NCGNE1632_Application_20230801

Ne61iE IC 32
AETERRA
RFcFI���
July 26, 2023 DENI(R RUC ` 1d13
•Sto��,�r�r
DEMLR —Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
RE: NSI Electrical —Huntersville Northcross
NPDES No Exposure Certification for Exclusion Application
To Whom It May Concern:
On behalf of NSI Electrical —Huntersville Northcross (NSI), this submittal provides the application for the
NPDES No Exposure Certification (NEC) for Exclusion for the facility below.
Facility Name: NSI Electrical — Huntersville Northcross
Facility Address: 9730 Northcross Center Court
Huntersville, North Carolina 28078
Facility County: Mecklenburg
Facility Contact: Jim Wiedow, Corporate EHS Manager
[e-mail]
[phone]
This application includes the required following information:
The completed application form,
• The most recent Annual Report to the NC Secretary of State,
• A copy of USGS quad sheet with the location of the facility clearly marked.
NPDES No Exposure Certification for Exclusion Application 1/11 07/26/2023
NSI Electrical-Huntersville Northcross

Aeterra, LLC
If you have any questions regarding this submittal or require additional information, please contact Abby
Francis, Aeterra Environmental Consultant.
Sincerely,
rl
%J, _
Abby Francis
Aeterra Environmental Consultant III
260-515-1986
[e-mail]
Cc:
Jim Wiedow, Corporate EHS Manager, [phone]
Cheryl Horn, [e-mail]
Attachments:
No Exposure Certification for Exclusion Application Form
2022 NSI Electrical — Huntersville Northcross Annual Report to the NC Secretary of State
USGS quad sheet with the location of the facility
NPDES No Exposure Certification for Exclusion Application 2/11 07/26/2023
NSI Electrical-Huntersville Northcross

Attachment 1 : No Exposure Certification for
Exclusion Application Form

/Vic( ,)r I�32
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):
NSI Industries,LLC Jim Wiedow
Street address: City: State Zip Code
13235 Reese Boulevard Huntersville NC 28078
Telephone number: Email address:
439-24 [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:
NSI Electrical-Huntersville Northcross Jim Wiedow
Street address: Telephone number:
9730 Northcross Center Court 704 793-7448
Email address:
[e-mail]
City County State Zip Code
Huntersville Mecklenburg NC 28078
Latitude of entrance: 35.448074592998246,
Longitude of entrance: -80.86362458845058
Parcel Identification Number(PIN):
00504232
Dale operation began: Standard Industrial Classification(SIC)Code:
2003 3494
Brief description of the types of industrial activities and products produced at this facility:
Office area,warehouse with shipping and receiving,packaging area for NSI Electrical division.
3. Consultant(if applicable):
Name of consultant: Consulting firm:
Abby Francis Aeterra, LLC
Street address: City: State and zip code:
1 North Franklin,Suite 1875 Chicago IL 60606
Telephone number: Email address:
260-! 1 [e-mail]
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 ❑Yes ® No ❑ N/A
stormwater
Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑Yes ® No ❑ N/A
Materials or products from past industrial activity ❑Yes ® No ❑ N/A
Material handling equipment(except adequately maintained vehicles) ❑Yes ® No ❑ N/A
NPDES No Exposure Certification for Exclusion Application 4/11 07/26/2023
NSI Electrical-Huntersville Northcross

Materials or products during loading/unloading or transporting activities ❑ Yes ® No❑ N/A
Materials or products stored outdoors(except final products intended for outside use[e.g.,new ❑Yes ❑ 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 ❑ No ® N/A
and similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑Yes ® No❑ N/A
Final products that would be mobilized in stormwater discharges(e.g.,rock salt) ❑Yes ❑ 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 ® No ❑ N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise ❑Yes ❑ 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 ® 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 ® 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 not eligible for the no exposure exclusion.
Are exterior ASTs or piping free of rust,damaged or weathered coating,pits,or deterioration,or ❑Yes❑No ® 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 IN N/A
evidence of leaks,and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers(including drums, ❑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 El Yes❑ No M 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 ® N/A
Reauthorization Act(SARA)water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR§316? ❑Yes❑No ® N/A
Are release valves on all secondary containment structures locked? ❑Yes❑No ® 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 ® No ❑ 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 I@ No❑ N/A
NPDES No Exposure Certification for Exclusion Application 5/11 07/26/2023
NSI Electrical-Huntersville Northcross

Does this facility have air emissions associated with industrial activity(e.g.,degreasing operations, ❑Yes ® 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:
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 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)
®This completed application and any supporting documentation
® Copy of county map or USGS quad sheet with the location of the facility clearly marked
NPDES No Exposure Certification for Exclusion Application 6/11 07/26/2023
NSI Electrical-Huntersville Northcross

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:
® 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)).
M I understand that 1 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.
® 1 understand that in the event that the site no longer qualifies for a No Exposure Exc u o t at rpu; obtain coverage
under an NPDES permit prior to anyyoint source discharge of stormwater from the facility.
M The information submitted in;hfs N01 is,to the best of my knowledge and belief,true,accur5te,Fhd complete based on
my inquiry of the person ur persons who manage the system,or those persons directly responible`ior~gathering the
Information. .i,•' i t!" t ''
Printed Na eof Person Si ni
g rtlirnWiedow
rV
�,tyei J
Title: Corporate EH5 Manager
w u� 22 Zo23
SIgrVofAppll n a Sign
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh,NC 27699-1612
- Page 6 of 6
NPDES No Exposure Certification for Exclusion Application 7/11 07/26/2023
NSI Electrical-Huntersville Northcross

Attachment 2; 2022 NSI Electrical — Huntersville
Northcross Annual Report to the NC Secretary of
State

0�r frl' � LIMITED LIABILITY COMPANY ANNUAL REPORT
r„
vsnou
NAME OF LIMITED LIABILITY COMPANY: NSI Industries, LLC
Filiq Offm U.ONy
SECRETARY OF STATE ID NUMBER: 0725468 STATE OF FORMATION: NC E-Filed Annual Report
0725468
17
REPORT FOR THE CALENDAR YEAR: 2023 CA0: 33
1117/2027/2023 10:30
SECTION A:REGISTERED AGENT'S INFORMATION ❑Changes
1.NAME OF REGISTERED AGENT: Corporation Service Company
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
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Raleigh, NC 27608 Wake County Raleigh,NC 27608
SECTION B:PRINCIPAL OFFICE INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS: Sales - Electrical Connectors and Related Products
2.PRINCIPAL OFFICE PHONE NUMBER: (518) 339-331 O 3.PRINCIPAL OFFICE EMAIL: Privacy Redaction
4.PRINCIPAL OFFICE STREET ADDRESS S.PRINCIPAL OFFICE MAILING ADDRESS
9730 Northcross Center Court 9730 Northcross Center Court
Huntersville,NC 28078 Huntersville,NC 28078
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:COMPANY OFFICIALS(Enter additional company officials in Section E.)
NAME: G.R. SChrotenboer NAME: Dave DlDonato NAME:
TITLE: Manager TITLE: Manager TITLE:
ADDRESS: ADDRESS: ADDRESS:
9730 Northcross Center Ct 9730 Northcross Center Ct
Huntersville, NC 28078 Huntersville,NC 28078
SECTION D:CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
G.R.Schrotenboer 1/17/2023
SIGNATURE DATE
Form must be signed by a Company Official listed under Section C of This form.
G.R.Schrotenboer Manager
Print or Type Name of Company Official ednt or Type TNe_of company_Ofricial ——
This Annual Report has been filed electronically.
MAIL TO:Secretary of State, Business Registration Division,Post Office Box 29525,Raleigh,NC 27626-0525
NPDES No Exposure Certification for Exclusion Application 9/11 07/26/2023
NSI Electrical-Huntersville Northcross

Attachment 3 : USGS Map

u.ell SR�Yn, S f J
Y SITE
54Y .Ilp
ramro Y
1 Y
I �/../ •"""' r �°caw* I .
f t �. k B. � iuiurx,ge�a 2r Iz�
mo „ t
O
ttr SO Ln aw.a PF^�� \ �qA
y tY "a"a
Q1Ln IAr
Figure 1: Site Location Map
NSI Electrical - Huntersville Northcross
13235 Reese Blvd West, Huntersville, North Carolina N
Not to Scale I Source: TopoZone
NPDES No Exposure Certification for Exclusion Application 11/11 07/26/2023
NSI Electrical-Huntersville Northcross