NCG081041_Application_20230615

-,
FOR AGE Cyy E ONLY -CEiVED
NCGOS ll JUN 141013
Assigned to: dk ARO FRO MRO RRO WARD WIR C MLR-Stormwater Program
SRO
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG080000 Notice of Intent
i
This General Permit covers STORM WATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC 40[Railroad Transportation],SIC 41[Local and Suburban Transit and Interurban
High way Passenger Transportation],SIC 42(Motor Freight Transportation and Warehousing—except for SIC
4221-42251,SIC 43[United States Postal Services],SIC 5171]Petroleum Bulk Stations and Terminals—when total
petroleum site storage capacity is less than 1 million gallons]. The following activities are also included:other
industrial actives where the vehicle maintenance area(s)are the only area requiring permitting;stormwater
discharges from oil water separators and/ar from secondary containment structures associated with petroleum
storage facilities with less than 1 million gallons of total petroleum site storage capacity. You can find information
on the DEMLR Stormwater Program at deq.ncgov/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:
Terra Nova Solutions. LLC Byron Bellman
Street address: City: State: Zip Code:
127263
Telephone number: Email address:
TN [e-mail]
Type of Ownership:
Government
❑County ❑Federal ❑Municipal ❑State
Non-government
112313usiness(If ownership is business,a copy of NCSOS report must be included with this application)
❑Individual
2. Industrial Facil facility being permitted):
Facility name: Faclhty environmental contact: ayleA Xt(tyq„
TArra Nr)vq Solutions -H'ah Point F Terra Nova to Prqvwde
Street address: City: t ((`� State: Zip Code:
Parcel Identification Number(PIN): County: Ut`TOtl 8C-
Telephone number: Email address:
bbt mwn@k%iWi co
4-digit SIC code Facility is: Date operation is to begin or began:
El New ❑Proposed MExistin Trra Nolat Pirnwitlo
Latitude of entrance: Longitude of entrance:
o o o 28 n
Page 1 of 5

Brief description of the types of industrial activities and products manufactured at this facility:
Soldfication of non-hazardous flaund waste and waste water treatment
If the stormwater discharges to a municipal separate storm sewer system(MS4), name the operator of the li
O N/A
3. Consultant(if applicable):
Name of consultant: Consulting firm:
Alessandra Braswell Geosyntec Consultants of NC, P.C.
Street address: City: State: Zip Code:
314 Walnut Street Suite 200 Wilminaton NQ 128401
Telephone number: Email address:
II
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.
Cre k Class (;: W ❑O This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
350 .8742" ' 2 "
Brief description of the industrial activities that drain to this outfall:
Sioldfication of non-hazardous I*au*d wastes truck r)arkana
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? E]Yes ❑No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
55 Gallons
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?
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):
❑This facility has other NPDES permits.
1 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:
0 This facility uses best management practices or structural stormwater control measures.
If checked,briefly describe the practices/measures and show on site diagram:
Ri -ra rainaae ditches and stormwater drainage system re used to a
�. 0 This facility has a Stormwater Pollution Prevention Plan(SWPPP).
If checked,please list the date the SWPPP was implemented:
Arril2023
❑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 a mate is-1'—sto�edf
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
O This completed application and any supporting documentation
0 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
0 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 143-215.6B(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).
i
Under penalty of law,I certify that:
O 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.
!+ El 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.
0 I will abide by all conditions of the NCGO80000 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.
1 O I hereby request coverage under the NCG080000 General Permit.
Printed Name of Applicant:Byron Bellman
I
Title: Director of Health &Safety
(Sig atureof,Applicant) (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`Outfalis
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
' 1 ❑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.
i 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:
i
Brief description of the industrial activities that drain to this outfall•
i
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

- - - Annual-Report to the NC-
Secretary of State

CA202306500789
SOSID:0766635
�`- Date Filed:3/6/2023
BUSINESS CORPORATION ANNUAL REPO
t� _ s Elaine F.Marshall
forth Carolina Secretary of State
uaruu - -- - - -- - - - - -- -- - - CA2023 065 00789
NAME OF BUSINESS�CORPORATIOM Zebra_Environmental:&Industrial Se .
0766635 d.V my usa y
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC
REPORT FOR THE FISCAL YEAR END: 12/31/2021 '91� RE
SECTION A: REGISTERED AGENT'S INFORMATION
RIA
fF ❑X Changes
1.NAME OF REGISTERED AGENT: U RS Agents, LLC
2.SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3.REGISTERED AGENT OFFICE STREETADDRESS&COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Raleigh, NC 27615 Wake Raleigh, NC 27615 Wake
SECTION B:PRINCIPAL OFFICE.INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS: Environmental.& Industrial Services
2-.PRINCIPAL-OFFICE PHONE NUMBER: [phone] 3.PRINCIPAL OFFICE EMAI Privacy Redaction
4.PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILING ADDRESS
901 East Springfield Road 901 East Springfield Road
High Point,NC 27263 2017 Guilford High Point,NC 27263-2017 Guilford
6.Select one of the following if applicable.(Optional see instructions)
❑ Ther 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: Michael Cauthen NAME: NAME:
TITLE: Chief Financial Officer TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
PO Box 357
High Point, NC 27261 Guilford
SECTION D:CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirely by a personibusiness
entity. M 1 e March 2,2023
SIGNATURE DATE
Form must be signed by an oRcer Ilsted under Secliori C of this form.
Michael Cauthen Chief Financial Officer
Print or Type Name or Officer Print or Type.Title or officer
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF$25
MAIL TO:,Seuetary of State. Business Aegislracon Division,Post Once Box 29525,Raleigh,NC 276280525

- -- -- Figures

822
Acreage
Untamed Tributary to Richland Creek 82o e2z Site Area: 13.7
Area exposed to
Industrial Activity: 4.0
�e
Outfall001
Lat: 350 56'6.8742"
Long:-79° 58'29.298"
Impervious Drainage Area: 4.0 ac
m N
W p
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� A
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Outfall 001
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g74
'- .i�TIV ! 816 T6
8
\ ,.. td Road aqg
E SPt1n9f\e o 678
Legend �F
Q Ouffall Main Site Building N
® Spill Kits Non-Hazardous Waste Processing Building Site Map
S1ormWaler Drain Storage Building
Stream Panung and Leydmn/Storage Area 901 E Springfield Road
—► Stormwater Runoff Impervious Surfaces
High Point,North Carolina
— Topographic Contour Site Boundary
® French Drain Geosyntec
!__�i Rip Rap Drainage Ditch '1 +..
Notes: cDnsWmn s
1.Aerial imagery obtained through ESRI online database.
2.Parcel boundary information provided by NC One Map GIS vrebsite. GeeFigure
syntec Censultavts a(NC.P.C.PC. 9
3.Site is comprised of Guilford County Tax Parcel 179789.
4.Building and road labels sourced from Google Maps. 1
5.Site features locations are based on observations made from Geosyntec personnel during 18 Wlmington.NC January 2023
October 2022 site visit.
N:\T\Terra Nova\GN9050 Compliance Program\Environmental Compliance\High Paint NC\Stormvvater,Pennits and Plans\SWPPP Figure.msd 1/11/2023 1'.29:49 PM

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