NCG210509_Application_20230417

)ocuSign Envelope ID: 954DA68A-F603-447B-9F5D-8275CD18B4DE
FOR AGENCY USE ONLY NC Dept of Environmental Quality
NCG21 0 5 o q
Assignedto: S• C \1'
ARO FRO MRO R WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land QualitVAiftlolulU#ice
National Pollutant Discharge Elimination Systm
NCG21O000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC 24 [Timber Products, including Wood Chip Mills — except as specified below] and like
activities deemed by DEMLR to be similar in the process and/or the exposure of raw materials, products by-
products, or waste materials. The following activities are specifically excluded from coverage under this General
Permit: SIC 2434 [Wood Kitchen Cabinets], SIC 2491 [Wood Preserving], and SIC 2411 [Logging]. 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:
Pacific Mulch, Inc.
Scotty Hipps
Street address:
City:
State:
Zip Code:
650 Peter Gill Road
Henderson
Nonh Carolina
127537
Telephone number:
Email address:
1 [phone]
[e-mail]
Type of Ownership:
Government
OCounty ❑Federal ❑Municipal ❑State
Non -government
0 Business (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:
Pacific Organics
Scotty Hipps
Street address:
City:
State:
Zip Code:
650 Peter Gill Rd
Henderson
North Carolina
27537
Parcel Identification Number (PIN):
County:
G457 01013
Vance
Telephone number:
Email address:
1 [phone]
scottyrelpacific-organics.com
4-digit SIC code:
Facility is:
Date operation is to begin or began:
5099
1 0 New 0 Proposed D Existing
2004
Latitude of entrance:
Longitude of entrance:
I
36015'43.00"N
78023'50.33'W
Brief description of the types of industrial activities and products manufactured at this facility:
Potting Mix Media Base
This facility will produce Wood Pellets: DYes ONo
If the stormwater discharges to a municipal separate storm sewer system (MS4), name the operator of the MS4:
O N/A
Page 1 of S

DocuSign Envelope ID: 954DA88A-F603-447B-9F5D-8275CD1884DE
3. Consultant (if applicable):
Name of consultant:
Consulting firm:
Stacey A. Smith
Smith Gardner, Inc.
Street address:
City:
State:
Zip Code:
14 North Boylan Avenue
Raleigh
North Carolina
127603
Telephone number:
Email address:
[phone]
stacey®smithgardnehnc.com
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.
SDO-01
Lynch Creek
C;NSW
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
36015'36.22"N
78023'52.33"W
Brief description of the industrial activities that drain to this outfall:
Potting Mix Media Base
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? El Yes ❑ No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
-55
3-4 digit identifier:
Name of receiving water:
Classification:
❑ This water is impaired.
SDO-02
Lynch Creek
C;NSW
❑ This watershed has a TMDL.
Latitude of outfall:
Longitude of outfall:
36015'32.53"N
78°23'48.00"W
Brief description of the industrial activities that drain to this outfall:
Potting Mix Media Base
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? El Yes E3 No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
-55
3-4 digit identifier:
Name of receiving water:
Classification:
❑This water is impaired.
SDO-03
Lynch Creek
C;NSW
❑This watershed has a TMDL
Latitude of outfall:
Longitude of outfall:
36015'35.06"N
78023'45.31 "W
Brief description of the industrial activities that drain to this outfall:
Potting Mix Media Base
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 month when averaged over the calendar year?
-55
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? 0 Yes E3 No
If yes, how many gallons of new motor oil are used each month when averaged over the calendar year?
All outtalk must be listed and at least one outfall is required. Additional outfalls may be added in the section
"Additional Outfalis" found on the last page of this NCI.
Page 2 of 5
I

)ocuSign Envelope ID: 954DA88A-F603-447B-9F5D-8275CD18B4DE
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:
O This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
Diversion berms, retention ponds
❑ This facility has a Stormwater Pollution Prevention Plan (SWPPP).
If checked, please list the date the SWPPP was implemented:
TBD
❑ 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 following items have been included):
0
Check for $100 made payable to NCDEQ
0
Copy of most recent Annual Report to the NC Secretary of State (if applicable)
0
This completed application and any supporting documentation
0
A site diagram showing, at a minimum, eAsting 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 materials are stored
g)
impervious areas
h)
site property lines
0
Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 3 of 5

DocuSign Envelope ID: 954DA88A-F603-447B-9F5D-8275CD18B4DE
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).
Under penalty of law, I certify that:
0 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.
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, orthose persons directly responsible for gathering the
information.
0 1 will abide by all conditions of the NCG210000 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 NCG210000 General Permit.
Printed Name of Applicant: Scoff Hipps
Title: General Manager
o«us�an.a M:
, ffs 4/12/2023
0 EB]E9 lU66..
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, INC 27699-1612
Page 4 of 5

0 BUSINESS CORPORATION ANNUAL REPOR'INC u,:p .), YLnviror.mental Qualix
1/fi12022
NAME OF BUSINESS CORPORATION: Paciflc Mulch, Inc.
0733877ng 9e my
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: INCNC
E - Filed An 1 Re ort
Raiet i2,tp
rglol'* Ce
REPORT FOR THE FISCAL YEAR END: 12/31/2022 CA202303203574
2/1/202305:30
SECTION A: REGISTERED AGENT'S INFORMATION ❑X Changes
1. NAME OF REGISTERED AGENT: CUnninham, George R. Jr
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
650 Peter Gill Road 650 Peter Gill Road
Henderson, NC 27537 Vance County Henderson, NC 27537
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
650 Peter Gill Road
5. PRINCIPAL OFFICE MAILING ADDRESS
650 Peter Gill Road
Henderson, NC 27537 Henderson, NC 27537
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: George R. Cunningham , Jr NAME:
TITLE: President TITLE:
ADDRESS:
1309 Heritage Club Ave
Wake Forest, NC 27587
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business
ena&orge R. Cunningham Jr 2/1/2023
Foon must be signed by an officer listed under Section C of this form.
George R. Cunningham Jr
Print or Type Name of Officer
DATE
President
Print or Type Title of Officer
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

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DocuSign Envelope ID: AD40FBDD-673B-4B63-A389-4DF6D2A4BD3F
SMITHAARDNER
ENGINEERS
April 13, 2023
Thad Valentine
Environmental Senior Specialist
Division of Energy, Mineral Land Resources
Department of Environmental Quality
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
RE: Pacific Organics
NCG21 Notice of Intent
Vance County, North Carolina
Dear Thad:
ABORESS TEL WEB
14 N. Boylan Avenue. Raleigh NC 27603 919.828.0577 wwwsmithgardnednc.com
NC Dept of Environmental Quality
APR 13 2023
Raleigh Regional Office
On behalf of Pacific Organics, Smith Gardner, Inc. IS+G) is submitting the attached NCG21
Notice of Intent WOO application package for the active timber products facility located in
Henderson, North Carolina.
The following documents are attached for the application package:
• Check for $100 made payable to NCDEQ
• Copy of most recent Annual Report to the NC Secretary of State
• Completed application and any supporting documentation
• A Site plan
• USGS quad sheet with location of the facility
Please contact us with comments of questions at 919-828-0577 or by email below.
Sincerely,
SMITH GARDNER, INC.
D«usi9nea by.
/FFA09669MMDE.
Lou J. Krasuski
Staff Engineer, Ext. 154
loufasmithgardnerinc.com
Att. NCG21 NOI Application Package
CC: Scotty Hipps, Pacific Organics
CDcusignb4S FA
0.LM: 45'r
Stacey A. Smith, P.E.
Senior Engineer, Ext. 127
stacevfasmithgardnerinc.com
File
H:\Projects\Pacific Organics [Vance County. NCI\01 Compliance\NPDES\N01\NCG21 N01 Cover Letter.docx

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0 1.000 2.000 3.000 4.000
Feet
YARD WASTE FACILITY
650 PETER GILL RD
HENDERSON,NC27537
SITE LOCATION MAP
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♦�'� SITE LOCATION
REFERENCE
1. USGS 7.5-MIN QUAD "HENDERSON, NC'. DATED
2022.
SMITH GARDNER
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JD M L 1:24,000 Apr.2023 PACIFIC-23-1 2