WQ0019543_Application_20220630

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02U — CLOSED -LOOP RECYCLE SYSTEM — RENEWAL
FORM: CLRS-R 02-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02U, and Division Policies. For more information, visit the Water Quality Permitting Section's
Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments uploaded as
a single Portable Document Format (PDF) file to httt)s://edocs.deci.nc.Ilov/Forms/NonDischarge-Branch-Submittal-Form-Ver2,
or emailed to Non-Dischar2e.Reports(a)ncdenr.gov if less than 20 megabytes (MB).
1. Applicant: JW Jones Lumber Company, Inc.
2. Permit No.: WQ0019543
3. Signature authority: Mark Delosreyes Title: Vice President
Phone number: [phone] Office Email: [e-mail]
4. Mailing address: 1443 Northside Road
City: Elizabeth City _ _ _ _ State: NC Zip: 27909-
5. Contact person: Mark Delosreyes Email: [e-mail]
Primary phone number: [phone] Select Secondary phone number: (252) 548-815 Select
1. Physical address: 1443 Northside Road County: Pasquotank Parcel No.: 0002631
City: Elizabeth City State: NC Zip: 27909-
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 36.395710' Longitude:-76.3180700 Method: Select
1. Billing address: 1443 Northside Road
City: Elizabeth City State: NC Zip: 27909-
2. Verify the Applicant does not have any overdue annual fees:
https://de q. n c.2ov/about/divisions/water-resources/water-resources-permits lwq-epaayments
Pursuant to 15A NCAC 02T A 120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.

SEC i to V I-:14'IUNIT�iJRII G W 1GL
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude
Longitude
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Select
Select
Select
°
- °
Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02U .0201(d). These
requirements are:
❑ A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
all facility -related strictures and fences within 500 feet of the treatment, storage, and recycle areas.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108.
❑ Setbacks as required by 15A NCAC 02U .0701.
❑ Site property boundaries within 500 feet of all treatment, storage, and recycle sites.
® No — Skip Attachment A.
ATTACHAIEI T'I3 - SIGNAfiURG AUTHORITY DELEGATI®N
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
® Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
Does the Permittee own all of the land associated with the treatment, storage, and recycle system?
® Yes — Skip Attachment C.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the treatment, storage, and recycle system on property not owned by the Permittee.
ATTACH14 , N i}—A FILIATIC3I S
Are the Permittee's affiliations of record correct? Check affiliations.
R Yes — Skip Attachment D.
❑ No — Provide the Corrected affiliations and their contact information.
FORM: CLRS-R 02-21 Page 2 of 3

ATTACI-IMEN,r E — 1C,',OMPLIANCE SCHEDULES
rXes the existing pernik include any Compliance Schedules? (See Section I of the most recenfly issued permit)
El Yes — Subink ductimentatiun that the compfiance schedules have beeninet.
0 No— 9kip Attachmen(E—
ATT'ACHMENT F — CIVII , IIENALTIES AND OUTSTAN 11ING VIOLATIONS
Does Abc 11cruflAtee have any cxistjng civil penalties or outstanding violations?
F] Ye' (CiVil PeffititiCS) -, Submit payinent for the civil penalty, or prool'of reinission request.
Ej Yes, (vioNtiarras ) - Subini, a Grap
y' y 01-your response to fl]Q Notice (if Violat,
Z No — Skip Altachinent F.
'I I" ACHMENT G — INDUSTRIAL WASTEWATER
Me$ die. Oosed-joop recycle systern treat an(j,aof
stare, industrW wastewater'?
Yes Proceed to ihe next question,
Z No —'Skip Attachmoil G,
Etas the nature of the industrial wastewater changed since tl,w hast perrnit issuance (i.e.,,changges in. industrial process, intro&,tction of
nem, materials or chemicals, etc. ?
Yes — Provide as OieniicM analysis of the wastewater pursuant to the requirements in 15,E NQA.Q OBI OIOJU� , Provide: an
overview of the manufacturing process; an inventory ol'all chemical and biological materiak used in the rnanu.facturiingprocess;
an,d an overview of the cleaning and tl"eaUnent methodolo y.
No Provide an overview of the manullicturing procez, an iriventor), of all choir,ical and biologkal materials used in the
manufacturing, process; and an o;vcrvi'cw of tht cleaning and treatrnaA rnethodology.
ATTACHMENT 14 — SETTACK W
Does the ex)sfing pet"mit, inalludesetback waivers?
Yes-- P'ursaalll to,1,5 a
Provide sckw s aivers that have Wen wvrjtton i, otariz;cd, signb ed by all parties
,et�b,
involved, and recorded Nvith the counq, Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with
E 'Nlo — Skip Attachment 1-1.
APTILICAN'T'S CTRITFICATION
1, Adaeh ......... ....... . . . . . mm.that dais application
(Signature authority's name aas oote4 in seulioo 1, Rem 3)
has been reviewed by me and is accurate and complete to the best of nay knowledge. I undcirstand that if all required parts ofthis
applicall,on package are not completed, and ilial if all required stipparting infortart ion and attachnierits are noi included, this
applicatk)a package will be returned as incomplete. I further certify pursuant to 15A NCAC 022-17 .0 12'GC�), tt Olea plicant, oran y
parent, subs id k ry, or other afffliate of the appflcanthans: tlot been corwicted of environmontal cn ivanur ondor; not prow: iously abandonai
a wastewater1reatnient tb6JI'), V011out Proper]), Closing the facility,, not paid a civil perraltwyr, 11M been comphant with any, cornpliance
schedUIC� in, 91 agreenient, or order; im paid an aantjaV fe-
NoW The Applicarit's Certification shall be signed jiurswlnt to 15ANCAC ar.010605, Aiialternate person may be delegated as
In,
the signhig official if a letter is provided, ptirsuant to 1,5A NCA.Q...97
....... . . ..... . . . . .................. . j �TQ Pursuant to and any
person whokiamvingly makes any I'alse statenient� represcatation, orce�tificafion in any ap!pkation package shall be guilty x.,)faC1zss
2 misdenreanor, w" i. may include as fine riot to exceed $10,000 as well as civil panallies up to S25,000 per violation,
Date.-
TIFIE' (7,OMPIA-71"E'D APPLICATION AND ATTAC11MENTS SHALL 1317 SUBRI TTED AS A SINGLE J`DF FILE VIA:
Email: Imserfiche Upload:
Non-MLojigroe.1 emorisl-ii
FMM CLRS-R 02-21 llaeae 3 of 3