NCGNE1639_Application_20230905

FOR AGENCY USE ONLY
NCGNE
Assigned to: 1B. Coal&
ARO FRO MRO RRO WARO WIRO WSR D���RS\otmwa�tpto9
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCGNEOOOO
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, DEMLR 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 Until you are issued a No Exposure Certification and your NPDES permit is rescinded,your facility must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://deo.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):
out ►uN-, CcL vkckl Iosc- . J ,� 7cr i?A
Street address: City: State Zip Code
3HO(V W. VJ-e"o\refL 'Ave She E CTX-ecjsba" nJG you
Telephone number: Email address:
33(o-`t bl —0p`AO e. oa
Type of Ownership:
Government
❑ County ❑ Federal ❑ Municipal ❑ State
No overnment
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:
5(0.�Lv-- MttkS .T;. . JnsR [ Natn1 60-4y
Street address: Telephone number:
43 (-0640
Email::',:.Press:
City t County State Zip Code
�1;.4&3'
Latitude of entrance:
Longitude of entrance: j ; g A 3`7a2 77`, , eLc20
Parcel Identification Number(PIN):
770-7wat P&
Date operation began: Standard Industrial Classification (SIC) Code:
s to 3p(
Brief description of the types of industrial activities and products produced at this facility:
oc(ks rjL-A c-C'fuu�
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 J
using,storing,or cleaning industrial machinery or equipment remain and are exposed to ❑Yes W0 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 VNo ❑ N/A
Material handling equipment(except adequately maintained vehicles) El Yes No ❑ N/A
Page 3 of 6

Materials or products during loading/unloading or transporting activities ❑Yes VNo ❑ N/A
Materials or products moored outdoors (except final products intended ofride 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, El Yes �No ❑ N/A
and similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑ Yes VNo ❑ N/A
Final products that would be mobilized in stormwater discharges(e.g., rock salt) ❑ Yes VNo ❑ N/A
Waste material (except waste in covered,non-leaking containers[e.g.,dumpsters]) ❑Yes fJNo ❑ N/A
Application or disposal of process wastewater(unless otherwise permitted) ❑Yes EPANo ❑ N/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise ❑Yes eNo ❑ 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
_ a
If you answer"No"to any of the foOW!, tgrrtems yotrtaYe n'of eligible fort a n exposure exclusion ' r,
a M -
Are exterior ASTs or piping free,of rust damagg ed or weathered coating pds',or deteoratton or,,'aa.:
-Yes a�N/A
rn x = , ❑
evidence of leaks? #
Is secondary containment provided for all extenar ASTs?Ifso is it free of any cracks hales or
C -Yes'D No L�N/A
in evidence of leaks, and are drain valves maintaed locked shut? '+ �
..duo- aSFan.ewx«y;nvhcttwv«.: s.'-:e ,nit gSK .a .... ns(inc%lu.` rr" sIssecondary(contm a fgip bvgndta` m ..h hpn a .f
❑Ye., "- '"�
barrels,etc.)with a capacity of more than 660-gallons? - ="
s"❑No Cyl N/A
Is secondary co tail}mentprovided for above grpund storage contamers,.stored m close,Prokimit�°
.i . 1, . , is .;o�,ttgt '4 .:.Ft ❑Yes❑ NoWrv/A
to each other with a combined capacity of more than 1,320 gallons? 1
Is secondary containment provided for Title III Section 313 Superfund Amendments and l�/A
Reauthorization Act(SARA)water priority chemicals? ❑Yes❑ No
Is secondary containment provided for hazardous substances designated in 40 CFR§116? ❑Yes❑ No /A
Are release valves on all secondary containment structures locked? ❑Yes❑ No VNIA
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 eJ Np ❑ N/A
Does this facility store used,recycled,or otherwise reclaimed pallets outside? ❑ Yes eNo ❑ 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 No ❑ N/A
Page 4 of 6

Does this facility have air emissions associated with industrial activity(e.g.,degreasing operations, ❑Yes VNo ❑ N/A
-plating,.painting,or_metaLfinishing)?
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
*._
El Hazardous Waste Disposal Faulity�07'
r BVA
If checked,indicate: % V,
• Kilograms of wastt eir'erated each month # **:"; ffi " +�;
• Type(s) of waste`tr
• How material is stored
•
Where,matenal�sstored ' s a °
• Number of waste shipments per year
• _Name of tlransport/disposal vendor I I -i i*" t t�,v„ �
..
• 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
Page 5 of 6

7. Applicant Certification
NortFCa�ohna General SfafGte`I43=2iS.68(iJ prod that: Any person whoknowmg y mks any false staemen�,
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, 1 certify that:
L 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.
fr� I have read and understand the eligibility requirements for claiming a condition of"no exposure"and obtaining an
exclusion from NPDES stormwater permitting.
IQ 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)).
h 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 understand that in the event that the site no longer qualfies for a No Exposure Exclusion thatl must obtain coverage
under an NPDES permit prior to any,p n so rrce'd&harge of stormwater from"the facility.
a's�a
The information submitted l nthisN01 is t16 thte best ofymy knowledge and belief,true accdr9te 'and complete based on
my inquiry of the persgp or:persons who manage the system;orthose persons directly responable gathering the
information. rs 9 (
csN�R2H Asa QjL�c� a 3 I
Printed Na[n e: f Person Signing - -: �.�� N ; „aJY e, *,,
Title:
3
r=r ' �# P ?11 err'} "7€
Signature of A icant Date Sig ed
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 6 of 6

f
� tS33 r
fill
om
T
�rll �Y� Nr k 4 l794
a G h v+w A f��a ip ad a,f��-I) �x s r T•� N;"p•i G {`t .✓K�':.,t-� i �'} i: f
x^'6#n'beT`a as y �``�` ��i SEY I��iS�'Sblr� Jafikz, � A"`P:•r�' �� l+- i{G j d
[COUNTY
ry �4'1 y � � ^
° "`•+' �02A t
ht{'N
S .r C.r r $ •� z � s �e � h
.� q w �.ns ALL✓✓ ! c G wRB4 '�v� � � ' b
4,4 i!h 4!'1 J: I '1 4`I\t -k•3•y f�',� �� ��..4 ,F-'T�1 I ."� 4 �..��. :I.�GJ'� i'� 1
ll,E gxh x a i+� i ! P7� Sh - fw r 1 SH.��i^ ^ �t# e'ax, r:�.ri*mzx rt^yl �� a aFl 4". i ,•, � n 2
t
Li
t• I R .���,� s � �a "� ��r "� ! ' _ ^ r a � �1� ,1 E r �i u (E+c. �#w§aie
t/ P ?}? i� 3 U' +;`$3T k R14dm`'f rawF '•y W �. x�-.. e '':.`^ ..,a` P '� 1.�i'..�' i d.
I 3 ] ►►e''a r - _tdVA Mick-. -
4 vx'#,k„{,'?r�,;A �,Ll 1' tM
a
i"�:.��a '� h �2'i �'i•.p 1�+>ti+i try' ` �$' `���
�? 4 tfi �
.. ,t �„, ��,• rIN , � :- � ti;- .... � rt�n>»t+a Marx•
9l
p
,ix Y �3 S e i iF•;c t^ t '{ryk �'k
w i �
�;���4���� '' �",'�"' M�+�^"1.� ���� r�, � RANno�PN•cauNTr= � �
i x�'T�5 i I , i• %:1 4'�: �� 3ri�4's - [,yK r W!

8/24/23,3:19 PM GIS Data Viewer
Guilford County, NC
�~, P�"3, v� � r� �� .��-•may�v I,�. ._ r�'�k', �r�i„1."r �„}v9 .
1' ..a GIBSONVI F dE,LON
Ov, i , r _r � t ti;17 Z I,
stint 1 ;
)70
I.v -WHITSETT v () I
%) ti cRn,mx/.70 'Eskrml
V.'$''Aiil',
1v9
,�, - 68 ���7�'JAME TOWN'; � ie _ . 'r °•���� �� r�� � .'PILLAGE OF�AL�MANC
4
Parcel Number 177727 Total Out Building Value 127000
PIN 7709624666 Total Land Value 264000
i
Owner 550 WF LLC Total Deferred Value 0
Mail Address 3406 W WENDOVER AVE STE E Bldg Card 1
Mail city GREENSBORO Appraisal Model Code 1
Mail State NC Deed Data 5/10/2016
Mail Zip 27407 Neighborhood 7709101
Property Address 550 W FAIRFIELD RD Property Type IND
Legal Description 550 WF LLC L01 Structure Size
Deed 007811-02699 Lot Size 6.6
Plat 191-133 Year Built 1972
CopColndo Bedrooms
do
al Assessed 991600 Bathrooms
To al Building Value 600600 Grade Fair r
`* Disclaimer.,While every effort is made to keep information provided over the internet accurate and up-to-date,Guilford County does not certify the Map Scale
M1; authenticity oraccuracyof such information.No warranties,express orimplied,are provided for the records andlormapping data herein,orfor their f inch=3.0 miles
su) use orinterpretation by the User. 8/24/2023
hfps://gisd .guilfordcountyne.gov/guilford/ 1/1

9 BUSINESS CORPORATION ANNUAL REPORT
1/6/2022
NAME OF BUSINESS CORPORATION: Staunton CapjitaLl Inc._ _
0255992 dcg Otbce Use Only
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC E-Filed Annual Report
0255992
REPORT FOR THE FISCAL YEAR END: 12/31/2022 CA202320901188
7/28/2023 02:30
SECTION A: REGISTERED AGENT'S INFORMATION FX� Changes
1. NAME OF REGISTERED AGENT: .Jordan, Robert M
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
3406 W Wendover Ave Ste E 3406 W Wendover Ave Ste E
Greensboro, NC 27407-1527 Guilford County Greensboro, NC 27407-1527
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Manufacturing/Distribution
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3.PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILING ADDRESS
3406 W Wendover Ave Ste E 3406 W Wendover Ave Ste E
Greensboro, NC 27407-1527 Greensboro, NC 27407-1527
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: Robert M Jordan NAME: NAME:
TITLE: President TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
3406 W Wendover Ave Ste E
Greensboro, NC 27407-1527
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business
entitvbbert M Jordan 7/28/2023
K SIGNATURE DATE
Farm must be signed by an officer listed under Section C of this form.
Robert M Jordan President
Print or Type Name of Officer 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,NO 27626-0525