NCG060435_Application_20220816

RECEIVED
FOR AGENCY USE ONLY
NCG06 o I� 3 5 AUG 16 2027
Assigned to: • W soJ^ vI
DENR-LAND QUALITY
ARO FRO MRO RRO WARO WIRO WSRO STORMWATERPERMIT I-ING
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG060000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC20 [food and Kindred Products], SIC21 [Tobacco Products], SIC283 [Drugs], SIC284
[Soaps, Detergents, & Cleaning Preparations; Perfumes, Cosmetics, & Other Toilet Preparations], SIC 422 [Public
Warehousing and Storage — except for 4226]. You can find information on the DEMLR Stormwater Program at
deq.nc.gov/SW.
Directions: Print or type all entries on this application. Send the original, signed application with all required
items listed in Item (6) below to: NCDEMLR Stormwater Program,1612 MSC, Raleigh, NC 27699-1612. The
submission of this application does not guarantee coverage under the General Permit. Prior to coverage under
this General Permit a site inspection will be conducted.
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:
Origin Food Group, LLC
Halil Ulukaya
Street address:
City:
State:
Zip Code:
306 Stamey Farm Road
Statesville
NC
28677
Telephone number:
Email address:
704-768-9000
[e-mail]
Type of Ownership:
Government
©County [I Federal DAunicipal ❑State
Non -government
ElBusiness (If ownership is business, a copy of NCSOS report
must be included with this application)
Individual
2. Industrial Facility (facility being permitted):
Facility name:
Facility environmental contact:
Origin Food Group
Brian Foor
Street address:
City:
State:
Zip Code:
306 Stamey Farm Road
Statesville
NC
28677
Parcel Identification Number (PIN):
County:
Iredell
Telephone number:
Email address:
704-768-9000
[e-mail]
4-digit SIC code:
Facility is:
1
Date operation is to begin or began:
2023
❑ New ❑ Proposed M Existing
2011?
Latitude of entrance:
Longitude of entrance:
35.780507208
80.9733833105
Brief description of the types of industrial activities and products manufactured at this facility:
Ice cream, frozen dessert, drinkable yogurt, cup yogurt
facility processes meat: ©Yes No
r1ft'hestormwaterdischarges to a municipal separate storm sewer system (MS4), name the operator of the MS4:
/A
Page 1 of 5

3. Consultant (if applicable):
Name of consultant:
Consulting firm:
Street address:
City:
State:
Zip Code:
Telephone number:
Email address:
4. Outfall(s) At least one outfall is required to be eligible for coverage.
3-4 digit identifier:
Name of receiving water:
Classification:
❑This water is impaired.
OFG1
hird Creek
Other
❑ This watershed has a TMDL
Latitude of outfall:
Longitude of outfall:
35.7798530
-80.9715547
Brief description of the industrial activities that drain to this outfall:
Loading and unloading trucks. Disposal of trash and debris.
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes [3 No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfalk
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? []Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
All outfalls must be listed and at least one outfall is required. Additional outfalls may be added in the section
"Additional Outfalls" found on the last page of this NOI.
Page 2 of 5

S. Other Facility Conditions (check all that apply and explain accordingly):
O This facility has other NPDES permits.
If checked, list the permit numbers for all current NPDES permits:
NC077615
❑ This facility has Non -Discharge permits (e.g. recycle permit).
If checked, list the permit numbers for all current Non -Discharge permits:
0 This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
0 This facility has a Stormwater Pollution Prevention Plan (SWPPP).
If checked, please list the date the SWPPP was implemented:
❑ 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)
❑ 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
6. Required Items (Application will be returned unless all of the followinz items have been includedl:
0 Check for $100 made payable to NCDEQ
O Copy of most recent Annual Report to the NC Secretary of State
O This completed application and any supporting documentation
El A site diagram showing, at a minimum, existing and proposed:
a) outline of drainage areas
b) surface waters
c) stormwater management structures
d) location of stormwater outfalls corresponding to the drainage areas
e) runoff conveyance features
f) areas where industrial process materials are stored
g) impervious areas
h) site property lines
O Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 3 of 5

7. Applicant Certification:
North Carolina General Statute 143-215.68 (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).
Under penalty of law, 1 certify that:
O 1 am the person responsible for the permitted industrial activity, for satisfying the requirements of this permit, and for any
civil or criminal penalties incurred due to violations of this permit.
O 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.
O I will abide by all conditions of the NCG060000 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.
O I hereby request coverage under the NCG060000 General Permit.
Printed Name of Applicant: Brian Foor
Title: Plant
(Signature of Applicant)
8/12/22
(Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 4 of 5

Additional Outfalls
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes O No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? 10 Yes 0 No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
Page 5 of 5

A' 4 ` �� LIMITED LIABILITY COMPANY ANNUAL REPORT
10=1]"
NAME OF LIMITED LIABILITY COMPANY. Origin Food Group LLC —
SECRETARY OF STATE ID NUMBER: 1139660 STATE OF FORMATION: NC
1139660
REPORT FOR THE CALENDAR YEAR: 2022
SECTION A:
1. NAME OF REGISTERED AGENT: Corporation Service Company
2. SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
2626 Glenwood Ave Ste 550
2626 Glenwood Ave Ste 550
Raleigh, NC 27608 Wake County Raleigh NC 27608
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Manufacturing
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
5. PRINCIPAL OFFICE MAILING ADDRESS
306 Stamey Farm Rd. 306 Stamey Farm Rd.
Statesville, NC 28677 Statesville, NC 28677
6. Select one of the following If applicable. (Optional see instructions)
❑ 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: Eleni Group LLC NAME:
TITLE: Manager TITLE:
ADDRESS:
306 Stamey Farm Road
Statesville, NC 28677
ADDRESS:
NAME:
Yi1111W
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Eleni Group LLC, by Halil Ulukaya President
SIGNATURE
Form must be signed by a Company Official listed under Section C of This forth.
8/2/2022
DATE
Eleni Group LLC, by Halil Ulukaya President Manager
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
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NO 276250525

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