NCG180261_Application_20210217

W, &lip) o as I
Environmental
Quality
Division of Energy, Mineral, and Land Resources
Land Quality Section
National Pollutant Discharge Elimination System
NCG180000
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
2J21
02
l
Certificate of Coverage
NCG 11012-3011
Check # Amount
21 Cotoo
Pennit Assi ned to
Ne6rIe02lal
NOTICE OF INTENT M • mtl0
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG180000: .R,r,:(� �!
1, j
STORMWATER DISCHARGES associated with activities classified as:
�
M V2_0
SIC' 25 Furniture and Fixtures, and SIC 2434 Wood Kitchen Cabinets, r-Eg 1.7 2021
And, Like activities deemed by DEMLR to be similar in the process, or the exposure of raw 11�L" y
materials, products, by-products, or waste materials. I... ;t; %'LiiPJil CTIiG
* Standard Industrial Classification Code
(Please print or type)
1) Mailing address of owner/operator (address to which official permit correspondence will be mailed):
Name Haworth, Inc.
Street Address One Haworth Center
City -
Telephone No.
E-mail address
Holland
[phone]
[e-mail]
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
Haworth Conover
State MI
Fax: (616)
ZIP Code 49423
393-1570
Jeff Rees
1610 Deborah Herman Road
Conover State NC ZIP Code 28613
Catawba
[phone]
3) Physical Location Information:
4)
5)
Fax: [phone]
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). at 1610 Deborah Herman Drive
near the intersection with 1 st Street West (Tate Boulevard) in the western part of Conover
(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)
Latitude 35 4T Y N
Longitude 81 15' 38° w (degrees, minutes, seconds)
This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility
® Existing
6) Standard Industrial Classification:
Date operation is to begin 03/15/21
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 2 5 2 1
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: Manufacture of wood furniture products including seating and health care products; wood working with dust collection,
spraybooth stain & topcoat application & curing, water -based adhesive spray, upholstering & assembly
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NCGI80000 N.O.I.
8) Discharge points / Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? 1
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. 1
Latitude (degrees/minutes/seconds): 35 43' 3"
N
Longitude (degrees/minutes/seconds): 81 15' 38"
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
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? drainage directed SW toward an unnamed tributary of Cline Creek; Cline Creek feeds Clark Creek, a tributary of the Catawba 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). City of Conover storm sewer
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NCG180000 N.0.1.
10) Does this facility have any other water quality permits?
No
❑ Yes
If yes, list the permit numbers for all current water quality permits for this facility:
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
0 No
❑ 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
Yes
If yes, please briefly describe: ISO 14001 EMS with documented chemical management & emergency response procedures
13) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
M Yes
If yes, when was It implemented? Draft SWPPP 02/09/21 to be finalized after receiving the SW Certificate of Coverage
14) Are vehicle maintenance activities occurring at this facility?
4 No ❑ Yes
15) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
❑ No 11 Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
❑ No 0 Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
No ❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste: waste stains and topcoats from wood finsihing
How is material stored: drums
Where is material stored: flammables storage room or cabinets indoors
How many disposal shipments per year: 2 to 3
Name of transport / disposal vendor: Univar Sol utions/ChemCare
Vendor address: Charlotte NC
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NCG180000 N.O.I.
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 Article 21 or regulations of the Environmental
Management Commission implementing that Article, or who falsifies, tampers with or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under Article 21 or regulations of
the Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed $10,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001
provides a punishment by a fine of not more than $10,000 or imprisonment not more than 5 years, or both, for a similar
offense.)
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: Dominic Pitocco
Title: Plant Manager
(Signature of
(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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NCG180000 N.O.I.
Final Checklist
This application will be returned as incomplete unless all of the following items have been included.
Please do not ask us to hold an incomplete application in anticipation of a check under separate cover.
❑ Check for $100 made payable to NCDEQ
❑ This completed application, signed by the owner/operator, and all supporting documents
❑ Copy of county map or USGS quad sheet with the location of the facility clearly marked on the map
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Please 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 http://portaLncdenr.org/weblirlstormwater
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 .........
[phone]
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SWU-233-82814 Last revised 8/28/14

Haworth, Inc. Conover 1610 Deborah Herman Road
7,
41
VI
APPROXIMATE PROPERTY BOUNDARY
f- 7
SOURCE- HICKORY, NC (C. 1993)
SITE LOC.kTIO.N NIAP
ER -NI N-C, lu c. 1610 DEBM4H HElLNVVN. ROAD
ERM C0.N0NTR,.N0rTH CAROLLNA

nformation
cawbacountysch
5Services
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Parcet 372216839476,1610 DEBORAH HERMAN RD SW CONOVER, 28613
Owners: HAWORTH INC.
Owner Address: ONE HAWORTH CENTER

North Carolina Secretary of State Search Results
Page 1 of 1
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Business Corporation
Legal Name
Haworth, Inc.
Information
Sosld: 0066602
Status: Current -Active O
Date Formed: 5/17/1983
Citizenship: Foreign
State of Incorporation: MI
Fiscal Month: December
Annual Report Due Date: April 15th
Registered Agent: Corporation Service Company
Addresses
Reg Office Reg Mailing
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608 Raleigh, NC 27608
Officers
Vice President
Kevin Bailey
One Haworth Center
Holland MI 49423-9576
Secretary
Carl J Nelson
One Haworth Center
Holland MI 49423
Stock
Class: 99 SEE CERT
Shares: 0
Par Value 0
President
Franco Bianchi
One Haworth Center
Holland MI 49423
Vice President
Paul Nemschoff
One Haworth Center
Holland MI 49423-9576
Vice President
Ann Harten
One Haworth Center
Holland MI 49423-9576
Vice President
Scott Poulton
One Haworth Center
Holland MI 49423-9576
Mailing
One Haworth Center
Holland, MI 49423-9576
Vice President
Joseph James
One Haworth Center
Holland MI 49423-9576
Vice President
Michael Warsaw
One Haworth Center
Holland MI 49423-9576
Principal Office
One Haworth Center
Holland, MI 49423-9576
Vice President
John K Mooney
One Haworth Center
Holland MI 49423
https://www.sosnc.gov/online_services/search/Business_Registration_Results 2/22/2021