDD

Central Files: APS _ SVVP _
7/28/2016
Permit Number NCGO60373 Permit Tracking Slip
Program Category
Status
Project Type
NPDES SW
In review
New Project
Permit Type
Version
Permit Classification
FoodlTobacco/Soaps/Cosmetics/Public Warehousing Stormwater Discharge COC
COC
Primary Reviewer
Permit Contact
Affiliation
rick, riddle
Coastal SWRule
A
LA
Jill- A
Permitted Flow
FILES
SECTION
pWR
Facility
Facility Name
Major/Minor
Region
House of Raeford - Filet of Chicken
Minor
Winston-Salem
Location Address
County
251 Eaton Dr
Davie
Mocksville- NC 27028
Owner
Owner Name
House of Raeford
Datm/Evente
Facility Contact Affiliation
Shannon Maul
251 Eaton Dr
Mocksville
Owner Type
Non -Government
Owner Affiliation
Shannon Maul
NC 27028
251 Eaton Dr
Mocksville NC 27028
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
6/1712016
Regulated Activities Requested (Received Events
Food and kindred products manufacture RO staff report requested 6/27/16
RO staff report received 7127/16
Outfall 1
Waterbody Name Streamindex Number Current Class Subbasin
Leonard Creek 12-102-16 C 03-07-05

Energy, Mineral
and Land Resources
ENVIRONMENTAL OUALITY
Shannon Maul
House of Raeford
251 Eaton Drive
Mocksville, NC 27028
Dear Shannon Maul:
PAT MCCRORY
Gowrnor
DONALD R. VAN DER VAART
.S'ecmfary
July 27, 2016 TRACY DAVIS
!hector
Subject: General Permit No. NCG060000
House of Raeford —Chicken Filet
COC NCG060373
Davie County
In accordance with your application for a discharge permit received on March 30, 2016, we are
forwarding herewith the subject certificate ofcoverage to discharge under the subject state -- NPDES
general permit. This permit is issued pursuant to the requirements of North Carolina General Statute 143-
215.1 and the Memorandum of Agreement between North Carolina and the US Environmental Protection
Agency dated October 15, 2007 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except after notice to the Division of
Energy, Mineral, and Land Resources, The Division may require modification or revocation and
reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be required by the
Division of Energy, Mining, and Land Resources, or permits required by the Division of Water
Resources, Coastal Area Management Act, or any other federal or local governmental permit that may be
required.
If you have any questions concerning this permit, please contact Richard Riddle at telephone number
[phone].
Sincerely,
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and
Land Resources
CC' Winston-Salem Regional Office
Central Files
Stormwater Permitting Program File
State of North Carolina I Environmental Quality I Enerp-, Mineral and Land Resources
1612 Mail Service Center 1 512 Nolth Salisbury Street I Raleigh, NC 27699-102
9l9 707 9200 T

STATE OFNORTH H CAROLINA
DEPAR`1'MENT OF ENVIRONMENTAL. QUAL11-Y
DIVISION 01, ENI"'RGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG060000
CERTIFICATE OF COVERAGE No. NCG060373
S!'ORMWA"ITER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision ol'North Carolina Gcneral Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
House of Raeford, Inc.
is hereby authorized to discharge stormwater from a facility located at
House of' Raeford — Filet of Chicken
251 Caton Drive
Mocksvil le
Davie County
to receiving waters designated as I.,eonard Creek, a class C water in the Yadkin Pee -Dee River
Basin, in accordance with the effluent limitations, monitoring requirements, and other conditions -
set forth in farts I, II, 111, and IV ol'General Permit No. NCG060000 as attached.
This certificate of coverage shall become effective July 27, 2016.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 27, 2016.
for Tracy I"E. Davis, P.E., Director
Division of Encrgy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission

IK f
f+ ' "
NCDENR
Npx CAROL NA OFIM ENT OF
[N VIRgN—T uio N� RE504RctF
NOTICE OF INTENT
Division of Energy, Mineral and Land Resources
Land Quality Section
National Pollutant Discharge Elimination System
NCG060000
l OR AGENCY USE ONLY
[Dale Received
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG060000: R EC r i?t D
STORMWATER DISCHARGES associated with activities classified as: MAR 3 a
SIC (Standard Industrial Classification) 20 Food and Kindred Products
SIC 21 Tobacco Products DEhIR-LA%'D Q,,t I-Fy
SIC 283 Drugs STQRUWATER PERrtglJ7;1gG
SIC 284 Soaps, Detergents, & Cleaning Preparations; Perfumes, Cosmetics, & Other Toilet Preparations
SIC 422 Public Warehousing and Storage (except 4226)
For questions, please contact the DEMLR Regional Office for your area. See page 4.
Do Not use this NO! for renewals.
(Please print or type)
1) Mailing address of owner/operator (address to which all permit correspondence will be mailed:
Name
Street Address
City
Telephone No.
Shannon Maul
251 Eaton Drive
Mocksville
336 469-8926
2) Location of facility producing discharge:
Facility Name
Facility Contact
Facility Address
Facility City
Facility County
Telephone No.
House of Raeford .
Shannon Maul
251 Eaton Drive T
Mocksville
Davie
336-751-4752
[e-mail]
3) Physical Location Information:
State NC ZIP Code 27028
Fax:
State NC ZIP Code 27028
Fax:
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). Turn off of 601, just down Eaton road on the left
(A copy of a county map or USGS quad sheet with the facility clearly located must be submitted with this application.)
4) Latitude 35,52,49.26 Longitude 80,33,11.23 (deg, min, sec)
5) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
X Existing
SWU-221
Page 1 of 4
Last revised 6124114 1

NCG060000 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: 2 0 1 5
7) Activities
a) Provide a brief narrative description of the types of industrial activities and products manufactured
at this facility: We bring in fully dressed and USDA Inspected raw poultry and/or package, cook, freeze
to sell for consumption.
b) Check all activities occurring at this facility:
X use or process meats ❑ use or process animal fats/byproducts
8) Discharge points I Receiving waters.
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? 2
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? The plant storm water flows into an UT then to Leonard's Creek
Receiving water classification: C
Is this a 303(d) listed stream? _No Has a TMDL been approved for this watershed?
No
_
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).
9) Does this facility have any other NPDES permits?
X No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
10) Does this facility have any Non -Discharge permits (ex: recycle permit)?
X No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
11) Does this facility employ any best management practices for stormwater control?
❑ No
X Yes (Show any structural BMPs on the site diagram.)
If yes, please briefly describe: We have a storm water retention pond for the storm water that flows at the back
of the plant.
12) Does this facility have a Stormwater Pollution Prevention Plan?
No,
X Yes
If yes, when was it implemented? 4-1-2016
13) Are vehicle maintenance activities occurring at this facility?
X No ❑ Yes
Page 2 of 4
SWU-221 Last revised 6124/14
1

NCG060000 N.O.I.
14) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
X No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
X No ❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
X No ❑ Yes
d) Is hazardous waste stored in the 100-year flood plain?
X No ❑ Yes If yes, include information to demonstrate protection from flooding.
e) 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:
15) Certification:
North Carolina General Statute 143-215.613 (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 of method required to be
operated or maintained under this Article or rules of the 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.
1 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: _ ��a��.o,r, r W\-Cor\
Title: o r,
(Signature of Applicant) (Date Signed)
This Notice of Intent must be accompanied by a check or money order for $100.00, made payable to:
Page 3 of 4
SWU-221 Last revised 6124/14

NCG060000 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 NCDENR. Must be included with this application (not sent separately).
❑ This completed application and all supporting documents.
❑ A site diagram showing, at a minimum, (existing or proposed):
(a) outline of drainage areas, (b) stormwater management structures, (c) location of stormwater outfalls
corresponding to the drainage areas, (d) runoff conveyance features, (e) areas where materials are stored,
loaded, and unloaded, (f) impervious areas, (g) site property lines.
❑ Copy of county map or USGS quad sheet with the location of the facility clearly marked on the map.
Mail the entire package to:
Stormwater Permitting Unit Program
Division of Energy, Mineral and !_and Resources
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee coverage under the General Permit.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR 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 .........(919)
807-6300
Page 5 of 4
SWU-221 Last revised 6124/14

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}
Energy. Mineral
and Land Resources
ENVIRONMENTAL QUALITY
Lisa Darden
House of Raeford Farms, Inc.
251 Eaton Road
Mocksville, NC 27028
Ms. Darden:
PAT MCCRORY
Govenjor
DONALD R. VAN DER VAART
Secnrory
TRACY DAVIS
March 31, 2016 '(— 0&6 3 73
RECEIVED
SEP 16 &6
CENTRAL FILES
DVVR SECTION
Subject: Mocksville Division
Return of Check
On March 30, 2016 our office received a NPDES Stormwater permit application for the House of Raeford
Mocksville Division. The application package included a check in the amount of $200.00. This is not the correct
application fee for this general permit coverage. The NPDES Stormwater Permit fee is $100.00. It appears that
maybe your process may have run to fee twice be accident. We are returning your previous check and ask that
you provide our Department with an application fee in the amount of $100.00 to complete the permit application
package.
If you have any further questions please feel free to contact me at brad ley, ben [e-mail] or by
phone at [phone].
Sincerely
Bradley Bennett
Stormwater Permitting Program
cc: Shannon Maul — mouse of Raeford
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Center I $ I2 N. Salisbury St. I Raleigh, NC 27699
919 707 9200 T
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NCG060373 House of Raeford
Filet of Chicken
N
Latitude: 351 52' 49" N
W ' E Longitude: -80° 33' 11" W
County: Davie
S Receiving Stream: Leonard Creek
Stream Class: C
Map Scale 1:24,000 Index Number: 12-102-16 (Yadkin Pee -Dee Basin)
Facility Location