NCGNE1552_Application_20220825

RECEIVED
AUG 2 5 2VI
DENR-LAND QUALITY
1. Owner/Operator (to whom all permit correspondence will be mailed): STORWATER PERMITTINO
Name of legal organizational entity:
Legall responsible pkrson (as signed in Item 7 below):
Street address:
City:
tate
Zip Code
—I,
\3T . C)
Tele hone number:
Email address:
�1
Type of Ownership:
Government
❑ County ❑ Federal ❑ Municipal ❑ 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:
Facif y environm ntal contact:
tMLA'C'
Street address:
Tel hone number:
V63%
E ail address:
City County
State `
lV
Zip Code 1
CT7
Latitude of entrance: �jrJ. a--l�i 1 q `fJ
Longitude of entrance:
Parcel Identification Number (PIN):
Date operation began:
Standard Ir dustri I Classification (SIC) Code:
Brief description of t e types of industrial activities and products produced at this facility:
e
• - - J
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
stormwater
❑ Yes XNo ❑ N/A
Materials or residuals on the ground or in stormwater inlets from spills/leaks
❑ Yes) l No ❑ N/A
Materials or products from past industrial activity
❑ Yes ❑ No EKIN/A
Material handling equipment (except adequately maintained vehicles)
❑ Yes No ❑ N/A
Page 3 of 6

Materials or products during loading/unloading or transporting activities
❑ Yes)l,No ❑ N/A
Materials or products stored outdoors (except final products intended for outside use [e.g., new
cars) where exposure to stormwater does not result in the discharge of pollutants)
❑Yes I�[,No ❑ N/A
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks,
and similar containers
❑ Yes ® No ElN/A
/
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑ Yes R No ❑ N/A
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
❑ Yes EA No ❑ N/A
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes No ❑ N/A
Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes o ❑ N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise
regulated (i.e. under an air quality control permit) and evident in the stormwater outflow
❑ Yes jNo ❑ N/A
Empty containers that previously contained materials that are not properly stored (i.e., not closed
and stored upside down to prevent precipitation accumulation)
❑ Yes ljLNo ❑ N/A
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has
the facility had any releases in the past three (3) years?
❑ Yes 4,No ❑ N/A
'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
p Yes ❑ No K 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 IXN/A
evidence of leaks, and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers (including drums,
p Yes ❑ No 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
❑Yes ❑ No )(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 Wl N/A
Reauthorization Act (SARA) water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
❑ Yes ❑ No [`A N/A
Are release valves on all secondary containment structures locked?
❑ Yes ❑ No tK 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?
❑ YesNo ❑ N/A
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
❑ Yes No ❑ N/A
Does this facility have coal piles on site?
❑ Yes No ❑ N/A
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
❑ Yes EA No ❑ N/A
Page 4 of 6

Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, ❑ Yes I No ❑ N/A
plating, painting, or metal finishing)?
If yes:
Describe the industrial activity:
Are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No
Please specify:
S. 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)
❑ 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)
1AThis completed application and any supporting documentation
)3 copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 5 of 6

7. Applicant Certification
North Carolina General Statute 143-215.66 (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:
❑ 1 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.
❑ 1 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)).
❑ 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 recertification on file at the facility.
❑ 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.
❑ 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 Person Signing:
Title:
Signa ure fApplica t Date Signed
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 6 of 6

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