NCG180263_Application_20230202

RECEIVED
FOR AGENCY USE ONLY FEB 012023
NCG18 01 C3
Assigned to: @, - COOK,
ARO FRO MRO RRO WARD WIRO WSRO DEMLR-Stormwater Program
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG180000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC25 [Furniture and Fixtures], SIC2434 [Wood Kitchen Cabinets], and like activities
deemed by DEMLR to be similar in the process, or the exposure of raw materials, products, by-products, or waste
materials. 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:
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M� �e llP ti02� �r 102�s
Street address:
City:
State:
Zip Code:
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Telephone number:
Email address:
33�4-(&Ss- 350`\
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Type of Ownership: S CpQ.,eOQ�+hU^�
Government
❑County ❑Federal ❑Municipal ❑State
Non -government
IsKusiness (If ownership is business, a copy of NCSOS report must be included with this application)
❑ Individual
2. Industrial Facility (facility being permitted):
Facility name:
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Facility environmental contact:
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Street address:
City:
State:
Zip Code:
Parcel Identification Number (PIN):
County.
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Telephone numb
33La-la ' >Soo\
Email address:
nn.%-'Z.CXr\CCaepQ_�•+v��t\.C��
4-digit SIC code:
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Facility is: ��//
❑ New ❑ Proposed Existing
Date operation is to begin or began:
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Latitude of entrance:
Longitude of entrance:
Brief description of the types of industrial activities and products manufactured at this facility:
If th stormwater discharges to a municipal separate storm sewer system (MS4), name the operator of the MS4:
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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:
I?me of receiving water:
Classifiicajjon:
O This water is impaired.
CC31
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O This watershed has a TMDL.
Latitude of outfall:
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Longitude of outfall:
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Brief description of the industrial activiti s that drain to
is outfall: �^
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Do Vehicle NXintenance 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.
O 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? 0 Yes 13 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 E3 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? E3 Yes El 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

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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 uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
❑ 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----------�-t--�
❑ Hazardous Waste Disposal Facility
-7 If checked, indicate: -, '
Kilograms of waste generated==each month d
i ,' �
T e s of waste
yp O
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r �
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How matenal,is stored: �__._ =
Whereinaterialisstored i
'1
� y
Number of -waste shipments per year:
-Name of transport/disposalvendor
Transport/disposalevendor EPA ID
Vendoraddress:
❑ This facility is located on a Brownfield or Superfund site
If checked, briefly describe the site conditions
6. Re aired Items (Application will be retumed unless all of the following items have been included):
ErCheck for $100 made payable to NCDEQ
Ca'Copy of most recent Annual Report to the NC Secretary of State
This completed application and any supporting documentation
M'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
I'fopy 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 ($10,000).
Under penalty of law, I certify that:
i$ I 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.
W 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. �
ff 'Iwill abide by all conditions of the NCG180000 permit. I understand that coverage under this permit will constitute the
Zrmit requirements for the discharge(s) and is enforceable in the same manner as an individual permit.
I hereby request coverage under the NCG180000 General Permit.
Printed Name of Applicant:t
Title: U Vj t e
� 13A\ Zo23
ignature of p licant) (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 ❑ 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 impa„ired.-.
-.„
�❑This watershed Fias,aaTMDL
Latitude of outfall:
Longitude of outfall:
- -- ;s
r
Brief description;ofthe industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall?
_, 0 Yes ❑ No
If yes, how many gallons of new motor oil are used each`month1when 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

BUSINESS CORPORATION ANNUAL REPORT
,rsnmz
NAME OF BUSINESS CORPORATION: MUF Ana Corporation
SECRETARY OF STATE ID NUMBER: 2109994 STATE OF FORMATION: NC
REPORT FOR THE FISCAL YEAR END: 12/31/2021
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Flores, Miguel Uribe
2. SIGNATURE OF THE NEW REGISTERED AGENT:
E - Filed Annual Report
2109994
CA202210509623
4/1 SM022 02:47
❑X Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
1046 Briles Dr
1046 Briles Dr
Asheboro, NC 27205-2012 Randolph County Asheboro, NC 27205-2012
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Furniture Manufacturing
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
3548 Pine Lakes dr
Asheboro, NC 27205
5. PRINCIPAL OFFICE MAILING ADDRESS
3548 Pine Lakes dr
Asheboro, NC 27205
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: OFFICERS (Enter additional officers in Section E.)
NAME: Miguel Uribe Flores NAME: Felipe Uribe NAME: Javier Uribe
TITLE: Corporate Offer TITLE: President TITLE: Vice President
ADDRESS:
1046 Briles Dr
Asheboro, NC 27205-2012
ADDRESS:
ADDRESS:
355 Deerbeery CT 3544 Pine Lakes Dr
Asheboro, NC 27205-8793 Asheboro, NC 27205-8642
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a personibusiness
entiNiguel Uribe Flores 4/15/2022
SIGNATURE DATE
Form must be signed by an officer listed under Section C of this form.
Miguel Uribe Flores Corporate Officer
Print or Type Name of Officer Pdnt or Type T'Ne of Officer
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Once Box 29525, Raleigh, NC 27626-0525

1130/23, 4:12 PM
Randolph County GIS
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