NCG210436_NOI_20150804

Division of Energy,Mineral and Land Resources FOR AGENCY USE ONLY
Stormwater Permitting Program v� D MR wd o,
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�-� National Pollutant Discharge Elimination System crn a of e
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NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG210000:
For STORMWATER DISCHARGES associated with activities classified as:
SIC 24 Timber Products(except as specified below), including Wood Chip Mills;
And, 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:
• Wood Kitchen Cabinets(SIC 2434) RECEIVED
• Wood Preserving (SIC 2491)
• Logging (SIC 2411) `05
Standard Industrial Classification Code
DENR•LAND QUALITY
(Please print or type) STORMWATER PERMITTING
1) Mailing address of owner/operator(address to which official permit correspondence will be malted):
Name 4-". NU rS rmJ r1 Ci
Owner Contact(a person) W it 00. 1 A NI n
Street Address VS 7.S
City State PJ C� ZIPCode 2'75Z
Telephone No. fax: A101 - 399 01 4 55
E-mail Address kS R p m QX 2 ry) A l a n nn
2) Location of facility prod/ Ing discharge:
Facility Name I `►�'L4, Nwa"-.t% , S • J L
Facility Contact(a person) 12- Covf r-k _Z
Contact E-mail L)RG%
Street Address ^ok^1 x NG Hv4 1 ft
City i IY[t State d ZIP Code 2-7ra.
County r�
Telephone No. Ti 4 `•t .12 --7 Y (.1 Fax: 914 �q^1- 9`t )
3) Permit Contact ) /� (�
Permit Contact(a person) �r�! 111 t` , `O re A tJ
Contact E-mail G 2 C
Contact phone number + ( 7_2
4) Physical Location Information:
Please provide a narrative description of how to get to the facility(use street narPes, state road numbers, and
distance and direction from a roadway inter ection). (4 5 t 1 W 2 S-F 1b W c. 1(.�H 7 S t 6)C
(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)
5) Latitude S1-1YOIS Longitude:? . ION (degrees, minutes, seconds)
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NCG210000 N.O.I.
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6) This NPDES Permit Application applies to which of the following
❑ New or Proposed Facility Date operation is to begin
W Existing
7) Standard Industrial Classification(SIC):
Provide the 4 digit Standard Industrial Classification Code(SIC Code)that describes the primary industrial
activity at this facility
SIC Code:
8) Provide a brief narrative description of the types of industrial activities and productp manufactured at
this facili ei f-!r► "1 G�1 U r, C /
L-A n d Se- "
9) Discharge points/Receiving waters:
How many discharge points(ditches, pipes, channels, etc.)convey stormwater from the property.
10) Receiving waters: U7,00
What is the name of the bob or bodies of water(creek stream, ri er, I ke, etc.)that the facility stormwater
discharges end up in? 1 n
A,�.5-T- , W.5 v✓ ! -.6- (i) ./
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).
11) Does this facility have any other water quality permits?
5/No
❑ Yes
If yes, list the permit numbers for all current water quality permits for this facility:
12) Does this facility have any Non-Discharge permits(ex: recycle permits)?
6340
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
13) Does this facility employ any best management practices for stormwater control?
❑ plo
®'Yes
If yes, please iefly describe: C �` �- AVIS ✓1 e j4 r- S
14) Do s this facility have a Stormwater Pollution Prevention Plan?
No
❑ Yes
If yes, when was it implemented?
15) Does this facility have exposed accumulations of sawdust, bark, mulch,wood chips,or similar size
woody material on-site for longer than seven(7)days? (Exposed directly to rainfall or to run-on from
other areas of the facility.)
❑ No VYes
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NCG210000 N.O.I.
16) vehicle maintenance activities occurring at this facility?
7NO
❑ Yes
17) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
5/No ❑ Yes
b) Is this facility a Small Quantity Generator(less than 1000 kg.of hazardous waste generated per month)of
ha ardous waste?
No ❑ Yes
c) Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste generated per month)of
h ardous waste?
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:
18) 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: 1
Title: O J s EG
`7 z" s
(Signature of Applicant) (Dat Signe )
Notice of Intent must be accompanied by a check or money order for$100.00 made payable to:
NCDENR
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NCG210000 N.O.I.
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
heck for$100 made payable to NC DENR
p��ppp////// his completed application and all supporting documents
Dx Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
Stormwater Permitting Program
Division of Energy, Mineral, and Land Resources
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.
To visit our website,go to httpJ/portal.ncdenr.oro/webAr/stormwater
DEMLR Regional Office Contact Information:
Asheville Office ...... [phone] r Win ale r�
Fayetteville Office ... [phone] ✓'L(� \i gh
Mooresville Office ... [phone]
Raleigh Office ........ [phone] `= -
Is a oorr le JJJ
Washington Office ...[phone]
Wilmington Office ... [phone]
Winston-Salem ...... [phone] F Ile ^"
Central Office .........[phone] `
Wi ngfon
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