NCGNE0083_COMPLETE FILE - HISTORICAL_20180507

STORMWATER DIVISION CODING SHEET
.NCG PERMITS
DOC TYPE
k?T- HISTORICAL FILE
YYYYMMDD

o HALYARD Lexington f�
May 7, 2018
Division of I"'nergy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh; North Carolina 27699-1612
Re: rl,ransfer of No Exposure Certification NCGNE0083
"fo Whom It May Concern:
In connection with a business transaction, Halyard Health Corporation requests that permitting
responsibilities for the above -referenced No Exposure Certification be transferred to Halyard
North Carolina, LLC, a wholly -owned subsidiary of Halyard Health Corporation.
Sincerely,
1
Eddie Motsinger
RECEIVED
MAY OgW18
DENR-LAND QUALITY
4TORMWATER PERMITTING
HALYARD 389 Clyde Fitzgerald Road Linwood, North Carolina 27299
[phone]

® PAT MGCRORY
Governor
DONALD R. VAN DER VAART
Svcrrlary
S. JAY ZIMMERMAN
Direefor
Wetter Resources
ENVIRONMENTAL QUALITY
PERMIT NAMEIOWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCGNE0083
1. Facility Name: Halyard Health Corporation
IL NEW OWNERINAME INFORMATION:
1. This request for a name change is a result of:
_X _a. Change in ownership of property/company
b. Name change only
X c. Other - Transfer of permit from parent company to wholly subsidary
2. New owner's name (name to be put on permit):
Halyard North Carolina, LLC.
3. New owner's or signing official's name and title: Richard J. Tucker- Plant Manager
4. Mailing address:389 Clyde Fitzgerald Rd. City: Linwood
State: N_C Zip Code:27299 Phone: [phone]
E-mail address: rich ard.tucker a().hyh.com
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/about/divisions/water-resources/water-resources-permitshi asiewater-branchlnpdes-Nwastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, Richard J. Tucker, attest that this application for a name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. I understand that if all
required parts of this application are not completed and that if all required supporting
information and attachments are not included, this application package will be returned as
incomplete. / r
Signature:
Date:
THE COMPLETED APPI—WATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ 1 DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 712016

NORTH CAROLINA
Department Of the Secretary Of State
To all whom these presents shall come, Greetings:
I, Elaine F. Marshall, Secretary of State of the State of North Carolina, do hereby certify
the following; and hereto attached to be a true copy of
ARTICLES OF ORGANIZATION
OF
HALYARD NORTH CAROLINA, LLC
the original of which was filed in this office on the 27th day of April, 2018.
IN WITNESS WHEREOF, I have hereunto set my
hand and affixed my official seal at the City of
Raleigh, this 27th day of April, 2018.
Scan to verify online.
Certification# C201811701614-1 Reference# C201811701614-1 Page. 1 of4 Secretary of State
Verify this certificate online at http://www.sostic.gov/verification

SOSID: 1381334
Date Filed: 4/27/2018 2:17:00 PM
Effective: 4/30/2018
Elaine F. Marshall
State of North Carolina North Carolina Secretary of State
Department of the Secretary of State C2018 117 01614
ARTICLES OF ORGANIZATION
INCLUDING ARTICLES OF CONVERSION
Pursuant to §§ 57D-2-21, 57D-9-20 and 5713-9-22 of the General Statutes of North Carolina, the undersigned
converting business entity does hereby submit these Articles of Organization Including Articles of Conversion
for the purpose of forming a limited liability company pursuant to the conversion of another eligible entity.
The name of the limited liability company is: Halyard North Carolina, LLC
The limited liability company is being formed pursuant to a conversion of another business entity.
(See Item I of the Instructions for appropriate entity designation)
The name of the converting business entity is: Halyard North Carolina, Inc.
and the organization and internal affairs of the converting business entity are governed by the laws of the
state or country of North Carolina
A plan of conversion has been approved by the converting business entity as required by law.
3. The converting business entity is a (check one): © domestic corporation; ❑foreign corporation;
❑ foreign limited liability company; 0 domestic limited partnership;
❑ foreign limited partnership; ❑ domestic registered limited liability partnership;
❑ foreign limited liability partnership; ❑ professional corporation; or.❑ other partnership as defined in
C.S. 59-36, whether or trot formed under the laws of North Carolina.
4. , The mailing address of the converting.entity prior to the conversion is:
Number and Street: 5405 Windward Parkway
City: Alpharetta State: GA Zip Code: 30004 County: Tulton
If different, the mailing address of the resulting business entity is:
Number and Street:
City:
State: Zip Code: County:
The name and. address of each person executing these articles of organization is as follows: (State
whether each person is executing these articles of organization in the capacity of a member,
organizer or both) Note: This document must be signed by all persons listed.
Avent, Inc., (Member), 6951 East Southpoint Road, Tucson, AZ 85756-9407
BUSINESS REGISTRATION DIVISION
(Remised July 2017)
P.O. BOX 29622,
Page 1
RALEIGH, NC 27626-0622
(Form L-01A)
Certification# C201811701614-1 Reference# C201811701614- Page: 2 of 4

6. The name of the initial registered agent is: Corporation Service Company
7. The street address and county of the initial registered office of the limited liability company is:
Number and street: 2626 Glenwood Avenue, Suite 550
city: _Raleigh State: NC Zip Code: 27608 County: Wake
S. The North Carolina mailing address, if different from the street address, of the initial registered office is:
9.
Number and Street:
City: State: NC Zip -Code: . County:
Principal Office. information: Select either a orb. '
a. The limited liability. company has a principal office.
The principal office telephone number: [phone]
The street address and county of the principal office of the limited liability company is:
Number and Street: 5405 Windward Parkway
City: Alpharetta ^� State: GA zip Code: 30004 County: Fulton
The mailing address, if different from the street address, of the principal office of the limited liability
company is:
Number and Street:
City: State: Zip Code: County:
b, The limited liability company does not have a principal office.
10. Any other provisions which the Iimited liability company elects to include (e.g., the,purpose of the entity)
are attached.
11. (Optional): Please provide a business e-mail address:
The Secretary of State's Office will e-mail the business automatically at the address provided at no
charge when a.document is filed. The e-mail provided will not be viewable on the website. For more
information on why this service is being offered, please see the instructions for this document.
BUSINESS RE.oisTRATION DIVISION P.O. BOX 29622 RALETGH, NC 27626-0622
(Revised July 2017) Page 3 (Farm L-014)
Certification# C20181 [701614-1 Reference# C201811701614- Page: 3 of 4

12. These articles will be effective upon filing, unless a future date is specified: Effective 12:01 am, April 30, 2018
This is the 25 day of April , 20 18
Avent, l
(Opti al: Bu press Entity Name)
ti
Si Y ure
Ross Mansbach, VP & Secretary
Type or Print Name and Title
The below space to be used. if more than one organizer or member is listed in Item #5 above.
(Optional: Business Entity Name) (Optional: Business Entity Name)
rgnature Signature
Type or Print Name and Title Type or Print Name and Title
(Optional: Business Entity Name)
rgnature
Type or Print Name and Title
NOTES:
1. Fi ft fee is $125. This document must he filed with tht Secretary of State.
BUSINESS REGISTRATION DIVISION P.O. BOX 29622
(Revrxer AIY 2017) Page d
(Optional: Business Entity Name)
• Signature
Type or Print Name and Title
RALEIGH, NC 27626.0622
(corm L-0IR)
i
I
Certification# C201811701614-1 Reference# C201811701614- Page: 4 of 4

ASSIGNMENT OF MEMBERSHIP INTERESTS
Reference is made to that certain Purchase Agreement, dated as of October 31, 2017 (the "Purchase
Agreement"), by and among Halyard Health, Inc., a Delaware corporation ("Parent'), each of the
Sellers (as defined in the Purchase Agreement), including Avent, Inc. ("Assignor"), and Owens &
Minor, Inc., a Virginia corporation (`Buyer").
For value received and pursuant to the Purchase Agreement, Assignor hereby assigns, transfers
and delivers unto O&M Halyard, Inc., a Virginia corporation and a wholly owned subsidiary of
Buyer ("O&M Halyard"), all of Assignor's right, title and interest to the membership interests of
Halyard North Carolina, LLC, a North Carolina limited liability company (f/k/a Halyard North
Carolina, Inc.) (the "Company"), held by Assignor (collectively, the "Membership Interests") free
and clear of all Encumbrances other than Permitted Encumbrances (each as defined in the Purchase
Agreement), and hereby irrevocably constitutes and appoints Buyer as attorney to transfer the
Membership Interests on the books of the Company with full power of substitution in the premises,
and O&M Halyard hereby accepts such assignment.
r
AVENT, INC. f
By:
Name: Ross Manstadl
Title: Vice President and
Secretary
[Signature Page to Membership Interest Assignment/

T AM
, w&*mow►
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
December 9, 2014
Mr. Eddie Motsinger
Halyard Health Corporation
389 Clyde Fitzgerald Road
Linwood, NC 27299
John E. Skvarla, III
Secretary
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0083
Halyard Health Corporation
Formerly Kimberly Clark Corporation
Davidson County
Dear Mr. Motsinger:
The Division has reviewed your submittal of the permit name/ownership change form for the
subject No -Exposure Certification, which we received on November 7, 2014. Division
personnel have reviewed and approved your request to transfer the exclusion from NPDES
stormwater permitting requirements.
Please note that by our original acceptance of the No -Exposure Certification and by our
approval of your request to transfer it, you are obligated to maintain no -exposure conditions at
your facility. If conditions change such that your facility can no longer qualify for the no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your
stormwater discharge. Otherwise, the discharge becomes subject to enforcement as an un-
permitted discharge.
Annual re -certification is required, and we have enclosed one blank Annual No Exposure
Exclusion Self Re -Certification form for your use. Your certification of no exposure does not
affect your facility's legal requirements to obtain environmental permits that may be required
under other federal, state, or local regulations or ordinances.
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 I FAX: [phone]
512 !North Salisbury Street, Raleigh, North Carolina 27604 • Internet: httn:llaortal.nodenr.grg/web/Ir/
An Equal opportunity 1 Affirmative Action Employer — 50% Recycled l 10% Post Consumer Paper

If you have any questions or need further information, please contact the Stormwater Permitting
Program at [phone].
Sincerely,
OR,GfNAL SIGNED BY
BETHANY GEORGQDLIAS
for Tracy E. Davis, P.E., CAM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office, M. Gantt
Stormwater Permitting Program Files
Central Files

�� Division of Water Quality 1 Surface Water Protection
"" �" . National pollutant Discharge Elimination System
NCDENR
oN�Re or PERMIT NAME/OWNERSHIP CHANGE FORM
FOR AGENCY USE ONLY
Date Received
Year
Mon.th
Day
I. Please enter the permit number for -which the change is requested.
NPDES Permit
(or) Certificate of Coverage
i
C $S 1 0I I I L=N
C G N E 1 0 0 8 3
11. Permit status prior to requested change.
a.
Permit issued to (company name):
Kimberly Clark Corporation
b.
Person legally responsible for permit:
Brian Crandall
First MI Last
Site Manager
Title
389 Clyde Fitzgerald Rd
Permit Holder Mailing Address
Linwood NC 27299
City State Zip
[phone] [phone])
Phone Fax
c.
Facility name (discharge):
Kimberly Clark Lexington Mill
d.
Facility address:
_389 Clyde Fitzgerald Rd ^
Address
Linwood NC 27299
City State Zip
e.
Facility contact person:
William E Motsinger [phone]
First / MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a.
Request for change is a result of:
® Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain:
b.
Permit issued to (company name):
Halyard Health Corporation
c.
Person legally responsible for permit:
Brian Crandall
First MI Last
Site Manager
Title
389 Clyde Fitzgerald Rd
Permit Holder Mailing Address
Linwood NC 27299
City State Zip
[phone] [e-mail]
Phone E-mail Address
d.
Facility name (discharge):
Halyard Health Corporation
e.
Facility address:
389 Clyde Fitzgerald Rd
Address
Linwood NC 27299
City State Zip
f.
Facility contact person:
William E Motsinger
First MI Last
[phone] [e-mail]
Phone E-mail Address
rE
Revised 2012Apr23

NPDES PERMIT NAM EIOWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: William E Motsinger
First MI Last T�
P.S Safety Consultant
Title
389 Clyde Fitzgerald Rd
Mai Iing Address
Linwood NC 27299
City State Zip
[phone] [e-mail]
Phone E-mail Address
Will the permitted facility continue to conduct the same industrial activities conducted prior
V. to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both name change and/or ownership change
requests.
® Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, N/A . I, attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
0 1W L�5x
z /
V1 Signature Date
APPLICANT CERTIFICATION
1, Brain Crandall attest that this application for a name/ownership change has been reviewed and is accurate
and complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature
Z1 — 6�4 - — Z.:-� t -�—
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008

C� Kimberly-Clark Corporation
c/o Halyard Health, Inc.
Attn: Jane Hart
5405 Windward Parkway, Suite 100 South
Alpharetta, GA 30004
October 20, 2014
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, NC 27699-1641
RE: Storm Water Permit
Located at Kimberly-Clark Corporation's Lexington Facility
RECEiVEMENR/M
OCT 2 S 2014
Water Quality
Permitting Section
TRANSFEROR: Kimberly-Clark Corporation (hereinafter "Kimberly-Clark")
351 Phelps Drive, Irving, Texas 75038
Tax ID #: 39-0394230
TRANSFEREE: Halyard Health, Inc. (hereinafter "Halyard")
PO Box 619100, Irving, Texas 75261-9100
Tax ID# 46-4987888
Halyard's Mailing Address effective NOVEMBER 1, 2014:
Halyard Health, Inc., 351 Phelps Dr., Irving, TX 75038
Halyard's Mailing Address effective FEBRUARY 1, 2015:
Halyard Health, Inc., 5405 Windward Parkway, Suite 100, Alpharetta, GA
30004
To Whom It May Concern:
Please be advised that on November 1, 2014 all of the assets of Kimberly-Clark's
Lexington Facility located at 389 Clyde Fitzgerald Rd, Linwood NC 27299 will be transferred
from Kimberly-Clark, a Delaware corporation, to Halyard, a Delaware corporation. Attached
hereto and made a part hereof is a copy of the Storm Water Permit to be transferred. Also
attached are corporate resolutions from Kimberly-Clark and Halyard attesting to this transfer.
Accordingly, please transfer the following from Kimberly-Clark to Halyard effective November 1,
2014:
Permit # NCGNE0083
Issued: 8/1/2012
Expires: 7/31/2015
Location: Kimberly Clark, 389 Clyde Fitzgerald Rd, Linwood, N.C. 27299
Also enclosed is a completed Change of Ownership Form.
Halyard assumes all of Kimberly-Clark's rights and obligations for this Permit. There is
no change in any other aspect of this permit. Halyard will continue the same operations at the
Lexington Facility as are presently being conducted with the same employees.

This Letter is being signed simultaneously in two or more counterparts, each of which
shall be deemed an original, but all of which together shall constitute one and the same
document.
Should any of this information be incomplete and/or should you need any additional
information, we appreciate your contacting Eddie Motsinger at [phone] to assist in
completing the paperwork required or to answer any questions about this transfer notification.
Very truly yours,
KIMBERLY-CLARK CORPORATION
HALYARD HEALTH, INC.
By:
Si natu
By:
Signature
Name: Jeff Melu 1
Name: John Wesley
Title: VP & Depblceneral Counsel KCI &
Corp. Sec.
Title: General Counsel
Attachments
Cc: Ms. Aana Taylor -Smith
NC DENR
Land Quality Section
585 Waughtown Street
Winston Salem, NC 27107
RECEIVEDIDENRIDWR
OCT 2' 8 9014
Water Quality
Permitting Section
2

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This Letter is being signed simultaneously in two or more counterparts, each of which
shall be deemed an original, but all of which together shall constitute one and the same
document.
Should any of this information be incomplete and/or should you need any additional
information, we appreciate your contacting Eddie Motsinger at [phone] to assist in
completing the paperwork required or to answer any questions about this transfer notification.
Very truly yours,
KIMBERLY-CLARK CORPORATION
HALY
RD EA TH, I C.
By:
By:A�W'
Signature
Si nature
Name: Jeff Melucci
N
: John Wesley
Title: VP & Deputy General Counsel KCI &
Corp. Sec.
Ti le:
General Counsel
Attachments
Cc: Ms. Aana Taylor -Smith
NC DENR
Land Quality Section
585 Waughtown Street
Winston Salem, NC 27107
2

As filed with the Securities and Exchange Commission on October 15, 2014
File No. 001-36440
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
WASHIINGI`ON, D.C. 20549
Amendment No. 6
to
FORM 1®
GENERAL FORM FOR REGISTRATION OF SECURITIES
Pursuant to Section 12(b) or 12(g)
of the Securities Exchange Act of 1934
Halyard Health, Inc.
(Exact name of registrant as specified in its charter)
Delaware 46-4987888
(State of incorporation (I.R.S. Employer
or organization) Identification No.)
P.O. Box 619100, Dallas, Texas 75261-91.00
(Address of principal executive offices) (Zip Code)
Registrant's telephone number, inchtding area code: [phone]
Securities to be registered pursuant to Section 12(b) of the Act:
Name of each hxcliange on which L;acli Class is to be
Title of Each Class to be so Registered Registered
Common Stock, $0.01 par value New fork Stock Exchange
Securities to be registered pursuant to Section 12(g) of the Act: None
htdicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non -accelerated
filer, or a smaller reporting company. See the defioitions of "targe accelerated filer," "accelerated filer" and
"smaller reporing company" in Rule 12b-2 of the Exciange Act.
Large accelerated filer ❑ Accelerated filer ❑
Non -accelerated filer g (Do not check if a smaller reporting company) Smaller reporting company ❑

SIGNATURES
Pursuant to the requirements of Section 12 of the Securities Exchange Act of 1934, the registrant has drily
caused this registration statement to be signed on its behalf by the undersigned, thereunto duly authorized.
Date: October B, 2014 halyard Health, Inc.
73y: Is/ Robert E. Abern
Name: Robert B. Abernathy
Title: Chairman of the Board and Chief Executive
Of lcer

fl, ' %
Kimberly-Clark Corporation
October 2014
Dear Fellow Kimberly-Clark Stockholder:
I am pleased to inform you that on October 6, 2014 the executive committee of our Board of Directors approved
the spin-off of Halyard Health, Inc., a wholly -owned subsidiary that owns Kimberly-Clark's health care business.
The spin-off of Halyard will allow us to further sharpen our focus on our consumer and professional brands,
while allowing Halyard to optimize its performance and flexibility in a rapidly changing industry.
The spin-off of Halyard is scheduled to occur on October 31, 2014. If you hold Kimberly-Clark common stock at
the close of business on the record date for the spin-off, which is October 23, 2014, you will receive a
distribution of one share of Halyard common stock for every eight shares of Kimberly-Clark common stock that
you hold on that date.
You don't need to take any action to receive shares of Halyard common stock to which you are entitled as a
Kimberly-Clark stockholder. In addition, you don't need to pay any consideration or surrender or exchange your
Kimberly-Clark common stock.
Following the spin-off, Kimberly-Clark common stock will continue to trade on the New York Stock Exchange
under the symbol "KMB," and Halyard's common stock will trade on the New York Stock Exchange under the
symbol "HYH."
1 encourage you to read the attached information statement carefully, which provides a description of the spin-off
and includes important information about Halyard, including its historical combined financial data.
We look forward to your continued support as a stockholder in both Kimberly-Clark and Halyard
Sincerely,
Thomas J. Falk
Chairman of the Board and Chief Executive Officer

OM=M iff "IM
October 2014
Dear Future Halyard Health, Inc, Stockholder:
It is my pleasure to welcome you as a stockholder of our new company, Halyard Health, Inc.
Halyard will be a global healthcare company that seeks to advance health and healthcare by preventing infection,
eliminating pain and speeding recovery. We will focus on delivering clinically -superior solutions with
remarkable service to improve the well-being of the people we touch every day.
Our employee teams are excited about the opportunity and are committed to realizing the potential that exists for
us operating as a more focused company, independent of Kimberly-Clark.
I encourage you to learn more about Halyard by reading the attached information statement. Halyard has been
authorized to list its common stock on the New York Stock Exchange under the symbol "HYH."
Thank you for your support of our new company. We Iook forward to having you as a fellow stockholder.
Sincerely,
Robert E, Abernathy
Chairman of the Board and Chief Executive Officer

h Eu wre •} , y �*- !T lr f h l�z. a �, w, xr .•1 " - s P -
r �'• .: i- - ��t �• 1.4 �' �T �. M Y . s ��! ; ryf •}r ,j...t. ytS�,•.
+ti Michael F. EasleY, Governo r{�ikY4
1 i Wllham G. Ross'Jr:, Secretary. ,"
�"'' w' is ` a ±"3� �' "� :North CaroHita Department of Environment and , Iatural Resources
� t � -' � L.:s-41 ,, s of �' 't A,� � , ' { 1 a n�• �•., ,� .. _.
`'`"; g�`�lph� lw�?" n';trs �`" }�� uF:i rt� Alan W. Klimek; P.E.�Director
a , tti t, ;j t 1 Division of Water Quality
h . - � ,'r� r rr}k ��s �i��s':tra � 1 :, i,S'� �,t°,. ��. �� *! i 'F "s•r •�
t ' V.
r3;dTlll* March 13, 2007
Eddie Motsin er d a a '
a
g ,Ny t "1N i,;r �•'E:lylT
Kimberly-Clark Corporatton� Lexington Mlll ` T/�rS,
P.O. Box 2016'.'�r� �,,'�`t'`' .��:'t,+ s x
Lexington,'NC 27293
Subject; Compliance Evaluation Inspection
Certificates of Coverabe#NCGNE0083 & NCG500098
Kimberly-Clark Corporation Lexington Mill ..'
Davidson County
Dear Mr. Motsinger:
A Compliance Eval dtion Inspection was performed at Kimberly-Clark Corporation's Lexington Mill in 1
Lexington, i\rorth Carolina on February 27, 2007 by Jenifer Carter of the Winston-Salem Regional Office. Mr. Eddie
Motsinger was present for the inspections. The purpose of the inspections was to confirm the No -Exposure stormwater
status of the facility, and.to review compliance with the National Pollutant Discharge Elimination System (NPDES)
General Wastewater Permit. The following are the findings from the subject inspection:
r NCGNE0083: -
• There was no evidence of use, storage or cleaning of industrial machinery or equipment outdoors.
• There were no residuals from spills or leaks -observed on the ground, nor in or near surface waters
• No materials from past industrial activity were observed outdoors
• Used motor oil drums located outside were in a locked containment area
• All dumpsters and empty totes located outdoors were covered under a roof.
NCG500098:
• The only discharge is non -contact cooling water.
• When chlorine is added, the discharge is diverted to the City's Waste Water Treatment Plant, per the City's Sewer
Use Ordinance.
• A Biocide/Chemical Treatment Worksheet is currently being filled out for chemicals that are added to the system,
and will be submitted to the central office. A pen -nit renewal application has already been submitted as required.
• pH and Temperature Monitoring records were reviewed and found to be complete. l
The Division greatly appreciates your efforts to maintain compliance. Should you have any questions, please contact
Jenifer Carter at'[phone].
Sincerely,
Stcve W. Tedder
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
attachments
cc: WSRO Files
SWP — Central Files
North Carolina Division of Water Quality 585 Waughtown Street; Winston-Salem, NC 27107 Phone [phone]
Customer Service: 1.877-623-6748 Internet: www.ncwaterquality.org Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/ 10% Post Consumer Paper

MAR 19 07
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'T Water Com'0066 Inspection Re"60
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Apf val expires -31 -98,
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Section j ton A: a iona a ta nn Coding (i.e PCS
yste
Transaction Code NPIDES 14molday 'Inspection Type Inspector',, F6c Type
_2' '�7 19 US 20 1.1UN ' � I '1 31 �C650c)�98 1 11 .121 07/ 2/27 1 Cl 'A LL
­71
7
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R emarks
21 J6-
11
Inspection Work Days Facilily Seff.-Monitoring Evaluation Rating 81 CIA - - ------ --------------------- Reserved .......................
671 169 701 51 71 U14 72 UN 73 LLJ 74 - 751 -1 1 1 1 1 Lj 80
Section B' Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry TimelDate
Permit Effective Date
POTW name and NPDES permit Number)
01:00,PM. 07/02/27
.02/08/01
Exit Time/Date
Permit Expiration Date
398 Clyde Fitzgerald Rd
Lexington NC 27292
02:30'PM 07/02/27
07/07/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Eddie Motsinger//336-248-7332 /3362487355
Name, Address of Responsible Official/Tille/Phone and Fax Number
Contacted
Eddie Motsinger,PO Box 2016 Lexington NC
27293//336-24B-7332/3362487355 .No.
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Operations &-Maintenance ERecords/Reports 0 Self -Monitoring Program
EffluentlReceiving Waters
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Narne(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Jenifer. Carter WSRO WQ//336-771 5000/
f;
Signature of Management Q A Reviewer Agency/Office)Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9.94) Previous editions are obsolete
Page # 1

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ti:.NCG5o0Q98,a�} ti, �+ 07/.o2/27Y C�
s Section D: Summary of Finding/Cori m' ents (Attach additional sheets of narrative and checklists as necessary) -
Discharges non-contactcooling water only.
Approximate ly-'once,every four. years; chlorine is added to clean the system. -'When this is done, the'
discharge is diverted to the City's Waste Water Treatment Plant, in keeping with the City's Sewer Use f '
Qrdiance. TRC monitoring is not required under these circumstances.
A Biocide/Chemical Tteatment Worksheet is currently being filled out, and will be sent to the Toxicity Unity,
as well as the Stormwater Permitting Unit, to go along.with the previously submitted application for permit
renewal.
Record of Effluent and Upstream/Downstream monitoring of Temperature and pH was complete and
available for review. Temperature was measured during the inspection and the results were as follows:
s . Upstream':22 degrees
.,.•
Effluent: 20 degrees C
Downstream: 18 degrees C
Environmental Maintenance Logs were available for review.
Great job overall. Housekeeping in general was excellent.
L.O 6 f c? w
Page # 2

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"Permit: NCG500098 z rY5 Owner - Facility:
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Inspection b8te: 02/27/2007 h r ,;� ' ' ` Inspection Type: Compliance Evaluations
... i« �.. ,.ra. .,
' •r"i-rt i r t•i. _.i . 'E1ts r;�1t i�k?i. t i•`, r
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' Permit r. r• 17R } ! ,_,
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Yes .
NO
NA NE
,. wtWitida
1. .� ..r 4,. � Ip •. -. +•.
(if the present permit expires in 6 months or less). •Has the permittee submitted a new applications '.� y - ; .
"'.�
❑
r❑ ❑
— Is the facility as described in the permit?
-❑
❑ Q'"
# Are there any special conditioris for the permit? '-
❑
■
❑ 'Q }
Is access to the plant site restricted to the general public?
n
❑
■ ❑
Is the inspector granted access to all areas for inspection?
■
n
n ❑
Comment:
Record Keeping �- .
Yes
No
NA NE
w❑
Are records kept and maintained as required by the permit?
■
❑
❑ ,
Is all required information readily available, complete and current?
■
Cl
Q ❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
■
Q
❑ ❑
Are analytical results consistent with data reported on DMRs? '
Cl
Q
■ Q
Is the chain -of -custody complete?
n
n
■ n
Dates, times and location of sampling
n
Name of individual performing the sampling -
❑
Results of analysis and calibration
❑
Dates of analysis
❑
Name of person performing analyses
❑
Transported COCs
n
Are DMRs complete: do they include all permit parameters?
❑
❑
■ ❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
n
■ n
(If the facility is = or > 5 MGD permitted flaw) Do they operate 24/7 with a certified operator on each shift?
❑
n
■ ❑
Is the ORC visitation log available and current?
Q
❑
■ Q
Is the ORC certified at grade equal to or higher than the facility classification?
n
n
■ n
Is the backup operator certified at one grade less or greater than the facility classification?
n
Q
■ n
Is a copy of the current NPDES permit available on site?
®
fl
❑ Q
Facility has copy of previous year's Annual Report on file for review?
Q
❑
■ Q
Comment:
Operations & Maintenance
Yes
No
NA NE
Is the plant generally clean with acceptable housekeeping?
®
n
n n
Page # 3

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Permit: NCG500098 Owner Facility: Lexington MiV,
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Inspection Date:' 0212712007 ; `' ' " Inspection Type: Compliance Evaluation
F.�2•
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&'Maintenance i
Yes `No
NA NE5 j a
.Operations
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO Sludge n
n
® n
Judge; and other that are applicable? .
_...
Comment:
Effluent Sam lin
Yes
No
NA NE
Is composite sampling flow proportional?
n
n
■ n
Is sample collected below all treatment units?
e
n
n n
Is proper volume collected?
In
n
® n
4; Is the tubing clean?
n
n
■ n
, .
Is proper temperature set for sample storage (kept at 1.0 to 4.4 degrees Celsius)?
n
n
■ n
Is the facility sampling performed as required by the permit (frequency, sampling type representative)?
®
n
n n
Comment:
Upstream ! Downstream Sampling
Yes
No
NA
NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling iocation)? ■
n
n
❑
Comment:
Effluent Pipe
Yes
No
NA
NE
Is right of way to the outfall properly maintained?
®
n
n
n
Are the receiving water free of foam other than trace amounts and other debris?
®
n
n
n
If effluent (diffuser pipes are required) are they operating properly?
n
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■
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Comment:
LQ 61 aw.
Page # 4

Question Areas:,
Discharges &3troam impacts
Certified Operator: Operator Certification Number:
. ' .
^
On-SiteRepreuenta\ve(y): Name ` Title Phone
24hour ountootname 'Eddie Motsinger Phona:338<2487332
Cart Phone:
Primary Inspector: J.enife
Inspector Signature: Date:
Secondary Inspecto,
Inspection Summary:
ErvimnmentoMaintenomce logs were available for review.
There were some used motor oil drums inulocked containment area
All processes, dumpu1acs&empty totes were indoors/covnroU.
Excellent housekeeping overall.
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Permit: NCGNE0083' ''Owner- Fa cllity: Kimberly-ClarkCoTporatior `' ”
'Facility Number:
'
_ _ ft.� . r �wyy —s4Y• : b,r",T• v..r'" T f. H s ..-�r.:r-:, _. tw:,
Inspection Date: 02I27I2007 Type: Compliance EvaluBirort '
Reason for Visit:
Routine
Inspection
..-
D1SGhaCeS $c $treartl Impacts s' - y -
r• '` -.
Yes
No
NA
NE
,-.-
1 Is any discharge observed from any part of the operation?
01
■
n
'n '
Discharge originated at:
Structure -
Application Field
Other
Q
Q
❑
a. Was conveyance man-rriade?
■
b. Did discharge reach Waters of the State? (if yes, notify DWQ)
fl
Q
■ci
C. Estimated volume reaching surface waters?
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
❑
❑
■
2. Is there evidence of a past discharge from any part of the operation?
0
■
n
n
3. Were there any adverse impacts or potential adverse impacts'to Waters of the State other
than from a n
■
n
n
discharge?
LO b 1 aw,
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rage: 2

o�oF w A rFQ Michael 1 . Easley, Governor
1
William G. Ross .Ir., Secretary
North Carolina Department of Environment and Natural Resources
� q
co Alan W. Klimek, 1'. E. Director
Division of Water Qualily
Q Coleen H. Sullins, Deputy Director
Division of Water Qualily
April 20, 2005
Eddie Motsinger
Kimberly Clark
32 Smyth Ave
Hendersonville, NC 28792
Subject: No Exposure Certification NCGNE0083
Kimberly Clark - Lexington Mill - 398 Clyde Fitzgerald R
Davidson County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 24, 2004. We apologize for the extended period it
has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. Based on your submittal and signed certification of no exposure at the above referenced facility
the Division is granting your certification as provided for under 40 CFR 126.22(g) which is incorporated by
reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (April 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Fifes — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
Lv
1CDENR
Customer Service
1-877-623-6748

-, 1
N�Nrb�g3
United States Environmental Protection Agency Form Approved
9 Y OM8 No. 2040-0291
NPDES rA Washington, DC 20460
FORM `�, EPA NO EXPOSURE CERTIFICATION for Exclusion from
3510-11
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities include the storage,
loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product. A storm resistant shelter is
not required for the following industrial materials and activities:
- drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational taps or valves;
- adequately maintained vehicles used in material handling; and
- final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual oulfalls. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information r-�
1. Name: ITIHI�II►iIAISI IIildiAiGhigi I I I I I I I I I I l l lI__J 2.Phone: I313i(22 SI /13Kd
3. Mailing Address: a. Street: 1�(�I"I h) 1P1C1yI 1,21011161 I
b. City: 4 A J(I_I /(31ir�17iC JWI I I I I I I I I I I I I I c. State: Oki, el d. Zip Code: lA 711 3i - I:�2 I&I ! I
B. FacilitylSite Location Information
1, Facility Name: t11�I .f�I i �rL i�(i_lt._I <I�I IQ.I f'il I Cl bA PA R A_i1 T G MQ I i I
2. a. Street Address: 13181 I 1+n1�1 y1�1�i - 1 �T z16�tIR I ►zl� I PCI-1!I I I I I I II
b. City: 1k4Xi41Q(9 TalQ i I I i i t i l I I i I_] c.County: �T) V4tV1-T1>15}
d. State: � e. Zip Code:
3. Is the facility located on Indian Lands? Yes ❑ No R j
4. Is this a Federal facility? Yes No 1 110?
7
5. a. Latitude:` f I � LY, l b. Longitude: 1 _19_� Loi-55 Q V
jY
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes--
(J .
b. it yes, enter NPDES permit number:
Imo} I
7. SIC/Activity Codes: Primary: p> 1211 Secondary (if applicable): I I I I
8. Total size of site associated with industrial activity: �______ acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes No ❑
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10-99)
Page 1 of 4

NPDES NO EXPOSURE CERTIFICATION for Exclusion from Farm Approved
FORM .—.EPA OMB No.2040-0211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No' in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
Rr
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spillslleaks
3. Materials or products from past industrial activity
4. Materiat handling equipment (except adequately maintained vehicles)
5. Materials or products during loading/unloading or transporting activities
6. Materials or products stored outdoors (except final products intended for outside use ]e.g., new cars] where
Q
exposure to storm water does not result in the discharge of pollutants)
7. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
B. Materials or products handled/stored on roads or railways owned or maintained by the discharger
Q
9. Waste material (except waste in covered, non -leaking containers (e.g., dumpstersj)
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10. Application or disposal of process wastewater (unless otherwise permitted)
✓�
1 t , Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
v�
(i.e. under an air quality control permit) and evident in the storm water outflow
D. Certification Statement
I certify under penalty of law thal I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES storm water permitting.
I certify under penalty of law that there are no discharges of storm water 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 years to the NPDES permitting authority 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 I must
allow the NPDES permitting authority, 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. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water 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.
Print Name: I f I/401/4IA I S I isi lbA&61RIg I I I I I I I I I I I I I I I I I I I I
Print Title: Aili�,i 4 ImANIRICS EA I I I I I I 11 I I I I I I I I I I i I
Signature:
Date: 0
EPA Form 3510-11 (10-99)
Page 2 of 4