NCGNE1480_Application_20210519

FOR AGENCY USE ONLY
NCGNE I /(6 ��N
Assigned to: Li . Nye LA CEIVED
ARO FRO MRO WARS WIRO WSRO
MAY 19 2021
DER.L4ND
Division of Energy, Mineral, and Land ResourcesSTORMWATER ERM�NG
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCG N E0000
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rescinded,your facility must continue to abide by the terms and conditions of the current permit.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 for the 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,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,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://deq.nc.gov/about/divisions/energy-mi neral-land-resources/npdes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 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.
Page 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):
SHM PYC, LLC Kathee Dishner
Street address: City: State Zip Code
18501 Harbor Light Blvd Cornelius NC 28031
Telephone number: Email address:
[phone] [e-mail]
Type of Ownership:
Government
❑County In Federal ❑Municipal ❑State
Non-government
In 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:
Safe Harbor Peninsula Yacht Club Harry Smith
Street address: Telephone number:
18501 Harbor Light Blvd [phone]
Email address:
[e-mail]
City County State Zip Code
Cornelius Mecklenburg NC 28031
Latitude of entrance: 35.28'4"N
Longitude of entrance:80.56'9"W
Parcel Identification Number(PIN):
00132299
Date operation began: Standard Industrial Classification(SIC)Code:
5/1996 4493
Brief description of the types of industrial activities and products produced at this facility:
Private Yacht Club with Marina, Restaurant and Pool
3. Consultant(if applicable):
Name of consultant: Consulting firm:
Street address: City: State and zip code:
Telephone number: Email address:
4. Exposure Checklists
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 ❑Yes in No ❑N/A
stormwater
Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑Yes 0 No ❑N/A
Materials or products from past industrial activity In Yes D No❑N/A
Material handling equipment(except adequately maintained vehicles) ❑Yes 0 No❑N/A
Page 2 of 5

Materials or products during loading/unloading or transporting activities ❑Yes El No❑N/A
Materials or products stored outdoors(except final products intended for outside use[e.g., new ❑Yes CI No❑N/A
cars]where exposure to stormwater does not result in the discharge of pollutants)
Materials contained in open,deteriorated, non-sealedl,or leaking storage drums barrels,tanks,
and similar containers ❑Yes No CI N/A
Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑Yes 0 No In N/A
Final products that would be mobilized in stormwater discharges(e.g.,rock salt) ❑Yes 0 No❑N/A
Waste material(except waste in covered,non-leaking containers[e.g.,dumpsters]) ❑Yes ID No❑N/A
Application or disposal of process wastewater(unless otherwise permitted) ❑Yes 0 No❑N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise ID Yes 0 No❑N/A
regulated(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 CI Yes 0 No❑N/A
and stored upside down to prevent precipitation accumulation)
For any exterior ASTs,as well as drums,barrels,tanks and similar containers stored outside,has ❑Yes❑No El N/A
the facility had any releases in the past three(3)years?
'Sealed means banded or otherwise secured and with locked or non-operational taps or valves.
Above Ground Storage Tanks(ASTs)and Secondary Containment
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 ❑Yes No 0 N/A
evidence of leaks?
Is secondary containment provided for all exterior ASTs?If so,is it free of any cracks,holes,or ❑Yes❑No 171 N/A
evidence of leaks,and are drain valves maintained locked shut?
Is secondary containment provided for single aboveground storage containers(including drums, ❑Yes CI No CI N/A
barrels,etc.)with a capacity of more than 660-gallons?
Is secondary containment provided for above ground storage containers stored in close proximity in Yes❑No El N/A
to each other with a combined capacity of more than 1,320 gallons?
Is secondary containment provided for Title III Section 313 Superfund Amendments and ❑Yes❑No 0 N/A
Reauthorization Act(SARA)water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR§116? CI Yes CI No 0 N/A
Are release valves on all secondary containment structures locked? ID Yes CI No ID N/A
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? CI Yes El No❑N/A
Does this facility store used,recycled,or otherwise reclaimed pallets outside? ❑Yes CI No❑N/A
Does this facility have coal piles on site? ❑Yes El No 0 N/A
Does this facility store other fuel sources outside in piles,such as wood chips,sawdust,etc.? ❑Yes CI No❑N/A
Page 3 of 5

Does this facility have air emissions associated with industrial activity(e.g.,degreasing operations, ['Yes 0 No❑N/A
plating,painting,or metal finishing)?
If yes:
Describe the industrial activity:
Are those emissions permitted by an Air Quality Permit? in Yes in No
Please specify:
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)
O 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):
❑ Copy of most recent Annual Report to the NC Secretary of State(if applicable)
This completed application and any supporting documentation
-----12 Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 4 of 5

7. Applicant Certification
North Carolina General Statute 143-215.6B(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). I 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.
1E1 I have read and understand the eligibility requirements for claiming a condition of"no exposure"and obtaining an
exclusion from NPDES stormwater permitting.
�E] 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)).
"El I 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.
19 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.
KID
The information submitted in this NOI 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 Personp Signing: / "
Title: Gery24 ,C mQ��t fj i'Tou vJtJ� (!',�,(,1 � ('1/,_ Q
,el/1 ." -Z S ' 5 _' (4"202/
gnature of Applicant Date Signed
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 5 of 5

Polaris 3G Map Mecklenburg County, North Carolina
Date Printed: 5/14/2021 11 :38:04 AM
iwieipli
1
PAA. 717 ‘611.
A D i I
0 ,.„... _ L^ ,J
'40
),,,...-1
' '16/ ,,,,,.,,,„,.,„ .
"� f�
- _ at..", '''
-,,,4-114-fir-43
-ter r`. �' a.~
_,.
:.'‘_ u,- ,__),
-
1, ( -- 2 ',,,,,,,,,
``
c
i, '
. , f4 Core us
:In -o �
V r
+ 1, r� ''�} 3 F,�
.-_-' '� j \' `� 1- a klenburg% �
,�r
IP ,---,.- ii,„
* ,,',-..._,,
1-
1
73 m'A'rrAc`
`,1� '`- Huners►r til,
J `p 4441 4 4:
i Ilk ,......_
is map or report is prepare. ort e inventory o rea property wit in v ec en.urg ounty an. is compi e. rom reco •e. .ee.s,pats,tax maps,surveys,
planimetric maps,and other public records and data. Users of this map or report are hereby notified that the aforementioned public primary information sources
should be consulted for verification.Mecklenburg Count and its mappin. contractors assume no legal responsibility for the information contained herein.

For Registration
Fredrick Smith
Register of Deeds
Mecklenburg County, NC
Electronically Recorded
2020 Jun 16 09:11 AM RE Excise Tax: $ 0.00
Book: 34691 Page: 305 - 305 Fee: $ 26.00
Instrument Number. 2020087903
iltrf
ASSUMED BUSINESS NAME CERTIFICATE (NCGS§66-71.51
Please print legibly.
1. The assumed business name is:
Safe Harbor Peninsula Yacht Club
(You may include no more than five(5)assumed business names on this form.)
2. The real name of the person or entity engaging in business under the assumed business name is:
SHM PVC, LLC
SOSID Number 1974061
(Corporations,LLC's,limited partnerships must provide the exact name registered with the NC Secretary of State's office and
the SOSID number assigned at the time of formation.Go to www.sosnc.gov/br/search to look up your information.)
3. The nature/type of the business is: Marina Operations
4. The street address of the principal place of business is: (PO Boxes are not acceptable)
18501 Harbor Light Boulevard, Cornelius, NC 28031
5. The mailing address, if different from the street address, is:
14785 Preston Rd., Suite 975, Dallas TX 75254
6. The counties where the assumed business name will be used to engage in business are:
El All 100 North Carolina counties
This certificate is signed by the owner/legal representative of the person or entity named above,
this 5 day of May , 20.20
Signature: C---749 . /eCe.-1:7
Printed/Typed Name: Michelle Olvedo
Tide: Member
(See instructions for who must sign for various business entity types.)
Assumed Business Name Certificate 10.03.17
Submitted electronically by NC Corporate Connection, Inc. in compliance
with North Carolina statutes governing recordable documents and the terms
of the submitter aareement with the Mecklenbura Reaister of Deeds.