NCG050472_Application_20230816

re62mi 3110-3
FOR AGENCY USE ONLY
NCGO5 0 *-1 1
Assigned to: $- cc olj�
ARO FRO MRO WARO WIRO S O
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCGO50000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC 23[Apparel and Other Finished Products Made from Fabrics and Similar Materials],
SIC265[Paperboard Containers and Boxes],SIC 267[Converted Paper and Paperboard Products],SIC27[Printing,
Publishing and Allied Industries],SIC 30[Rubber and Miscellaneous Products—except as specified below],SIC 31
[Leather and Leather Products—except as specified below], and SIC 39[Miscellaneous Manufacturing Industries],
and other like activities deemed by DEMLR to be similar in the process and/or the exposure of raw materials,
products, by-products, or waste materials.SIC 301[Tires and Inner Tubes]and SIC 311[Leather Tanning and
Finishing]are specifically excluded from coverage under this General Permit. 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:
Americhem, Inc. Paul (Nick) Brueckner
Street address: City: State: Zip Code:
7279 Liberty Park Ave Liberty NC 27298
Telephone number: Email address:
[phone] [e-mail]
Type of Ownership:
Government
®County ❑Federal E3Municipal ❑State
Non-government
08usiness(If ownership is business,a copy of NCSOS report must be included with this application)
C3 1 ndividual
2. Industrial Facility(facility being permitted):
Facility name: Facility environmental contact:
Americhem, Inc. Hana Cooley
Street address: City: State: Zip Code:
7279 Liberty Park Ave Liberty NC 27298
Parcel Identification Number(PIN): County:
5529 66 8201 /5529 76 1019 Randolph
Telephone number: Email address:
[phone] [e-mail]
4-digit SIC code: Facility is: Date operation is to begin or began:
3087 1 ONew ❑Proposed ElExisting 10/2011
Latitude of entrance: Longitude of entrance:
35.49 22 N 79.33 31 W
Page 1 of 5

Brief description of the types of industrial activities and products manufactured at this facility:
Process custom color masterbatch and additvies in thermoplastic polymers.
If the stormwater discharges to a municipal separate storm sewer system(MS4),name the operator of the MS4:
O N/A
3. Consultant(if applicable):
Name of consultant: Consulting firm:
N/A
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: Name of receiving water: Classification: 0 This water is impaired.
001 lRocky River C O This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
35.49'20" N 79.33'32"W
Brief description of the industrial activities that drain to this outfall:
Rain and snow melt runoff from site-surface of process custom color thermopolymers manufacturing.
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? Dyes D 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: 0 This water is impaired.
002 IRocky River C El This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
35.49'23"N 79.33'35"W
Brief description of the industrial activities that drain to this outfall:
Rain and snow melt runoff from site-surface of process custom color thermopolymers manufacturing.
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? Dyes 0 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.
N/A D 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? D 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 N01.
Page 2 of S

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:
O This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
Storm water Pollution Prevention Plan and Housekeeping Practices.
❑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
❑ 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):
O Check for$100 made payable to NCDEQ
O Copy of most recent Annual Report to the NC Secretary of State
O This completed application and any supporting documentation
El 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
O 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 143-215.66(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:
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.
0 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.
O I will abide by all conditions of the NCG050000 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.
0 I hereby request coverage under the NCGOS0000 General Permit.
Printed Name of Applicant: Paul Brueckner
Title: Plant Manager
5/24/2023
(Signatu icant) (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? F3 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? ❑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 0 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? 13 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

S O Feet . §ar+"'Yi`-ram' ...'xK'x '^Ls ,\ ,-.i+, ��y
1 ,ka's atir v r' nsssssxw -'�€TOL I r1716�33 1
''�-s
Measurement Result
u
—V,
y 1,708.7 Feet
Label all measurements
7f"S.A � A t' E.• � >) ,,,,,r�''i s .xxy (<Y�s � `"�' n �� t - P S s`" '
Double-click to finish a measurement. �" s'• e� w- " `� "� et,Ry` '1 r "y.. 7 "' * * s 'tf
� S«t }
Segment:17.4 Feel >k' "4
Bearing: N28*36'38"yy ,0 , y { `ra1� a�z y �. r j' �✓ * v
t y" 0 *- 2 S i w a it t) i t-'1f*." �� 5 ` K s" "a r r._ S r r k
r ..
Zoom to Coordinate ��
4.r� '" �`4 �; �� s.•�-'yg4, �i�t" a."� � Q. '_q� .�,.a .4 x, t e7i5ue®� 4_
_u',t:+.r I,._c� s. Zoom t0 *`: ..Ysgt k'A' x°"k'� '.�,. 4 'r*:'4.x, , �}l. r ,.-ss xi. +' ari , •}.: ( Y.
x rr f v J ^ a. t .a.• W7W 'Fr n k xjAi i' ;
Extentt.t {� f r�e7E3 187w
a r E t"F # +sy < ti a {�r < r V a +3?+ ,• iii z v a xs s+7a` r,
Me 4cr beau*. c..t
87.Mu 00
' �llr� to 4` ] `fx •\ w .ay7x + >3 a '� ,
,.� • � k�10 yy..,}pRc`.x. .�"[ y 1 .}l� h .�, } h� � x e �l.�M r � 9 4.m' f lR�SV3-.
0- 100 00 2001t.- S sir �... r . •� ♦' x( rk' '[ y{
0-� D "S.
- e _�y, aS. z- r aae � � r, I� � � -1 �'�L�6ew> `'�- ��'9 '��``� �>•,.. 'il
se�urswu:.a..vv r�r ..;�f..:_.>. .. •sk .:
Storm water runoff dumps into the rocky river at last point shown
I
I

' Archd lef
Trinity
Thomasville
Liberty
New Market
Randleman
Americhem
Tabernacle Franklinville
Randolph County, KC
Cedar
Grove