NCGNE1595_Application_20230314

FOR AGENCY U E NLY REC;EIv _D
NCGNEl� _ MAR 14 2023
Assigned to: COOK
ARO FRO MRO 5 WARO WIRO WSRO DEMLR-Stormwater Program
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCGNE0000
Submission of this No Exposure Certification constitutes notification that your facility does not require a permit for
stormwater discharges associated with industrial activity in the State of North Carolina because it qualifies for a no
exposure exclusion. A condition of no exposure at an industrial facility means all industrial materials and activities
are protected by a storm resistant shelter (with some exceptions) to prevent exposure to rain, snow, snowmelt,
and/or runoff. Industrial materials or activities include, but are not limited to:
• material handling equipment or activities, • by-products,
• industrial machinery, • final products, or
• raw materials, • waste products.
• intermediate products,
Material handling activities include the storage, loading and unloading, transportation, or conveyance of any raw
material, intermediate product, final product, or waste product.
A storm resistant shelter is not required for industrial materials stored in the following container types, provided
the containers are not deteriorated and do not leak:
• drums, • tanks, and
• barrels, • similar containers.
For new facilities, applicants should apply no earlier than 60 days before the start of operation. This will allow
DEMLR staff to verify conditions during active operation. For facilities that already have an industrial stormwater
permit in North Carolina, DEMUR must approve your application for No Exposure Certification before this exclusion
is effective. Until you are issued a No Exposure Certification and your NPDES permit is rescinded, your facility must
continue to abide by the terms and conditions of the current permit.
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. Additionally,
the exclusion from NPDES permitting is available on a facility -wide basis only — not for individual outfalls. If any
industrial activities or materials are, orwill be, exposed to precipitation, the facility is not eligible forthe no exposure
exclusion. By signing and submitting this No Exposure Certification form, you certify that a condition of no exposure
exists at this facility or site and are obligated to comply with the terms and conditions of 40 CFR 122.26(g).
For new facilities, applicants should not apply more than 60 days before the start of operation date. This
If approved, your conditional No Exposure Certification has no expiration date but must be self -recertified at least
annually. Please look for information about recertification under the No Exposure section on this page:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/npdes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 1612 MSC, Raleigh, NC 27699-1612. The submission of this form does not guarantee
exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a site
inspection will be conducted.
Page 1 of 6

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):
McLane Foodservice, Inc.
Michell Saxon
Street address:
City:
State
Zip Code
2641 Meadowbrook Road
Rocky Mount
NC
27801
Telephone number:
Email address:
252-450-4755
[e-mail]
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:
Facility environmental contact:
McLane Rocky Mount 01
Michell Saxon
Street address:
Telephone number:
2641 Meadowbrook Road
252-450-4755
Email address:
[e-mail]
City
County ;: --
State - - -
Zip Code
Rocky Mount
Edgecombe ; �`
North Carolina': ;"
27801--`0,
Latitude of entrance: 35.9324:"" '�• ' I,', y.. '' th
Longitude of entrance: ,-77.7449 c
Parcel Identification Number (PIN) ---
.. ..
3779-16-32J
_ -
Date operation began:''"- `' "" ' " " _...
StandardIndustrial Clas"sfication (SIC) Code:"`
8/1/1977
4225'„
Brief description pfShe types of,.industrial actiwtie@�and.prpducts produced atthis faahty:�;.
Activities include the receipt, storage (dry and cold), packaging, and distribution of wholesale grocery and merchandise.
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 X No ❑ N/A
Materials or residuals on the ground or in stormwater inlets from spills/leaks
❑ Yes X No ❑ N/A
Materials or products from past industrial activity
❑ Yes X No ❑ N/A
Material handling equipment (except adequately maintained vehicles)
❑ Yes X No ❑ N/A
Page 3 of 6

Materials or products during loading/unloading or transporting activities
❑ Yes X No ❑ N/A
Materials or products stored outdoors (except final products intended for outside use [e.g., new
❑ Yes X No ❑ N/A
cars] where exposure to stormwater does not result in the discharge of pollutants)
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks,
❑ Yes X No ❑ N/A
and similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑ Yes X No ❑ N/A
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
❑ Yes X No ❑ N/A
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes X No ❑ N/A
Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes X No ❑ N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise
❑ Yes X No ❑ N/A
regulated (i.e. under an air quality control permit) and evident in the stormwater outflow
Empty containers that previously contained materials that are not properly stored (i.e., not closed
❑ Yes X No ❑ N/A
and stored upside down to prevent precipitation accumulation)
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has
❑ Yes X No ❑ N/A
the facility had any releases in the past three (3) years?
'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 hot'ehgible forthe no exposure exclusion a
Are exterior ASTs or piping free ofru'st' damaged orweath`ered coating, pits,.or deterioration or
evidence of leaks?
XYes ❑Nq ❑ N/A
Is secondary containmeht provided for all exterior'ASTs�df sor is it free ofahy cracks, :holes, or'XYes
❑
evidence of leaks, and are drain valves -maintained locked shut? S '.. .-
❑No' N/A
Is secondary.containment.provided for single above ground storage containers (including drums,
barrels, etc.) with a capacity of more than 660-gallons? -" "�:. `XYes
0No ❑ N/A
Is secondary containmefor4. nt provided,above ground storage contamers.stored m close;proxrmrty' -
to each other with a combined capacity of more than 1,320 gallons?
❑Yes ❑ No X N/A
Is secondary containment provided for Title III Section 313 Superfund Amendments and
Reauthorization Act (SARA) water priority chemicals?
❑ Yes O No X N/A
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
❑ Yes ❑ No X N/A
Are release valves on all secondary containment structures locked?
X Yes ONo ❑ 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?
❑ Yes X No ❑ N/A
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
❑ Yes X No ❑ N/A
Does this facility have coal piles on site?
❑ Yes X No ❑ N/A
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
❑ Yes X No ❑ N/A
Page 4 of 6

Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, ❑ yes X 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: '
f w�
• Kilograms of waste generated each month, i
• Type(s) of waste:
• How material is stored;.
x
• Where material is stored:
• Numberof wasteshipments peryear.
• 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):
x❑ Copy of most recent Annual Report to the NC Secretary of State (if applicable)
❑O This completed application and any supporting documentation
® 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 143-215.6E (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:
O I 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.
0 1 have read and understand the eligibility requirements for claiming a condition of "no exposure' and obtaining an
exclusion from NPDES stormwater permitting.
IR 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 recertifications on file at the facility.
I] I understand that in the event that the site no longer qualifies for a No Exposure.Exdusion.that,l.mustobtain coverage
. S------ ---- :u i F.
under an NPDES permit prior to any,point source, discharge of3tormwater from the facility.
0 The information submitted m thi`s9N01 a, to the best of my knowledge and belief, true, accurate, and complete based on
my inquiryof the personforrpersons who manage the system or those persons directly responsible for gathering the
information.._
Printed Namelof Person
Title:
Signature of Applicant 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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REFERENCED FROM USGS 7.5 MINUTE QUARDRANGLE
<RARTSFASE, NC 2022>
<ROCI<Y MOUNT. NC 2022>
MCLANE ROCKY MOUNT 01
2641 MEADOWBROOK ROAD
2 ILEGEND
ROCKY MOUNT, NC 27801
SITE BOUNDARY
RepaN
0 1500 3000 4500' NO EXPOSURE CERTIFICATION FOR
EXCLUSION APPLICATION
DmWng
FACILITY LOCATION MAP
Date November ], 2022 Scale AS SNOWN Figure No.
SLR FaeplaaMsne-Rocky�M..�tCl NEC

re�w„
cPt' � BUSINESS CORPORATION ANNUAL REPORT
I,NINg
NAME OF BUSINESS CORPORATION: McLane Foodservice Distribution, Inc.
SECRETARY OF STATE ID NUMBER: 0073590
REPORT FOR THE FISCAL YEAR END: 12/31/2021
SECTION A:
STATE OF FORMATION: NC
1. NAME OF REGISTERED AGENT: CT Corporation System
2. SIGNATURE OF THE NEW REGISTERED AGENT:
Hing Office Use only
E - Filed Annual Report
0073590
CA202210415147
4/14/2022 05:00
❑X Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS & COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
160 Mine Lake Ct Ste 200
Raleigh, NO 27615 Wake County
SECTION B:
160 Mine Lake Ct Ste 200
Raleigh, NO 27615
1. DESCRIPTION OF NATURE OF BUSINESS: GROCERY WHOLESALE DISTRIBUTION
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
5. PRINCIPAL OFFICE MAILING ADDRESS
4747 MCLANE PARKWAY PO Box 6115
TEMPLE, TX 76504
TEMPLE, TX 76503-6115
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: Lawrence M Parsons NAME: Kevin J Koch
TITLE: .Secretary TITLE: Treasurer
ADDRESS:
ADDRESS:
NAME: Caroline R Mann
TITLE: Assistant Treasurer
ADDRESS:
4747 McLane Parkway 4747 McLane Parkway 4747 McLane Parkway
Temple, TX 76504 Temple, TX 76504 Temple, TX 76504
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business
enilrk D Zwerneman 4/14/2022
SIGNATURE
Fours must be signed by an officer listed under Section C of this torte.
Mark D Zwerneman Assistant Secretary
Print or Type Name of Officer Print or Type Title of Officer
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

SECTION E: ADDITIONAL OFFICERS
NAME: ANTHONEY W FRANKEN13ERGER NAME: SUSAN E ADZICK NAME: Mark D Zwememan
TITLE: Chief Executive Officer TITLE: President TITLE: Assistant Secretary
ADDRESS: ADDRESS: ADDRESS:
4747 McLane Pkwy 4747 MCLANE PKWY 4747 McLane Pkwy
Temple, TX 76504 TEMPLE, TX 76504 Temple, TX 76504
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