NCG030139_ROS Request_20210924

Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
REPRESENTATIVE OUTFALL STATUS (ROS)
REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
If a facility is required to sample multiple discharge locations with very similar stormwater discharges, the
permittee may petition the Director for Representative Outfall Status (ROS). DWQ may grant Representative
Outfall Status if stormwater discharges from a single outfall are representative of discharges from multiple
outfalls. Approved ROS will reduce the number of outfalls where analyticasampling requirements apply.
If Representative Outfall Status is granted, ALL out are still subject to the qualitative monitoring
requirements of the facility's permit —unless otherwise allowed by the permit (such as NC6020000) and DWQ
approval. The approval letter from DWQ must be kept on site with the facility's Stormwater Pollution
Prevention Plan. The facility must notify DWQ in writing if any changes affect representative status.
For questions, please contact the DWQ Regional Office for your area (seepage 3).
(Please print or type)
1) Enter the permit number to which this ROS request applies:
Individual Permit (or) Certificate of Coverage
N C S I I I I N C G 0 3 0 0 0 0
2) Facility Information:
Owner/Facility Name Mueller Systems
Facility Contact
Street Address
City
County
Telephone No.
John Small
10210 Statesville Blvd
Cleveland State NC ZIP Code 27013
Rowan E-mail Address ismall@muellenvp com
704-278-5334
Fax:
3) List the representative outfall(s) information (attach additional sheets If necessary):
Outfall(s) #2 is representative of Outfall(s) #1
Outfalls' drainage areas have the same or similar activities? a Yes ❑ No
Outfalls' drainage areas contain the same or similar materials? a Yes ❑ No
Outfalls have similar monitoring results? p Yes ❑ No ❑ No data*
Outfall(s) is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
a Yes
❑ No
Outfalls' drainage areas contain the same or similar materials?
o Yes
o No
Outfalls have similar monitoring results?
❑ Yes
❑ No ❑ No data*
Outfall(s) is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
❑ Yes
o No
Outfalls' drainage areas contain the same or similar materials?
❑ Yes
❑ No
Outfalls have similar monitoring results?
❑ Yes
❑ No ❑ No data*
*Non-compliance with analytical monitoring prior to this request may prevent ROS approval. Specific
circumstances will be considered by the Regional Office responsible for review.
Page 1 of 3
SW U-ROS-2009 Last revised 12/30/2009

Representative Outfall Status Request
4) Detailed explanation about why the outfalls above should be granted Representative Status:
(Or, attach a letter or narrative to discuss this information.) For example, describe how activities and/or
materials are similar.
I would like outfall #2 to be our re resenlalive outtall because it rs more hkel to contain stormwaler that re resents our
activities u a s a grea er is ante am a areas ere pro u on re a e ac ivy es gccurr. a runoit travels over
several acres of grass and then down a ditch with rip rap stone In It before kJ reaches a discharge point where samples are taken
5) 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 Representative Outfall Status for my NPDES Permit. i understand that ALL outfalls are still
subject to the qualitative monitoring requirements of the permit, unless otherwise allowed by the permit
and regional office approval. I must notify DWQ in writing if any changes to the facility or its operations
take place after ROS is granted that may affect this status. If ROS no longer applies, I understand I must
resume monitoring of all outfalls as specified in my NPDES 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: John Small
Title: EHS Manager ,?
of Applicant)
09115i2021
(Date Signed)
Please note: This application for Representative Outfall Status is subject to approval by the
NCDENR Regional Office. The Regional Office may Inspect your facility far compliance with the
conditions of the permit prior to that approval.
Final Checklist for ROS Reauest
This application should include the following items:
❑ This completed form.
❑ Letter or narrative elaborating on the reasons why specified outfalls should be granted representative
status, unless all information can be included in Question 4.
❑ Two (2) copies of a site map of the facility with the location of all outfalls clearly marked, including the
drainage areas, industrial activities, and raw materials/finished products within each drainage area.
❑ Summary of results from monitoring conducted at the outfalls listed in Question 3.
❑ Any other supporting documentation.
Page 2 of 3
SWU-ROS-2009 Last revised 12/30i2009

Representative Outfall Status Request
Mail the entire package to:
NC DENR Division of Water Quality
Surface Water Protection Section
at the appropriate Regional Office (See map and addresses below)
Notes
The submission of this document does not guarantee Representative Outfall Status (ROS) will be granted as
requested. Analytical monitoring as per your current permit must be continued, at all outfalls, until written
approval of this request is granted by DWQ. Non-compliance with analytical monitoring prior to this request
may prevent ROS approval. Specific circumstances will be considered by the Regional Office responsible for
review.
For questions, please contact the DWQ Regional Office for your area.
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone [phone]
FAX [phone]
Fayetteville Regional Office
Systel Building,
225 Green St., Suite 714
Fayetteville, NC 28301-5094
Phone [phone]
FAX [phone]
Mooresville Regional Office
610 East Center Ave.
Mooresville, NC 28115
Phone [phone]
FAX [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Phone [phone]
FAX [phone]
Washington Regional Office
943 Washington Square Mall
Washington. NC 27889
Phone [phone]
FAX [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone [phone]
FAX [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone [phone]
Water Quality Main FAX [phone]
Central Office
1617 Mail Service Center
Raleigh, NC 27699-1617
Phone [phone]
FAX [phone]
Page 3 of 3
SW U-ROS-2009 Last revised 12/30/2009