NCGNE1473_Application_20210414

RECEIVED
APR 14 7-021
FOR AGENCY USE ONLY
Date Received: !`( /� 202 ( UENR-LAND QUALITY
,,-;'�i:?I�4Wd,ATER PERMITTING
NCGNE i �' � �7
12. r2 o
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCGNE0000
Submission of this No Exposure Certification constitutes notification that your facility does not require a permit for
stormwater discharges associated with industrial activity in the State of North Carolina because it qualifies for a no
exposure exclusion. A condition of no exposure at an industrial facility means all industrial materials and activities
are protected by a storm resistant shelter (with some exceptions) 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, • by-products,
• industrial machinery, • final products, or
• raw materials, • waste products.
• intermediate 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 industrial materials stored in the following container types, provided
the containers are not deteriorated and do not leak:
• drums, • tanks, and
• barrels, • similar containers.
For permitted facilities in North Carolina, DEMLR must approve your application for No Exposure Certification
before this exclusion is effective. Until you are issued a No Exposure Certification and your NPDES permit is
rescinded, your facility must continue to abide by the terms and conditions of the current permit.
A No Exposure Certification must be provided for each facility qualifying forthe no exposure exclusion. Additionally,
the exclusion from NPDES permitting is available on a facility -wide basis only — not for individual outfalls. If any
industrial activities or materials are, orwill be, exposed to precipitation, the facility is not eligible forthe no exposure
exclusion. By signing and submitting this No Exposure Certification form, you certify that a condition of no exposure
exists at this facility or site and are obligated to comply with the terms and conditions of 40 CFR 122.26(g).
If approved, your conditional No Exposure Certification has no expiration date but must be self -recertified at least
annually. Please look for information about recertification under the No Exposure section on this page:
https://deg. nc.gov/about/divisions/energy-m ineral-land-resources/npdes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 512 N. Salisbury St., 1612 MSC, Raleigh, NC 27699-1612. The submission of this form does
not guarantee exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting
a site inspection will be conducted.
Paaa 1 of 5

1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person (as signed in Item 7 below):
Floorazzo Tile LLC
John Sich
Street address:
City:
State and zip code:
ING
1217 Harold Andrews Road
Siler City
27344
Telephone number:
Email address:
336-302-5737
[e-mail]
Type of Ownership:
Government
ECounty ®Federal QMunicipal state
Non -government
Business (if ownership is business, a copy of NCSOS report must be included with this application)
Individual
2. Industrial Facility (facility requesting exclusion):
Facility name:
Facility environmental contact:
Floorazzo Tile LLC
John Sich
Street address:
Telephone number:
1217 Harold Andrews Road
919-663-1684
City:
State and zip code:
INC
Email address.
Siler City
27344
[e-mail]
Latitude of entrance:
Longitude of entrance: Center Front of the building is an obvoius lobby
Parcel Identification Number (PIN):
Date operation began:
Standard Industrial Classification (SIC) Code:
1-1-2021
Brief description of the types of industrial activities and products produced at this facility:
This factory produces terrazzo flooring tile
3. Consultant (if applicable):
Name of consultant:
none
Consulting firm:
Street address:
City:
State and zip code:
Telephone number:
Email address:
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future? If you
answer "Yes" to any of these items, you are not eligible for the no exposure exclusion.
Using, storing, or cleaning industrial machinery or equipment, and areas where residuals from using,
storing, or cleaning industrial machinery or equipment remain and are exposed to stormwater
OYes No
Materials or residuals on the ground or in stormwater inlets from spills/leaks
OYes( No
Materials or products from past industrial activity
Oyes(F)No
Material handling equipment (except adequately maintained vehicles)
OYesE No
Materials or products during loading/unloading or transporting activities
EYes (F) No
2/5

Materials or products stored outdoors (except final products intended for outside use [e.g., new cars)
Yes No
where exposure to stormwater does not result in the discharge of pollutants)
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks, and
tYesNo
similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger
OYes(DNo
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
0Yes(No
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
0Yes(F) No
Application or disposal of process wastewater (unless otherwise permitted)
0YesG No
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
®Yes No
(i.e. under an air quality control permit) and evident in the stormwater outflow
Empty containers that previously contained materials that are not properly stored (i.e., not closed and
Yes Q No
stored upside down to prevent precipitation accumulation)
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has the facility
iYes No
had any releases in the past three (3) years?
'Sealed means banded or otherwise secured and with locked or non -operational taps or valves.
If you answer "No" to any of the following items, you are not eligible for the no exposure exclusion.
Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or deterioration, or evidence
QYesoNo
of leaks?
Is secondary containment, provided for all exterior ASTs? If so, is it free of any cracks, holes, or evidence of
(Dyes ONo
leaks, and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers (including drums, barrels,
GYes0No
etc.) with a capacity of more than 660-gallons?
Is secondary containment provided for above ground storage containers stored in close proximity to each
YesfNo
other with a combined capacity of more than 1,320 gallons?
Is secondary containment provided for Title III Section 313 Superfund Amendments and Reauthorization
G)YesoNo
Act (SARA) water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
I@YesoNo
Are release valves on all secondary containment structures locked?
E)Yes0No
Other information
If you answer "Yes" to any of the following items, you might not be eligible for the no exposure exclusion. A more
in-depth evaluation of the site circumstances may be required.
Are vehicles used in material handling in disrepair and/or leaking fluid?
Oyes(E)No
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
Yes No
Does this facility have coal piles on site?
Oyes(E)No
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
OYes(E) No
Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, plating,
Yes 0 No
painting, or metal finishing)?
If yes:
Describe the industrial activity:
The polyester resin we use to make tile has styrene in it.
Are those emissions permitted by an Air Quality Permit? oYesr-"No
Please specify: None required. We do not use enough in a year to need a permit
RM

5. Other Facility Conditions (check all that apply and explain accordingly):
❑ This facility has other NPDES permits.
If checked, list the permit numbers for all current NPDES permits:
® This facility has Non -Discharge permits (e.g. recycle permit).
If checked, list the permit numbers for all current Non -Discharge permits:
❑ This facility stores hazardous waste in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility is a (mark all that apply)
El Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked, indicate:
• Kilograms of waste generated each month:
• Type(s) of waste:
• How material is stored:
• Where material is stored:
• Number of waste shipments per year:
• Name of transport/disposal vendor:
• Transport/disposal vendor EPA ID:
• Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site.
If checked, briefly describe the site conditions:
® This facility is located on Native American Lands.
6. Required Items (Application will be returned unless all of the following items have been included):
0 Copy of most recent Annual Report to the NC Secretary of State (if applicable)
O This completed application and any supporting documentation
El Copy of county map or USGS quad sheet with the location of the facility clearly marked

7. Applicant Certification
North Carolina General Statute 143-215.6E (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000).1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
I am the person responsible for the industrial activity, for satisfying the requirements of this exclusion, and for any civil
or criminal penalties incurred due to violations of this exclusion.
I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES stormwater permitting.
There are no discharges of stormwater 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)),
0 1 understand that I am obligated to maintain no exposure conditions and complete a Self -Recertification form at least
once each year and, if requested, provide this certification 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 North Carolina
Division of Energy, Mineral, and Land Resources, or MS4 operator where applicable, to perform inspections to confirm
the condition of no exposure and to make such inspection reports publicly available upon request. I understand I must
keep a copy of annual recertifications on file at the facility.
0 I understand that in the event that the site no longer qualifies for a No Exposure Exclusion that I must obtain coverage
under an NPDES permit prior to any point source discharge of stormwater from the facility.
0 The information submitted in this'N01 is, to the best of my knowledge and belief, true, accurate, and complete based on
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information.
Printed Name of Person Signing: John Sich
Title: Owner
U�� &4-1 j: t r 4 - 2.02/
Sig ure of Applicant Date Signed
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612

nA_'t_. AMENDED LIMITED LIABILITY COMPANY ANNUAL REPORT
1012017
NAME OF LIMITED LIABILITY COMPANY: Floorazzo Tile, LLC
SECRETARY OF STATE ID NUMBER: 0652852 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2020
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: WASLAW, LLC
2. SIGNATURE OF THE NEW REGISTERED AGENT:
Filing Office Use Only
Preview
0652852
Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
101 College Court 101 College Court
New Bern, NC 28562 Craven County New Bern, NC 28562
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Wholesale Sales
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
215 West Third Street
Siler Citv, NC 27344-3443
5. PRINCIPAL OFFICE MAILING ADDRESS
215 West Third Street
Siler City, NC 27344-3443
6. Select one of the following if applicable. (Optional see instructions)
LJ The company is a veteran -owned small business
The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Nathan Dewitt NAME: Randy Shoff NAME: Jan Jacobson
TITLE: Managing Member TITLE: Member TITLE: Member
ADDRESS:
1207 Town Side Drive
ADDRESS:
9904 Soriano Street
ADDRESS:
8004 Belaium Drive
Apex, NC 27502 Denton, TX 76207 Raleigh, NC 27606
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Donna M. Sich
SIGNATURE
Form must be signed by a Company Official listed under Section C of This form.
Donna M. Sich
9/11 /2020
Managing Member
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF $200.00

SECTION E: ADDITIONAL COMPANY OFFICIALS
NAME: Donna M. Sich NAME: John Sich NAME:
TITLE: Managing Member TITLE: Manager TITLE:
ADDRESS: ADDRESS: ADDRESS:
547 Stoney Creek Way 547 Stoney Creek Way
Chapel Hill, NC 27517 Chapel Hill, NC 27517
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
Name:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:

SCHEDULE!.
tJFRVF—Y' C^R0L-1N^, PLLdil" c� fl
154 S Fayetteville St Ste B, Asheboro, NC 27203 .......... • - • .........
336-625-8000 Ffrm# P-.1110
June 18, 2020
22 Davie, LLC
52 Fairway Drive
Siler City, NC 27344
Legal description to Plat recorded in Book 2020, Page 133
Beginning At A Point in the Centerline of SR 1316 in the Current Western
Siler City Corporate Limit Line; Thence continuing S 35*0811611 W-A Distance
Of 150.211; Thence continuing along the Centerline 8 34*59141 " W A Distance
Of 66.01' Thence continuing along the Centerline S 35°04110" W A Distance
Of 319.20';Thence heaving the Centerline and running along Mary Davis Life
Estate property line N 86*0412911 W A Distance Of 620.491; Thence continuing
along the same line N 01*3115611 W A Distance Of 507.05'Thence continuing
along the same line N 01*3215411 W A Distance Of 816.17' to a point in the
Southern R/W of US HWY 421; Thence along US HWY 421 S 5500815211 E A
Distance Of 207,891; Thence continuing S 550111171, P A Distance Of 576.69,
To A 1° EIR with Cap Flush; Thence continuing S 55*031081, E A Distance Of
448.48' To an existing concrete monument at the intersection of US HWY 421
R/W and SR 1316 R/W ; Thence along the R/W line of SR 1316 S 26004,501, W A
Distance Of 111.421; Thence continuing S 180241401, W A Distance Of 104.34'
To A 1" EIR with Cap Blush; Thence continuing S 54*4314211 E A Distance Of
39.941; Which Is The Point Of Beginning, Having An Area Of 20.366 Acres.
Sincerely, t�h
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Dan W Tanner , P.L.S. W���`�

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To: Thad Valentine
Environmental Senior Specialist
Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
From: John Sich
Owner
Floorazzo Tile LLC
1217 Harold Andrews Road
Siler City, NC 27344
Dear Mr. Valentine,
Attached are the two completed documents you requested, a Rescission Request Form and a
No Exposure Certification for Exclusion.
I now know I should have submitted the Rescission Request Form years ago when Floorazzo
Tile made the capital investment required to eliminate the need to the permit.
The error, like many of them over the last 19 years of being in business, was mine.
On the good side the 250K we have spent has eliminated the problem that caused us to ask for
the permit in the first place.
Please let me know if you need anything else from Floorazzo Tile
John VII

Environmental Senior Specialist
Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
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Mailing Address: 1612 Mail Service Center
Raleigh, NC 27699-1612
I-j

North Carolina Secretary of State Search Results
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Limited Liability Company
Legal Name
Floorazzo Tile, LLC
Prev Legal Name
Jdc International, LLC
Information
Sosld: 0652852
Status: Current -Active O
Date Formed: 11/15/2002
Citizenship: Domestic
Annual Report Due Date: April 15th
CurrentAnnual Report Status:
Registered Agent: WASLAW, LLC
Addresses
Reg Office
101 College Court
New Bern, NC 28562
Company Officials
Reg Mailing
101 College Court
New Bern, NC 28562
Mailing
215 West Third Street
Siler City, NC 27344-3443
All LLCs are managed by their managers pursuant to N.C.G.S. 57D-3-20
Principal Office
215 West Third Street
Siler City, NC 27344-3443
Managing Member
Member
Member
Managing Member
Manager
Nathan Dewitt
Jan Jacobson
Randy Shoff
Donna M. Sich
John Sich
1207 Town Side Drive
8004 Belgium Drive
9904 Soriano Street
547 Stoney Creek Way
547 Stoney Creek Way
Apex NC 27502
Raleigh NC 27606
Denton TX 76207
Chapel Hill NC 27517
Chapel Hill NC 27517
https://www.sosnc.gov/online_services/search/Business_Registration_Results 4/14/2021