NCG050473_Application_20240315

FOR AGENCY USE ONLY
NCG05 0 Lk -L3
Assigned to: 'o•• COS
ARO FRO M RRO WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG050000 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],
SIC 265[Paperboard Containers and Boxes],SIC 267[Converted Paper and Paperboard Products],SIC 27[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 row 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:
POLYKEMI AMANDA CLEMMER
Street address: City: State: Zip Code:
2800 REPI COURT DALLAS NC 28034
Telephone number: Email address:
980-748-0267 [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 being permitted):
Facility name: Facility environmental contact:
POLYKEMI AMANDA CLEMMER
Street address: City: State: Zip Code:
2800 REPI COURT DALLAS NC 28034
Parcel Identification Number(PIN): County:
3547312173(PARCEL#219981) GASTON
Telephone number: Email address:
980-748-0267 [e-mail]
4-digit SIC code: Facility is: Date operation is to begin or began:
3087(NAICS 325991)1 ❑ New ❑ Proposed W Existing 2022
Latitude of entrance: Longitude of entrance:
35°17'58.81"N 81°12'3.25W
Page 1 of 5

Brief description of the types of industrial activities and products manufactured at this facility:
PLASTIC MOLDING COMPANAY
If the stormwater discharges to a municipal separate storm sewer system(MS4),name the operator of the MS4:
9 N/A
3. Consultant(if applicable):
Name of consultant: Consulting firm:
CHALAM PAKALA CP ENGINEERING AND ENVIRONMENTAL SOLUTIONS
Street address: City: State: Zip code:
10017 ALLYSON PARK DR. CHARLOTTE NC 28277
Telephone number: Email address:
704-756-7451 1 [e-mail]
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.
-01 1 UNNAMMED TRIBUTARY TO LONG CREEK C ❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
35"17'54.37"N 81°12'5.06"W
Brief description of the industrial activities that drain to this outfall:
FACILITY ROOF DRAINS, BAG FILTER AREA AND YARD STORAGE OF PLASTIC PELLETS
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes 8 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?
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 NCL
Page 2 of 5

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:
B This facility uses best management practices or structural stormwater control measures.
If checked,briefly describe the practices/measures and show on site diagram:
DETENSION POND TO COLLECT ALL STORMWATER FROM THE SITE
Ii This facility has a Stormwater Pollution Prevention Plan(SWPPP).
If checked, please list the date the SWPPP was implemented: IN PREPARATION
❑This facility stores hazardous waste in the 100-year floodplain.
If checked,describe how the area is protected from flooding: A 1 A
❑This facility is a(mark all that apply) I V i1
❑ 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):
B Check for$120 made payable to NCDEQ
Ii Copy of most recent Annual Report to the NC Secretary of State
8 This completed application and any supporting documentation
B 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
I@ 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).
Under penalty of law, I certify that:
B 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.
B 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.
M 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.
8 I hereby request coverage under the NCG050000 General Permit.
Printed Name of Applicant: AMANDA CLEMMER
Title: EHSQ MANAGER
(Signature of 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 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? ❑ 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: Fr-1
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 ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
Page 5 of 5

i
FIGURES
Figure— 1 Site USGS TOPO Map
Figure—2 Site Aerial Map

Map Name: GASTONIA NORTH Scale: 1 inch = 2,000 ft.
Print Date: 03/07/24 Map Center: 035° 17' 58.56" N, 081° 12'03.25"W
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SCALE 1:24000 SITE LOCATION MAP
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DALLAS, NC 28034
FEET FIGURE 1 JOB NO. 1231-001

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COPY OF MOST RECENT ANNUAL REPORT TO THE NC SECRETARY
OF STATE

`t ' BUSINESS CORPORATION ANNUAL REPORT
t,,jr I
NAME OF BUSINESS CORPORATION: Polykemi Holding,Inc.
2493944 Ung Office Use
Only
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC E-Filed Annual Report
2493944
REPORT FOR THE FISCAL YEAR END: 12/31/2022 CA202310006573
4/10/2023 02.47
SECTION A. REGISTERED AGENTS INFORMATION ❑K 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: To hold ownership interests in other operating entities.
2.PRINCIPAL OFFICE PHONE.NUMBER: [phone] 3.PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 5.'PRINCIPAL OFFICE MAILING.ADDRESS
2800 Repi Ct 70 W.Madison St.,Suite 5750
Gastonia;NC 28052 Chicago, IL 60602
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: Mats Ola HugoSOn NAME: Johan Lars Viktor Hugoson NAME: Thomas H. Thorelli
TITLE: President TITLE: Assistant Vice President TITLE: Secretary
ADDRESS: ADDRESS: ADDRESS:
2800 Repi Ct 2800 Rep!Ct. 70 W.Madison St.,Suite 5750
Gastonia,NC 28052. Gastonia,NC 28052 Chicago,IL 60602
SECTION D:CERTIFICATION OF ANNUAL REPORT, Section D must be completed in its entirety by a person/business
en Thomas H.Thorelli 4/10/2023
SIGNATURE DATE
Fonn must be signed by an officer Rated under Section C of this form.
Thomas H.Thorelli Secretary
Print or Type Name of Olficar Print or Type Title of Officer
MAIL TO:Secretary of State. Business Registration Division,Post Office Box 29525.Raleigh,NC 276260525

SECTION E:ADDITIONAL OFFICERS
NAME: Lars Ola Hugosson NAME: NAME:
TITLE: Treasurer TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
2800 Repi Ct.
Gastonia, NC 28052
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:'
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ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:

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Chalam Pakala Engineering and Environmental Solutions
10017 Allyson Park Dr.,Charlotte,NC 28277 Tel[phone],Fax:[phone]
March 6,2024
Ms. Brittany Cook,Permit Coordinator
NC DEMLR— Stormwater Permitting Unit
1612 Mail Service Center
Raleigh,North Carolina 27699-1612
Phone: [phone]
Email: Brittanv.cook(a deq.nc.gov
Re: NPDES Stormwater General Permit(NCG050000)Approval Request
Polykemi
2800 Repi Court
Dallas,Gaston County North Carolina 28034
CPEES Project No. 1231-001
Dear Mrs. Cook:
On behalf of Polykemi located at 2800 Repi Court, Dallas, Gaston County, North Carolina,CP
Engineering and Environmental Solutions(CPEES)is pleased to submit the attached Stormwater
NPDES General Permit(NCG050000)request for the subject facility operations. The facility
manufactures custom plastic molding parts and the operations are conducted under SIC/NAICS
Code 3087/325991, "Custom Compounding of Purchased Plastics Resin". We intend to
discharge stormwater from the facility roof drains and yard to the outfall (Outfall-01)via a
detention pond located west of the site. The outfall location with lat/long is provided on the Site
Map. Currently,NO process wastewater is being discharged to the stormwater outfall.
The Stormwater NPDES General Permit Application package includes:
• A check for$120 Payable to NC DEQ:
• A signed NC DELMR supplied NCG050000 NOI application;
• Copy of most recent Annual Report to the NC Secretary of State
• USGS TOPO Map;
• Site Aerial Map;
• County GIS Map; and
• TMDL and 303(d) Maps.
Please call me at 704-756-7451 or Ms. Amanda Clemmer at 980-748-0267 should you have any
questions on this permit application request.
Respectfully submitted,
CP Engineering and Environmental Solutions t1CAR I //
(A Cost Effective Solution Provider for Manufacturing ��`C�'`F S s `1k
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SEAL
V� .19S07�F�"
Managing Principal Chalam V. t ala, .E. /','yA�� i i�Pp`` 03/06/2024
Attachment: NPDES NCG050000 Application Package

NPDES STORMWATER GENERAL PERMIT (NCG050000) NOI FORMS