NCGNE0827_COMPLETE FILE - HISTORICAL_20111213

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V C& Nt U $a9
DOC TYPE 19/1-1ISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ aoli Ia Ic3
YYYYMMDD

NCDENR
North Carolina Department of Environment and Natural Resources
Division of water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 13, 2011
Grace Food Distribution, Inc.
Attn: Kuong Chung (Ben) Chui, Owner
77 North 1s' Street
Brooklyn, NY 11211
Subject: No-Exposure Certification NCGNE0827
Grace Food Distribution, Inc.
Wake County
Dear Mr. Chui:
The.Division has reviewed your submittal of the No-Exposure Certification for Exclusion from
NPDES Stormwater Permitting form. Based on your submittal and signed certification of no
exposure at the above referenced facility, the Division is granting your conditional exclusion from
permitting as provided for under 40 CFR 126.22(g), which is incorporated by reference in North
Carolina regulations. We are also hereby rescinding your current permit Certificate of Coverage,
NCG060313.
Please note that by our acceptance of your no-exposure certification, you are obligated to
maintain no-exposure conditions at your facility. If conditions change such that your facility can
no longer qualify for a no-exposure exclusion, you are obligated to immediately obtain NPDES
permit coverage for your stormwater discharge. Otherwise, the discharge becomes subject to
enforcement as an un-permitted discharge. You must self re-certify annually using the included .
form, or obtain NPDES permit coverage for any stormwater discharges from your facility. The
annual self re-certification does not need to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does not affect your facility's legal requirements to obtain
environmental permits that may be required under other federal, state, or local regulations or
ordinances.
Wetlands and Stormwater Branch One
16617 Mail Service Center,Raleigh,North Carolina 27699-1617 NorthCarolina
Location:512 N.Salisbury St.Raieigh,North Carolina 27604
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 Naturally
Internet:www.ncwalerquality.org
An Equal Opportunity 4 Affirmative Action Employer

Grace Food Distribution,Inc.
Attn: Kuong Chung(Ben)Chui,Owner
No-Exposure Certification,NCGNE0827
December 13,2011, Page 2 of 2
If you have any questions or need further information, please contact Ron Boone at (336) 771-
4967, or at [e-mail].
Sincerely,
for Coleen H. Sullins
Attachments:
1. No-Exposure Annual Self Recertification Form
cc: L_winston=Salem_Regional Officel.
2. Stormwater Permitting File NCG060313
3. Stormwater Permitting Unit No- Exposure Files
4. Fran McPherson-Budget Office
5, Grace Food Distribution, Inc.
Attn: Loy Lee
5646 Stattalon Drive
Winston-Salem, NC 27105
6. Kale Engineering
Attn: Randall G. Kale, P.E.
3550 Vest Mill Road
Winston-Salem, NC 27103

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
December 13, 2011
Grace Food Distribution, Inc.
Attn: Kuong Chung (Ben) Chui, Owner
77 North 15t Street
Brooklyn, NY 11211
Subject: No-Exposure Certification NCGNE0827
Grace Food Distribution, Inc.
Wake County
Dear Mr. Chui:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from
NPDES Stormwater Permitting form. Based on your submittal and signed certification of no
exposure at the above referenced facility, the Division is granting your conditional exclusion from
permitting as provided for under 40 CFR 126.22(g), which is incorporated by reference in North
Carolina regulations. We are also hereby rescinding your current permit Certificate of Coverage,
NCG060313.
Please note that by our acceptance of your no-exposure certification, you are obligated to
maintain no-exposure conditions at your facility. if conditions change such that your facility can
no longer qualify for a no-exposure exclusion, you are obligated to immediately obtain NPDES
permit coverage for your stormwater discharge. Otherwise, the discharge becomes subject to
enforcement as an un-permitted discharge. You must self re-certify annually using the included
form, or obtain NPDES permit coverage for any stormwater discharges from your facility. The
annual self re-certification does not need to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does not affect your facility's legal requirements to obtain
environmental permits that may be required under other federal, state, or local regulations or
ordinances.
Wetlands and Stornwater Branch One 1 1617 Mail Service Center,Raleigh,North Carolina 27699-1617 NorthCatrolina
Locatien'.512 N.Salisbury St.Raleigh,North Carolina 27604 „,y���N����
Phone:919-807'6300 l FAX:[phone] Custom �//�YJer Service:1-877-623-6748
Internet:wvnv.nmaterquality.org
AR Equal Opportunity 1 Afrmative Acton Employer

Grace Food Distribution,Inc.
Attn:Kuong Chung(Ben)Chui,Owner
No-Exposure Certification,NCGNE0827
December 13,2011, Page 2 of 2
If you have any questions or need further information, please contact Ron Boone at (336) 771-
4967, or at [e-mail].
Sincerely,
for Coleen H. Sullins
Attachments:
1. No-Exposure Annual Self Recertification Form
cc: 1. Winston-Salem Regional Office
2. Stormwater Permitting File NCG060313
�3. _Storm_ water Pe�mittirig=Unit_No.- Exposure Files
4. Fran McPherson-Budget Office
5. Grace Food Distribution, Inc.
Attn: Loy Lee
5646 Stattalon Drive
Winston-Salem, NC 27105
6. Kale Engineering
Attn: Randall G. Kale, P.E.
3550 Vest Mill Road
Winston-Salem, NC 27103

FOR AGENCY USE ONLY
Division of Water Quality/Surface Water Protection Y= D w `rd n,Y
NC®ENR National Pollutant Discharge Elimination System CervrkatoiCacc
r.�..M.,,. - NO EXPOSURE CERTIFICATION for Exclusion RECEIVED
tirCGINT0000 N.C.Dept.of ENH
NO EXPOSURE CERTIFICATION DEC 0 7 2011
National Pollutant Discharge Elimination System application for exclusion from a Slormwater Pe � ytem
on NO EXPOSURE:
ce
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.
For permitted facilities in North Carolina, DWC 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.
Industrial materials or activities Include, but are not limited to: material handling equipment or activities,
Industrial machinery,raw materials, intermediate products,by-products,final products.or waste 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 the following industrial materials and activities: drums, barrels, tanks,and similar containers
that are tightly sealed,provided those containers are not deteriorated and do not leak. "Seated"means
banded or otherwise secured and with locked or non-operational taps or valves;adequately maintained
vehicles used in material handling;and final products, other than products that would be mobilized in
stormwa ter discharges(e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In
addition, the exclusion from NPDES permitting is available an a facility-wide basis only--not for Individual
outfalls. if any Industrial activities or materials are, or will be,exposed to precipitation, the facility is not
eligible for the 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).
You are re uired to self re-certify our No Ex osure Exclusion anrtuall .
For questions,please contact the DWO Reglonai Office for your area. (See page 6)
(Please print or type)
1) Mailing address of ownerloperator(address to which all certification corresponden22 will be mailed):
Name _I1t-._Kvong CUn9 �aerl�—�l��ic.� GNQced �isf',�vfitxl
Contact /t. l�v6ng C�uhp�hC
Street Address _L.S'f' + _-et
City `Rfnal</vn. State/ ZIP Code lI z,
Telephone No. _.g_f]' $q 8 Fax: :7 j�_ `7e
Email Grace. g8 0YQ&2�'
aom-
10
Page i of 7 V
Swu-NE-12Aug2010 NOV 2 S 2011
• WETLANDS AND STORMWA RBRANCH

�r ? C.I�Ci�K i �� a��L?f5� Z+G�!�1t?' Ni�L t��26G'•':�il3i"c �I;il~t5 -�iGii�'rl'r'' : .
l�: �C_UC:ZC IYt;E VECEFOVU�, vrf 1i'r tom-
1111.Ft :iCl (7t i 1 + P- r u I r,rf- r^ r. '-� 'if1,F
NCGNt000 No Exposure Certi#ication
2) Location of facility producing dlscharge:A'� i
Facility Name �raxC _ Od d l5��'i l7u 7�U►� �14<
Facility Contact _�C e
Facility Street-Address �g G 5TO .S n
ll ry City - _ State_ZIP•Code �'71�5 *•
County
Telephone Al6.'3, -
t Email 6 Coin �-
3) Physlcal4ocatlowinformation:
N, �.
Please•provide:a narrative description.of, to get to,the.faciiity(use street names state road numb s;and
distance and direction from a roadway intersection). S�� Lk�]��C�P' �ytc�t� 1><fi&ws
,all r ^xf.,l (A copy of a rriap,with-the facility clearly located on it should be included with the certification application.)
t 4) Is the facilit—VOcated-on Native American Lands?,❑Yes;' >(No , >! 1.)
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5) is this aiFederallfaeility? ❑Yes (' No•.
tl IL. it
6) Latitude�6 �q 5A3. . Longltudei0o,17 j$ (deg.,min.,seconds)
? 7) This NPDES No:Exposure Exclusion application applies to which of the following:
❑ New:or'P.roposed Facility r` "'Date operation is to begin
t, .a f J Existing=' • � ,.Date operation began
r G Renewal,of existing No Exposure Certification,.Certification No.:.NCGNE
8) Was thls facility.'or site ever covered under amNPDES Stormwater Permit? Yes ❑ No
If yes,what is the NPbtS°Permit Number?` 0:6Do0o
t: 9) Standard IndustrialClas`sificattan ' f'. j. " ` F.
Provide the 4 digit Standard lndustrial'Classification Code(SIC Code)that describes the primary industrial
activity at this facility
SIC Code.u � '.4 , t
1 0) Provide a brief descriptiorll of the types'Of In striaf act vItles a products produced at this facility:
I�.ir P� �11• - yi' IrY. L.T, v4 - ti.rsra. 1 .µ _. , v .. w 'r1�!'iw J
11) Does this'facllity have any Non-Discharge permits(ex: recycle permits)?
❑;Yes
E if ye5,4 ist the permit numbers for all current Non-Discharge permits for this facility:
f(i JP
tjga.�.tti �.-
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NCGNE0000 No Exposure Certification
Exposure Checklists(12. - 14.)
12) Are any of the following materials or activities exposed to precipitation,now or in the foreseeable
future?(Please check either"Yes"or"No.") If you answer"Yes"to any of these items,you are not
eligible for the no exposure exclusion.
a- Using,storing,or cleaning industrial machinery or equipment,and areas where 0 Yes)(No
residuals from using,storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks Cf Yes XNo
c.Materials or products from past industrial activity EI Yes )LNo
d. Material handling equipment(except adequately maintained vehicles) C3 Yes NfQNo
e. Materials or products during loading/unloading or transporting activities ❑Yes )(No
f. Materials or products stored outdoors (except final products intended for outside Q Yes ' No
use[e.g.,new cars]where exposure to stormwater does not result in the discharge
of pollutants)
g. Materials contained in open,deteriorated or leaking storage drums, barrels,tanks, 0 Yes)(No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑Yes )kNo
the discharger
i. Waste material(except waste in covered, non-leaking containers[e.g.,dumpsters]) ©Yes ')dNo
j.Application or disposal of process wastewater(unless otherwise permitted) ❑Yes )<No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ©Yes X o
otherwise regulated(i.e.,under an air quality control permit)and evident in the
stormwater outflow
1. Empty containers that previously contained materials that are not properly stored 0 Yes )(No
(i.e.,not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs,as well as drums,barrels,tanks,and similar containers ©Yes )(No
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks(ASTs): If you answer"No"to any.of the following items,you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs and piping free of rust,damaged or weathered coating,pits,or ❑ Yes ❑ No NIA
deterioration,or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so,is it free of any ❑Yes 0 No N/A
cracks,holes,or evidence of leaks,and are drain valves maintained locked shut?
Page 3 of 7
SW U-NE-12Aug201 U

NCGNE0000 No Exposure Certification
14) Secondary Containment: If you answer"No"to any of the following Items,you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for all single above ground storage ❑ Yes ❑ No N/A
containers(including drums,barrels,etc.)with a capacity of more than 660
gallons?
b. Is secondary containment provided for above ground storage containers stored ❑ Yes ❑ No N/A
in close proximity to each other with a combined capacity of more than 1,320
gallons?
c. is secondary containment provided for Title Ill Section 313 Superfund ❑ Yes ❑ No YN/A
Amendments and Reauthorization Act(SARA)water priority chemicals'?
d. Is secondary containment provided for hazardous substances"designated in 40 ❑ Yes © No )(N/A
CFR§116?
e.Are release valves on all secondary containment structures locked? ❑ Yes © No IXNIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage,or Disposal Facility? ❑ Yes^i(No
b. 1s this facility a Small Ouantity Generator(less than 1000 kg.of hazardous waste ❑ Yes XNo
generated per month)of hazardous waste?
c. Is this facility a urge Quantity Generator(1000 kg.or more of hazardous waste ❑ Yes 1No
generated per month)of hazardous waste? /
If you answered yes to questions b.or c.,please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport/disposal vendor:
Vendor address:
Footnotes to Ouestions 14)c. &d.
'Note that amounts below the 660-gallon(single)and 1,320-gallon(combined)bulk storage minimums require
secondary containment. However,some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers,as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFR
§372.38,
"Note that amounts below the 660-gallon(single)and 1,320-gallon (combined)bulk storage minimums require
secondary containment. However,some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR§117.3.
Page 4 of 7
SWu-NE-12AU92010

NCGNE0000 No Exposure Certification
16) 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.
a. Does your facility store used,recycled,or otherwise reclaimed pallets outside? ❑ Yes )No
b. Does your facility have coal piles on site? ❑ Yes XNo
c.Does your facility store other fuel sources outside in piles,such as wood chips, © Yes
sawdust,etc.?
d. Does your facility have air emissions associated with its industrial activity(e.g., © Yes�No
degreasing operations, plating,painting and metal finishing)? if so,describe the
industrial activity:
e. If you answered yes to d.,are those emissions permitted by an Air Quality Permit? 0 Yes 0 NoXN/A
Please specify:
f. Please list any other environmental program permits(federal,state,etc.)not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
Swu-NE-12Aug20 i 0

"
NCGNE0000 No Exposure Certification,
.1 Certification: TvI i N 1 ,t .t '' F"�'�i.�r -�r-r
I certify under penalty pf w that I have read artd`uhdersta'hd eligibility.requirements for-claiming a condition of`no;
AV H-1 q_.I exposure'and obtaining an exclusion from NPDES stormwater"permitting.•
I certify under penalty of law that there are no discharges'of stormWater contaminated by exposure to industrial activities
or materials from the industrial facility or,site denti#fled to this,document=(except as allowed under}40 CFR t 22-26(g)(2)).
understand that I am obligated to annually,self re-cettifv-Ng Exposure and,if'regtiested!submit the re-certification to •.
DWQ or the operator of the local.municipal separate storm sewer system(MS4)into which the facility discharges(where
{ applicable) 1 understand that I must allow the North Carolina Division of Water Quality,or MS4 operator+nitiere the:' uT
,dischargatiVVa,the Focal MS4,to perform inspections to confirm the condition of no exposure and to make such v
inspection reports pubficty available upon request. y
In the event that the site no longer qualifies for a No Exposure Exclusion,,I understand that I-must obtain coverage under '
} an NPDES permit grior to any noinLAource dl�rharge of stotmwVter"fromi tile?f gitityl Additionally I certi#jr uricier penalty of
law that this document and all attachments were prepared under my direction or supervision,tn.accordsrice with a system
•.
deslgned to assure that qualified personnel property gathered and evaluated the information'sutimitted: Based on my
T W OM 3.)iinquiry;of the person or persons who manage the system orithose.persons directly responsible for gathering''Ahe C`, i ' +
information;the information submitted is to the best of.m knowled a and belief true,ta66 C to and eom late. l am aware'
{Ra i s., y• ., .: gig, P
that there are sigrtificarit penalties#or submitting false information;including the possiliI& of fine and imprisonment for
knowing violations'. t - ;• `' ', :J
' I certify that I am familiar with the information contained In this applicanon and that to the best gi my knowledge and belief -j µ,
such information is true,complete,and accurate-
•
P.rinledName of,Person Signing:
Title:
( (Signature of (Dal rtedJ
Please note: This application for the No Exposure Exclusion is subject to approval by the
I' NCDENRRegional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval.- The Regional Office may also ,
Inspect your facility at aq time:In-the futurefor compliance with,the No Exposure Exclusion. f
E
North Carolina General Statute 143-2i5.6 8(0 provides that:
Any person who knowingly makes any false statement,representation;or certification in any application,record,repot,plan,or.oth3 f
document filed or required to be maintained under this Article or a rule implementing this Article:or who knowingly makes a'alse
statement of a material fact in a rulemaking proceeding or ebntesmd case under this Article;or who falsifies,tampers with,or kruswingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
It:rtvironmental Management)Commission implementing this Article shall be guilty ot'a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($t 0,000). ,
There is currently no fee fora No Exposure Exclusion.
Page 6 of 7
5W U-NE•12Aug2010
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NEQ000 No Exposure Certification
Final Checklist
This application should include the following items:
0 This completed application and all supporting documentation.
0 A map with the location of the facility dearly marked.
0 If the site currently has an NPDES Stormwater Permit,be sure to indicate the permit number in Question 8.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quafliy
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions.please contact the DWO Regional Office for your area.
DWO Regional Office Contact information:
4
Asheville Office ...... [phone] w
Fayetteville Office ... [phone] t
Mooresville Office ... [phone]
Raieigh Office ........ [phone]
J�slavitle A{ooroiviile
Washington Office...[phone]
Wilmington Office ... [phone]
Winston-Salem ...... [phone] f
Central Office .........[phone] �
3
0
Page 7 of 7
Swt1-NE-12Aug2010
L -

KALE ENGINEERING
3550 Vest Mill Road
WINSTON SALEM,N.C. 27103
PROPERTY SURVEYS MEMBERS OF
CONSTRUCTION SURVEYS NATIONAL SOCIETY OF
DESIGN OF ROADS AND STREETS PROFESSIONAL.ENGINEERS
WATER AND SEWAGE SYSTEMS 336-768-0250 AMERICAN CONGRESS OF
SUBDIVISION PLANNING&LAYOUT email kaleengr©bellsouth.net SURVEYING AND MAPPING
November 23, 2011
NCDENR
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: NPDES General Stormwater Permit NCG060000,Grace Foods Distribution, Winston Salem, NC
References: 1. Letter from Mr. W.Corey Basinger of NCDENR to Mr. Loy Lee of Grace Food
Distribution, Inc,Compliance Inspection&Notice of Violation,dated 06/08/1 1.
Notice of Violation NOV-201 I-PC-0349.
2. 'Telephone conversations between Mr. Ron Boone and Randall G. Kale of Kale
Engineering on Friday 07/29/11 and Monday 08/01/1 1 for this project. Mr. Boone is an
employee of NCDENR in the Winston Salem office(Forsyth County).
3. No Exposure Certification Application Form(enclosed).
Dear Sir or Madame,
Enclosed with this letter is the reference 3 form as requested. To the best of my knowledge, this is what
you need. Please review and let me know what you think.
Thank you very much for your help in this matter this morning. Should you have any questions, please
feel free to call me at 336-768-0250.
Sincerely,
O��a "
Randall G. Kale P.E., P.L. .
�D
NpV2S 2011
W NDSANDSTpR QUgLlly
+4TER aW Cif

MR AGENCY-USE ONLY
• Division of Water Quality/Surface Water Protection Yr� °��'tra p„
�..�
��''® .,�� National Pollutant Discharge Elimination System t cerdfk--eorcurcrsr
1
*­CC Ix~- NO EXPOSURE CERTIFICATION for Exclusion
NCGNEU000
NO EXPOSURE CERTIFICATION
National Pollutant Discharge Elimination System application for exclusion from a stormwater Permit based
on NO EXPOSURE:
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.
For permitted faci€ities in North Carolina, DW© must approve your application for No
Exposure Certification before this exclusion is effective. Until you are Issued a No
Exposure Cert€fication and your NPDES permit is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
Industrial machinery, raw materials, intermediate products,by-products, final products, or waste 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 the following industrial materials and activities: drums,barrels, tanks,and similar containers
that are tightly sealed,provided those containers are not deteriorated and do not leak. "Sealed"means
banded or otherwise secured and with locked or non-operational taps or valves;adequately maintained
vehicles used in material handling;and final products, other than products that would be mobilized in
stormwater discharges(e-g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In
addition, the exclusion from NPOES permitting is available on a facility-wide basis only--not for Individual
outfalls. If any industrial activities or materials are, or will be, exposed to precipitation, the facility Is not
eligible for the 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 T 22.26(g).
You are required to self re-certity Vour No Exposure Exclusion annual) .
For questions,please contact the DWO Regional Office for your area. (See page 6)
{Please print or type}
1} Mailing address of owner/operator(address to which all certification correspondence will be mailed): )
Nar11e —M1�,�KLI0, 9 C613—_C 3-e& �l �,L 7 GNQCE FOoc�j}yr�btJ�1�Lti1
Contact v (2>ut
Street Address ,LS tte
City ,J State ZIP Code _ Ha
Telephone No. Cl 17 �� .5�8� S�j� Fax:
Email C21' �f_____.atf19 a _CO/A_
Page I of 7
SWU-NE-12Aug2810

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MY Stec ZIP Coda _&%2I0-5
Cowty
Tawowft NO. Fax: ,-Zj&
EMO Co/!t
3) Phy steM40caSon ttdrtnaft
Prue ptoride a wnzflve O=Wm of ftCw to get to the McRy(use sirs t e�sate too .at i
d Uom ands,frwn a roa&way wife abors). SCC Q��i(1 IM4 OWdUg &W-S
(A ccy of a snap wets te fad dWAy►bcaied on it Stroh be fndvcled vrtttr On ceff=tkm appflca*m.) w
4) to the 18CIRty[acated an ttte a Anwrican Lendfe?❑Yes t+to
• 5) to fits a FedMV4 ft~ 0 Yes tuo
9
` 7) Thts NPDES No Expmm Emdusbn applkdbn appRes,to whtbh of the ice:
❑ Mw or Proposed Fad5ty Bate operalbn to to beglr. -
Exis�g tM operation bates
� C� t�urst as rxratirrg wo Es�rra Chan C,atl�ion rta:NONE .
8) was this ftetitty or site~covered under an NPOES StotmwaW Perttslt?XYOS 0 No
a) Sbmdmd bufusht chmamwftn:
P VVW the 4 ftft&W lord h&am cw=Tmwm Code(sr.Code)tit dew gybes the pririmn kxhm
mcdvitt►at this f eft
• s�tom:�� � ,`.
110)Pnortde a Wei do , tptton of the typas of � PrO& tt;pradLmwd Qt oft Dal
11)Does tads fifty MW :oy Hon4D—Itmua perm€ts(ex;mcicie pemft)7
❑Yes
if yes,list the permit numbers for aH current Nor,-nee peMft ror tfeis f2dW.• .
S+an JC-1y L92010

NCGNE0000 No Exposure Certification
Exposure Checklists(12. - 14.)
12) Are any of the following materials or activities exposed to precipitation,now or in the foreseeable
future?(Please check either"Yes" or"No.") If you answer"Yes"to any of these items,you are no
eligible for the no exposure exclusion.
a- Using,storing,or cleaning industrial machinery or equipment,and areas where 0 Yes kc,
residuals from using,storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes N No
c. Materials or products from past industrial activity ❑ Yes XNo
d. Material handling equipment(except adequately maintained vehicles) ❑ Yes '*,No
e. Materials or products during loading/unloading or transporting activities ❑ Yes >�No
f. Materials or products stored outdoors(except final products intended for outside ©Yes No
use[e.g.,new cars]where exposure to stormwater does-not result in the discharge
of pollutants)
g. Materials contained in open,deteriorated or leaking storage drums, barrels, tanks, 0 Yes )(No
and similar containers
h. Materials or products handied/stored on roads or railways owned or maintained by ❑Yes `kNo
the discharger
i. Waste material (except waste in covered, non-leaking containers[e.g.,dumpsters]) ❑ Yes No
j. Application or disposal of process wastewater(unless otherwise permitted) ❑ Yes )(No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑Yes Xo
otherwise regulated(i.e., under an air quality control permit)and evident in the
stormwater outflow
1. Empty containers that previously contained materials that are not properly stored 0 Yes )(No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels,tanks, and similar containers 0 Yes )(No
stored outside, has the facility had any releases in the past three(3)years?
13) Above Ground Storage Tanks(ASTs): It you answer"No"to any of the following Items,you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs and piping free of rust,damaged or weathered coating,pits, or 0 Yes 0 No I N/A
deterioration,or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any 0 Yes 0 No N/A
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SWU-NE-12Aug2o10

NCGNE0000 No Exposure Certification
14) Secondary Containment: if you answer"No"to any of the following Items,you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for all single above ground storage ❑ Yes o No N/A
containers(including drums, barrels,etc.)with a capacity of more than 660
gallons?
b. Is secondary containment provided for above ground storage containers stored © Yes 0 No /A
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund © Yes 0 No XN/A
Amendments and Reauthorization Act(SARA) water priority chemicals'?
d. Is secondary containment provided for hazardous substances"designated in 40 © Yes ❑ No )(N/A
CFR§116?
e. Are release valves on all secondary containment structures locked? 0 Yes 0 No )(N/A
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage,or Disposal Facility? 0 Yes-�(No
b. Is this facility a Small Quantity Generator(less than 1000 kg.of hazardous waste ❑ Yes X No
generated per month)of hazardous waste?
c. Is this facility a Large Quantity Generator(1000 kg.or more of hazardous waste 0 Yes )<No
generated per month) of hazardous waste?
If you answered yes to questions b.or c.,please provide the following information:
Type(s)of waste:
How is material stored.
Where is material stored:
How many disposal shipments per year:
Name of transport/disposal vendor:
Vendor address:
Footnotes to Questions 14)c.&d.
"Note that amounts below the 660-gallon(single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SAl to 313 in 40 CFR
§372.38.
"Note that amounts below the 660-gallon(single)and 1,320-gallon(combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR§117.3.
Page 4 of 7
5Wu•NE-12Aug2010

NCGNE0000 No Exposure Certification
16) 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 ol the site circumstances may be required.
a. floes your facility store used, recycled,or otherwise reclaimed pallets outside? ❑ Yes *0
b. Does your facility have coal piles on site? ❑ Yes XNo
c. Does your facility store other fuel sources outside in piles,such as wood chips, o Yes '-"-lo
sawdust,etc.?
d. Does your facility have air emissions associated with its industrial activity(e.g., ❑ Yes�KNo
degreasing operations,plating, painting and metal finishing)? If so,describe the
industrial activity:
e. II you answered yes to d., are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ NoXN/A
Please specify:
f. Please list any other environmental program permits(federal, state,etc.) not
specified earlier in this application(such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: , Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
swu-NE-Mug201 o

a � � ; 65 � f � f � E� �t �! c �p ° i { e a f

NE0000 No Exposure Certification
IF Checklist
This application should include the following items:
© This completed application and all supporting documentation.
❑ A map with the location of the facility dearly marked.
❑ If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
Mail the entire package to:
Stormrwatet Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh,North CaroEina 27699-1617
, • Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions,please contact the DWO Regional Office for your area.
s -
DWO Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office ... [phone] -
_ Mooresville;Office...-,-(704)_663-1699
Raleigh Office ........ [phone] !
vo `to
Washington Office ...[phone] Y
Wilmington Office... [phone]
W instori-Salem .:..::(336)-77.1-5000 ! �a
Central Office ..........(919),807,- 300
Page 7 of 7
SwU-N E-12Aug2o 10

- r
A10A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
October 3, 2011
Grace Food Distribution, Inc.
Attn: Loy Lee, Manager
5646 Shattalon Drive
Winston Salem, NC 27105
Subject: Evaluation for No Exposure Exclusion
NPDES General Stormwater Permit NCG060000
Certificate of Coverage NCG060313
Grace Foods Distribution, Winston-Salem, NC
Forsyth County
Dear Mr. Lee:
1. Ron Boone of the Winston-Salem Regional Office of the NC Division of Water Quality (DWQ)
conducted an evaluation of the subject property for a No Exposure certificate on October 3, 2011 .
Your assistance and cooperation, as well as that of Randall Kale, with Kale Engineering, was
greatly appreciated. An evaluation form is attached for your records and the findings of the
evaluation are summarized below.
2. The facility is located at 5646 Shattalon Drive, in Winston-Salem, Forsyth County, North Carolina.
Stormwater related to industrial activity is discharged from the site to Leak Fork, which is currently
classified as Class C waters in the Yadkin River basin.
3. Mr. Boone found the site to be in good condition. Only one item remains that needs to be
addressed before a No Exposure certification can be granted; the garbage dumpster located on
the east side of the facility needs to have a permanent cover and needs to be kept covered at all
times when it is not in use. The existing dumpster's cover either needs to be repaired or a new
dumpster .with a cover needs to be acquired. Once this is accomplished, provided all site
conditions remain as they were during the evaluation, you can submit a No Exposure application
to our Central Office in Raleigh and the No Exposure certificate will be granted.
North Carolina Division of Water Quality,Winston-Salem Regional Office
Location:585 Waughtown St.Winston-Salem,North Carolina 27107 One
Phone:[phone] t FAX:[phone] Customer Service:1-8 -M-6748 NorthCarofina
Intemet:www.ncwaterquality.org )Vaturally
An Equal Opportunity 1 Affirmative Action Employer

r
Grace Foods Distribution,Inc.
Attn: Loy Lee,Manager
No Exposure Certifoation Evaluation, NCG060313
101312011, Page 2 of 2
4. Mr. Boone provided you with a copy of the No Exposure application during the evaluation, along
with a copy of the annual self recertifcation. Just fill out the application and follow all directions on
the form. If you have any questions you may call Mr..Boone or meat anytime at 336-771-5000.
Sincerely,
W. Corey Basinger
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
1. NEC Evaluation Report
cc: 1. SWP —WSRO
2. Central Files
3. Stormwater Permitting Unit
E4 Qrace_Foods_Distribution;Inc.
CRttn Bbh-Chiu,_President? fD/ l� I is
LBy_Fax:_718-782786692
5. Kale Engineering
Attn: Randall Kale
3550 Vest Mill Road
Winston-Salem, NC 27103

Compliance Inspection Report
Permit: NCGO60313 Effective: 07/31/09 Expiration: 1OJ31112 Owner: Grace Food Distribution Inc
SOC: Effective: Expiration: Facility: Grace Food Distribution, Inc.
County: Forsyth 5646 Sahthalon Dr
Region: Winston-Salem
Winston Salem NC 27105
Contact Person: Joseph Deluca Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 10/03/2011 Entry Time: 09:00 AM Exit Time: 09:30 AM
Primary Inspector: Ron Boone } Phone. [phone]
Secondary Inspector(s): �? /� 31/ 01I
Reason for Inspection: Routine Inspection Type:Compliance Evaluation
Permit Inspection Type: Food/Tobacco/Soaps/Cosmetics/Public Warehousing
Stormwater Discharge COC
Facility Status: ❑ Compliant ■ Not Compliant
Question Areas:
®Storm Water
(See attachment summary)
Page: 1

Permit: NCG060313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 1 010 312 01 1 Inspection Type:Compliance Evaluation Reason for Visit:Routine
Inspection Summary:
Grace Foods is attempting to qualify for a no exposure permit. Made site visit to evaluate their progress. At this point they
only need to get a new dumpster with a functioning cover. Other than that the site will qualify. Gave them a copy of the no
exposure application for them to fill out and submit to Central Office along with no exposure technical information.Will
now await their application and make another short site visit once we receive it to verify that the dumpster has been
repaired or replaced.
Page: 2

MEMORY TRANSMISSION REPORT
TIME : 10-04-r11 09:14
FAX NO.1 : 336-771-4632
NAME :DENR WSRO
FILE NO, 260
DATE 10.04 09:13
TO : 8 917187828669
DOCUMENT PAGES 4
START TIME 10.04 09:13
END TIME 10.04 09:14
PAGES SENT 4
STATUS OK
*** SUCCESSFUL TX NOTICE * *
North Carolina Department of Environment and Natural Resources
❑ivision of Water Quality
0 orly Eav nordue CoEcon H. Sullins Dee rrn©man
covarnor ❑irectar Secretary
October 3. 201 1
Grace Food Distribution, Inc.
Attn: Loy Lao, Manager
5646 Shattalon Drive
Winston Salem, NC 27105
Subject: Evaluation for No Exposure Exclusion
NPi7ES General Stormwater Permit N0G060000
Certificate of coverage NC-DO6031 a
Grace Foods Distribution, Winston-Salem, NC
Forsyth County
Dear Mr. Lao:
1. Ron Soono of the Winston-Salem Regional Offico of the NC Division of Water Quality (OWQ)
coradt,rcted an evaluation of the subject proporty for a No 1=xposuro cortiflcat© on October 3, 201 1.
Your assistance and cooperation, as well as that of Randall Kale. with Kale F_nginonring, was
grCatly appreciated. An evaluation form is [attached for your rocord9 and the findings of the
evaluation aro surnrraarizad below_
2. Ttte facility is located at 5646 Shattaion ariwv. in Winston.-Salem, Forsyth County, North Carolina.
Storrnwater related to industrial activity is discharged from the site to t_aak Fork, which is currently
classified as Class C waters in the Yadkin River basin-
3. Mr. Boone found the site to be in flood conciltion- Only one item romnlns that needs to bo
addrossed before a No axposura certification can be granted; the gartaago dumpstar located on
the east side of the facility needs to havo a permanent cov©r and needs to be kept covered at all
tines when it is not in use_ The existing dumpster's cover either needs to bn repaired or a new
ciumpster ,with a cover needs to be acquirod- Once this is accomplished, provided all site
conditions remain as they were during the evaluation. you can submit a No Exposure application
to our Central Offices In Raleigh and the No Exposure Certificate will Be granted_
Npnl,Garalina fJiW stun of Wabr Oaali[y Winston-Salem Repbnsl O/rltc
LOGPtivn:5S5 Wau�ihlown St.Winslat-taalom.Nortn Gawllrva 2'/1 �rtc
Pngny'J3a-]71-SCIOD l FAX:[phone] i Guaw.nar Ralvlca:t-6-Bey-623-6T<a Nox-t11C vr01 i n a
Internet:wwvr.ncv+aleryualily.pry
An 12 a 1 Oppartunity%Alfir .M,Actio Cnrpbyyr �u`

KALE ENGINEERING
3550 Vest Mill Road
WINSTON SALEM,N.C. 27103
PROPERTY SURVEYS MEMBERS OF
CONSTRUCTION SURVEYS NATIONAL.SOCIETY OF
i DESIGN OF ROADS AND STREETS PROFESSIONAL_ENGINEERS
WATER AND SEWAGE:SYSTEMS 336-768-0250 AMERICAN CONGRESS OF
SUBDIVISION PLANNING&LAYOUT email kateengoa beEtsouth.net SURVEYING AND MAPPING
August 9,2011
I
Mr. Ron Boone
NCDENR
Division of Water Quality
585 Wauahtown Street
Winston Salem, NC 27107
Subject: NPDES General Stormwater Permit NCG060000 Grace Foods Distribution, Winston Salem. NC
References: 1. Letter from Mr. W.Corey Basinger of NCDENR to Mr. Loy Lee of Grace Food
Distribution, Inc,Compliance Inspection&Notice of Violation.
2. Telephone conversations between Mr. Boone and Randall G. Kale of Kale Engineering on
Friday 07/29/11 and Monday 08/01/11 for this project.
3. No Exposure Certification Application Form.
Dear Mr.Boone,
I have spoken with Mr. Kuong Chung(Ben)Chiu of Winston Salem Real Estate Holding Inc.concerning
the reference I Notice of Violation, which we discussed during the reference 2 conversations,and Mr.Chiu
would very much like to pursue the No Exposure Certification.
Mr. Chiu is aware that the entire site will need to be cleaned up and that no exposure could be allowed on
this site. All of the items strewn across the property as noted in the reference I letter would need to be put
indoors or offsite. Thev can not clean out the trailers with water and they can not work on their vehicles in
the parking lot due to the petroleum spills.
Mr.Chiu is also aware that if they are unable to meet the standards of the reference 3 application,it will be
necessary to prepare and administer an SP3 Plan for this site.
We will get back with you very shortly with a clean up schedule and a date when we will be ready for a
visit from NCDENR, Thank you very much for your help in this matter this morning. It is appreciated.
Sincerely,
Randall G. Kale P.E., P.L.S.
{
i

.tea
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
June 8, 2011
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7008-3230-0003-2547-2446
Grace Food Distribution, Inc.
Attn: Loy Lee, Manager
5646 Shattalon Drive
Winston Salem, NC 27105
Subject: Compliance Evaluation Inspection & Notice of Violation
NOV-201 1-PC-0349
NPDES General Stormwater Permit NCG060000
Certificate of Coverage NCG060313 �- -
Grace Foods Distribution, Winston-Salem, NC
Forsyth County
Dear Mr. Lee:
1. Ron Boone of the Winston-Salem Regional Office of the NC Division of Water Quality(DWQ)conducted a compliance
evaluation inspection (CEI) at the subject facility on June 2, 2011. Your assistance and cooperation, as well as that of
Robert Coppersmith, was greatly appreciated. An inspection checklist is attached for your records and the inspection
findings are summarized below.
2. The facility is located at 5646 Shattalon Drive, in Winston-Salem, Forsyth County, North Carolina. Stormwater related
to industrial activity is discharged from the site to Leak Fork, which is currently classified as Class C waters in the
Yadkin River basin.
Documentation & Monitoring Review
3. The following violations were noted:
a. The facility does NOT have a Stormwater Pollution Prevention Plan (SP3);
b. Analytical monitoring has NOT been accomplished;
C. Qualitative monitoring has NOT been accomplished; and,
d. Analytical monitoring for vehicle maintenance activities has NOT been accomplished.
These are all violations of the NCG060000 general permit.
Site Review
4. The permittee had previously been issued a Notice of Violation from the city's Stormwater department for washing out
the insides of trailers and allowing the wastewater to run off into the creek. According to Mr. Lee and Mr.
Coppersmith, they have stopped this practice and will now take the trailers to a facility in Greensboro where it is legal
for them to wash them out. This is also a violation of the NCGO60000 general permit.
5. Other items noted throughout the site were:
North Carolina Division of Water Quality,Winston-Salem Regional Office
Location:585 Waughtown St.Winston-Salem,North Carolina 27107 One
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 NorthCarolina
Internet:www.ncwatefquality.org Naturally
An Equal Opportunity 1 Affirmative Action Employer

Grace Foods Distribution,Inc.
Attn:Loy Lee, Manager � J
Compliance Evaluation Inspection,NCG060313
NOV-2011-PC-0349
619/2011,Page 2 of 2
a. There were several items strewn throughout the property that must be properly disposed such as refrigerant
containers, waste oil filter receptacles, paint cans, oil and grease containers, general trash receptacles,
miscellaneous junk equipment, junked vehicles, etc. All of these items must be cleaned up and properly
disposed, in order to minimize exposure of transportable materials on these items to precipitation and the
subsequent pollution of the receiving stream(s). These are also violations of the NCGO60000 general permit.
b. There was also evidence of petroleum product spills in and around the vehicle maintenance facility. All such spills
must be immediately and properly cleaned up and waste materials properly disposed. Failure to do so eventually
leads to the pollution of the surrounding streams by mobilization of the contaminated materials by precipitation.
These are also violations of the NCGO60000 general permit.
6. Grace Foods must immediately endeavor to develop and implement a full SP3 for the facility. The Certificate of
Coverage (COC) was issued to Grace Foods in July, 2009. You have therefore had nearly two years to become
compliant with the permit. It is highly suggested that you employ the services of a professional environmental
engineer to develop the SP3 as required as it can become quite complicated and the permit has many technical
requirements which may require the services of an engineer.
7. Please reply to this letter in writing within 10 business days of receiving it. Your reply should include a narrative
action plan with time schedule to complete the SP3 and correct all the deficiencies noted above. Your written reply
will be critical to our further consideration of whether or not to pursue enforcement actions at this time. Please also
note that at this point DWQ grants Grace Foods another three months from the date of this letter to have a
fully developed and implemented SP3 for the facility; failure to do so will likely result in enforcement action.
The due date for the completion of the SP3 is therefore September 8, 2011.
8. You are reminded that violations of the NCGO60000 general permit are subject to civil penalty assessments not to
exceed $25,000 per day, per violation. Thank you for your cooperation in this matter. Should you have any
questions, please feel free to contact Mr. Boone or me at [phone].
Sincerely,
.. u Vr
W. Corey Basinger
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
1. BIMS Inspection Checklist
cc: 1. [SWP=WSRO
2. Central Files
3. Stormwater Permitting Unit
4. Grace Foods Distribution, Inc.
Attn: Ben Chiu, President
By Fax: [phone]
5. City of Winston-Salem Stormwater Division
Attn: William Baugher
P.O. Box 2511
Winston-Salem, NC 27102

Compliance Inspection Report
Permit: NCG060313 Effective: 07/31/09 Expiration: 10/31/12 Owner: Grace Food Distribution Inc
SOC: Effective: Expiration: Facility: Grace Food Distribution, Inc.
County: Forsyth 5646 Sahthalon Dr
Region: Winston-Salem
Winston Salem NC 27105
Contact Person: Joseph Deluca Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 06/0212011 Ent Time: 01:00 PM Exit Time: 02:00 PM
Primary Inspector: Ron Boone -I 1 �) Phone: [phone]
Secondary Inspector(s): r
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: FoodFFobaccolSoapslCosmeticslPublic Warehousing
Stormwater Discharge COC
Facility Status: ❑Compliant ■ Not Compliant
Question Areas:
Storm Water �Q 16l
i
(See attachment summary) k, ,(,Q c�.l� d,..�� .•��0
271 f
Page: 1

Permit: NCG060313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 06/02/2011 Inspection Type: Compliance Evaluation Reason for Visit:Routine
Inspection Summary:
Please refer to the attached inspection summary letter-
SECTIONSENDER: COMPLETE THIS
■ Complete items 1,2,and 3.Also complete A. signaturY!5�
item 4 if Restricted Delivery Is desired. ❑Argent
■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. B. Received by rr Name) C. Date of Deliver
y
' ■ Attach this card to the back of the mailpiece, �—i� r'
I or on the front if space permits.
D. Is delivery address different from item 17 ❑Yes
1. Article Addressed to: If YES,enter de wery'eddress below: ❑ No
DeDL ofErYR
jLoy Lee, Manager i 2011
i wMaton-Salem
Grace Food Distribution, Inc. _
5646 Shattalon Drive s. se ice Type
Winston-Salem, NC 2�ao5 )Certlfled Mail ❑ Express Mail
❑ egistered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restrict d e r xtra Fee) ❑Yes
Page: 2
?008 3230 0003 2547 2446 _ - � 6
�pl. oI� PC 03'(�}
- - N,j6y
i PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Permit: NCG060313 owner-Facility: Grace Food Distribution Inc
Inspection Date: 06/02/2011 Inspection Type: Compliance Evaluation Reason for Visit:Routine
Stormwater Pollution Prevention Plan Yes No NA NE
Does the site have a Stormwater Pollution Prevention Plan? Cl ® n n
#Does the Plan include a General Location (USGS) map? n ■ n
#Does the Plan include a"Narrative Description of Practices'? n ® Q n
#Does the Plan include a detailed site map including outfall locations and drainage areas? n ■ ❑ n
#Does the Plan include a list of significant spills occurring during the past 3 years? Q ® ❑ n
#Has the facility evaluated feasible alternatives to current practices? ❑ ■ 1) n
#Does the facility provide all necessary secondary containment? ❑ ■ n ❑
#Does the Plan include a BMP summary? ❑ ■ n ❑
#Does the Plan include a Spill Prevention and Response Plan (SPRP)? ❑ e n
#floes the Plan include a Preventative Maintenance and Good Housekeeping Plan? ❑ ■ n ❑
#Does the facility provide and document Employee Training? 0 C Cl n
#Does the Plan include a list of Responsible Party(s)? n ■ n n
#Is the Plan reviewed and updated annually? n ® Q
#Does the Plan include a Stormwater Facility Inspection Program? n p Cl n
Has the Stormwater Pollution Prevention Plan been implemented? ■ n n
Comment: Please refer to the attached inspection summary letter.
Qualitative Monitoring Yes No NA NE
Has the facility conducted its Qualitative Monitoring semi-annually? n ® n fl
Comment: Please refer to the attached inspection summary letter.
Analytical Monitoring Yes No NA NE
Has the facility conducted its Analytical monitoring? n ® n ❑
#Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas? n p 00
Comment: Please refer to the attached inspection summary letter.
Permit and Outfalls Yes No NA NE
#Is a copy of the Permit and the Certificate of Coverage available at the site? ® n n n
#Were all outfalls observed during the inspection? 8 n n ❑
#If the facility has representative outfall status, is it properly documented by the Division? n n ■ 0
#Has the facility evaluated all illicit(non stormwater)discharges? n ■ ❑ 0
Comment: Please refer to the attached inspection summary letter.
Page: 3

Postal Servicev.,
CERTIFIED y ■ ■
(Domestic Mail Only;No Insurance Coverage Provided)
ru
r` r
Postage $ i�3
rLi certFned Fee �'��
1�
m Poafmark
O Retum Recelp!Fee
p (Endomemen Requi �—Here v
red) 'Jo =
Restricted Delivery Fee
(Endomement Required) .03149
rn
rU Total Pc
rn � o Loy Lee, Manager
COnb+eer;Aa Grace Food Distribution, Inc. ...
'
0 orPoau, 5646 Shattalon Drive
c�i soh Winston-Salem, NC 27105

+ ,
AA
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
.tune 8, 2011
CERTIFIED MAIL
Post-it®Fax Note 7671 Date r
RETURN RECEIPT REQUESTED pages
7008-3230-0003-2547-2446 TO pje v� C�ti 4 iu From
J b
Co./Dept.l7i^!nC G a c12j Co. NC tV i v a# l�06V
Grace Food Distribution, Inc. Phone#
Attn: Loy Lee, Manager Phone# 3 3 b -7-1 1 y�7
5646 Shattalon Drive Fax# .7 i -�� B��e7 Fax# 33G �`]1 14&Z)C
Winston Salem, NC 27105
Subject: Compliance Evaluation Inspection & Notice of Violation
NOV-2011-PC-0349
NPDES General Stormwater Permit NCG060000
Certificate of Coverage NCG060313
Grace Foods Distribution, Winston-Salem, NC
Forsyth County
Dear Mr. Lee:
1. Ron Boone of the Winston-Salem Regional Office of the NC Division of Water Quality(DWQ)conducted a compliance
evaluation inspection (CEI) at the subject facility on June 2, 2011. Your assistance and cooperation, as well as that of
Robert Coppersmith, was greatly appreciated. An inspection checklist is attached for your records and the inspection
findings are summarized below.
2. The facility is located at 5646 Shattalon Drive, in Winston-Salem, Forsyth County, North Carolina. Stormwater related
to industrial activity is discharged from the site to Leak Fork, which is currently classified as Class C waters in the
Yadkin River basin.
Documentation & Monitorina Review
3. The following violations were noted:
a. The facility does NOT have a Stormwater Pollution Prevention Plan (SP3);
b. Analytical monitoring has NOT been accomplished;
C. Qualitative monitoring has NOT been accomplished-, and,
d. Analytical monitoring for vehicle maintenance activities has NOT been accomplished.
These are all violations of the NCG060000 general permit.
Site Review
•1
4. The permittee had previously been issued a Notice of Violation from the city's stormwater department for washing out
the insides of trailers and allowing the wastewater to run off into the creek. According to Mr. Lee and Mr.
Coppersmith, they have stopped this practice and will now take the trailers to a facility in Greensboro where it is legal
for them to wash them out. This is also a violation of the NCG060000 general permit.
5. Other items noted throughout the site were:
North Carolina Division of Water Quality,Winston-Salem Regional Office
Location:585 Waughtown St.Winston-Salem,North Carolina 27107 One
Phone:[phone] FAX:[phone] Customer Service:1-87U23-6748 NorthCarolina
Internet:www.navaterquality.org ;Vahzrally
An Equal Opportunity 1 Affirmative Action Employer

Grace Foods Distribution,Inc.
Attn:Loy Lee, Manager �.
Compliance Evaluation Inspection,NCG060313
NOV-2011-PC-0349
619/2011,Page 2 of 2
a. There were several items strewn throughout the property that must be properly disposed such as refrigerant
containers, waste oil filter receptacles, paint cans, oil and grease containers, general trash receptacles,
miscellaneous junk equipment, junked vehicles, etc. All of these items must be cleaned up and properly
disposed, in order to minimize exposure of transportable materials on these items to precipitation and the
subsequent pollution of the receiving stream(s). These are also violations of the NCG060000 general permit.
b. There was also evidence of petroleum product spills in and around the vehicle maintenance facility. All such spills
must be immediately and properly cleaned up and waste materials properly disposed. Failure to do so eventually
leads to the pollution of the surrounding streams by mobilization of the contaminated materials by precipitation.
These are also violations of the NCG060000 general permit.
6. Grace Foods must immediately endeavor to develop and implement a full SP3 for the facility. The Certificate of
Coverage (COC) was issued to Grace Foods in July, 2009. You have therefore had nearly two years to become
compliant with the permit. It is highly suggested that you employ the services of a professional environmental
engineer to develop the SP3 as required as it can become quite complicated and the permit has many technical
requirements which may require the services of an engineer.
7. Please reply to this letter in writing within 10 business days of receiving it. Your reply should include a narrative
action plan with time schedule to complete the SP3 and correct all the deficiencies noted above. Your written reply
will be critical to our further consideration of whether or not to pursue enforcement actions at this time. Please also
note that at this point DWQ grants Grace Foods another three months from the date of this letter to have a
fully developed and implemented SP3 for the facility; failure to do so will likely result in enforcement action.
The due date for the completion of the SP3 is therefore September 8, 2011.
8. You are reminded that violations of the NCG060000 general permit are subject to civil penalty assessments not to
exceed $25,000 per day, per violation. Thank you for your cooperation in this matter. Should you have any
questions, please feel free to contact Mr. Boone or me at(336)771-5000.
Sincerely,
'Am1&tU't'/r
W. Corey Basinger
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments:
1. BIMS Inspection Checklist
cc: 1. SWP—WSRO
2. Central Files
3. Stormwater Permitting Unit
4. LGrace-Foods DistribOtibh,-Ir�c_7)
�Attn:_Sen Chiu, President
LBy_Fax:_7_18-782=868_9)
5. City of Winston-Salem Stormwater Division
Attn: William Baugher
P.O. Box 2511
Winston-Salem, NC 27102

{
.� Compliance Inspection Report
1.
Permit: NCG060313 Effective: 07/31/09 Expiration: 10/31/12 Owner: Grace Food Distribution Inc
SOC: Effective: Expiration: Facility: Grace Food Distribution, Inc.
County: Forsyth 5646 Sahthalon Dr
Region: Winston-Salem
Winston Salem NC 27105
Contact Person: Joseph Deluca Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 0610212011 Ent Time: 01:00 PM Exit Time: 02:00 PM
Primary Inspector: Ron Boone L 1 l r! Phone: [phone]
Secondary Inspector(s): r f
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Food/Tobacco/Soaps/Cosmetics/Public Warehousing
Stormwater Discharge COC
Facility Status: n Compliant ■ Not Compliant
Question Areas:
Storm Water
(See attachment summary)
Page: 1

w s
Permit: NCGO6d313 owner-Facility: Grace Food Distribution Inc L1
Inspection Date: 06I0212011 Inspection Type:Compliance Evaluation Reason for Visit:Routine
Inspection Summary:
Please refer to the attached inspection summary letter,
Page: 2

}
41,E Permit: NCGO60313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 06102/2011 Inspection Type: Compliance Evaluation Reason for Visit:Routine
Stormwater Pollution Prevention Plan Yes No NA NE
Does the site have a Stormwater Pollution Prevention Plan? n M U n
#Does the Plan include a General Location (USGS) map? n ® n n
#Does the Plan include a"Narrative Description of Practices"? n 0 Cl n
#Does the Plan include a detailed site map including outfall locations and drainage areas? n ■ ❑ n
#Does the Plan include a list of significant spills occurring during the past 3 years? n ® n n
#Has the facility evaluated feasible alternatives to current practices? n ■ f l ❑
#Does the facility provide all necessary secondary containment? n ■ n n
#Does the Plan include a BMP summary? n ■ Cl n
#Does the Plan include a Spill Prevention and Response Plan(SPRP)? n ■ n n
#Does the Plan include a Preventative Maintenance and Good Housekeeping Plan? n ■ n n
#Does the facility provide and document Employee Training? n ■ n n
#Does the Plan include a list of Responsible Party(s)? n ■ n n
#Is the Plan reviewed and updated annually? n ■ n n
#Does the Plan include a Stormwater Facility Inspection Program? ❑ ® n n
Has the Stormwater Pollution Prevention Plan been implemented? n ® n n
Comment: Please refer to the attached inspection summary letter.
Qualitative Monitoring Yes No NA NE
Has the facility conducted its Qualitative Monitoring semi-annually? n ® n n
Comment: Please refer to the attached inspection summary letter.
Analytical Monitoring Yes No NA NE
Has the facility conducted its Analytical monitoring? Cl ■ n n
#Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas? n ® n n
Comment: Please refer to the attached inspection summary letter.
Permit and Outfails Yes No NA NE
#Is a copy of the Permit and the Certificate of Coverage available at the site? ® n 013
#Were all outfalls observed during the inspection? ® ❑ n n
#If the facility has representative outfall status, is it properly documented by the Division? n n ® n
#Has the facility evaluated all illicit(non stormwater)discharges? n ® n n
Comment: Please refer to the attached inspection summary letter.
Page: 3

_=__—
RE �
Aria
N.C.oao:,o!ENR
NC®NR AUG 0 5 2009
North Carolina Department of Environment and Natural Resources R g,eoaisot,c
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
July 31, 2009
Mr.Joseph DeLuca
Grace Food Distribution Inc.
5646 Shattalon Drive
Winston-Salem, NC 27105
Subject: General Permit No.-NCG060000
Grace Food Distribution Inc.
COC NCG060313
Forsyth County
Dear Mr. DeLuca:
In accordance with your application for a discharge permit received on May 22, 2009, we are
forwarding herewith the subject certificate of coverage to discharge under the subject state—NPDES
general permit. This permit is issued pursuant to the requirements of North Carolina General Statute
143-215.1 and the Memorandum of Agreement between North Carolina and the US Environmental.
Protection Agency dated October 15, 2007 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except after notice to the
Division of Water Quality. The Division of Water Quality may require modification or revocation and
reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be
required by the Division of Water Quality or permits required by the Division of Land Resources, Coastal .
Area Management Act or any other federal or local governmental permit that may be required.
If you have any questions concerning this permit, please contact Cory Larsen at telephone
number [phone] or [e-mail].
Sincerely,
CRG1NAL SIGNED BY
KEN PICKLE.
forColeen H. Sullins
cc: Winston-Salem Regional Office, Ms. Rose Pruitt
Central Files
Stormwater Permitting Unit Files
Wetlands and Stormwater Branch One
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 NorthCarol Ina
Location:512 N.Salisbury S1,Raieigh,North Carolina 27644 �Q�ura���
Phone:[phone] h FAX:[phone] Customer Service:1-877-623-6748
Internet:www.ncwaterquaiity.org
An Equal 0000dUnb 1 Atfirniative Adion Ennolover

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG060000
CERTIFICATE OF COVERAGE No. NCG060313 •
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
GRACE FOOD DISTRIBUTION INC.
is hereby authorized to discharge stormwater and from a facility located at
Grace Food Distribution Inc.
5646 Shattalon Drive
Winston-Salem
Forsyth County
to receiving waters.designated as Mill Creek, a class C water in the.Yadkin-PeeDee River Basin,
in accordance with the effluent limitations, monitoring requirements, and other conditions set
forth in Parts I, II, III, IV, V, and VI of General Permit No. NCG060000 as attached.
This certificate of coverage shall become effective July 31, 2009.
This Certificate of Coverage shall remain in effect for the duration of the General-Permit.
Signed this day July 31, 2009.
ORIGINAL.SIGNED BY
KEN PICKLE
for Coleen H. Sullins., Director
Division of Water Quality
By the Authority of the Environmental Management Commission

LOCATION MAP:
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NCG060313 Grace Food Distribution, Inc.
-' Labtude: 36° 10' 08"N
},. Longitude: 800 17' 14" W
County: Forsyth
Receiving Stream: Mill Creek
Stream Class: C
flap Scale 1.20,044 Sub-basin: 03-07-04 (Yadkin Pee-Dee River Basin) Facility Location

Compliance Inspection Report
Permit: NCGO60313 Effective: 07/31/09 Expiration: 10/31/12 Owner: Grace Food Distribution Inc
SOC: Effective: Expiration: Facility: Grace Food Distribution, Inc.
County: Forsyth 5646 Sahthalon Dr
Region: Winston-Salem
Winston Salem NC 27105
Contact Person: Joseph Deluca Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 02/2412009 Entry Time: 10:45 AM Exit Time: 11:45 AM
Primary Inspector: Rose Pruitt Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Complaint Inspection Type: Compliance Evaluation
Permit Inspection Type: Food/Tobacco/Soaps/Cosmetics!Public Warehousing
Stormwater Discharge COC
Facility Status: 0 Compliant B Not Compliant
Question Areas:
®Storm Water
(See attachment summary)
Page: 1

Permit: NCG060313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 02/24/2009 Inspection Type: Compliance Evaluation Reason for Visit:Complaint
Inspection Summary:
site visit with city of ws sw inspectors. facility washing out trucks to sw drop inlet. no permit
Permit and Outfalls Yes No NA NE
# Is a copy of the Permit and the Certificate of Coverage available at the site? ❑ ® n D
#Were all outfalls observed during the inspection? ® n n n
# If the facility has representative outfall status, is it properly documented by the Division? D D ® D
#Has the facility evaluated all illicit(non stormwater)discharges? D ® D D
Comment: Discharging w/o a permit. truck wash illicit discharge
Page: 2

Compliance Inspection Report
Permit: NCG060313 Effective: 07/31/09 Expiration: 10/31/12 Owner: Grace Food Distribution Inc
SOC: Effective: Expiration: Facility: Grace Food Distribution, Inc.
County: Forsyth 5646 Sahthalon Dr
Region: Winston-Salem
Winston Salem NC 27105
Contact Person: Joseph Deluca Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 06/02/2011 Entry Time: 01:00 PM Exit Time: 02:00 PM
Primary Inspector: Ron Boone f Phone: [phone]
Secondary Inspector(s): !Y1�2Y/Zo rr
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: FoodlTobacco/Soaps/Cosmetics/Public Warehousing
Stormwater Discharge COC
Facility Status: ❑ Compliant ■ Not Compliant
Question Areas:
0 Storm Water
(See attachment summary)
Page: i

r
Permit: NCG060313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 06/02/2011 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Please refer to the attached inspection summary letter.
Page: 2

Permit: NCG060313 Owner-Facility: Grace Food Distribution Inc
Inspection Date: 06/02/2011 Inspection Type:Compliance Evaluation Reason for Visit: Routine
Stormwater Pollution Prevention Plan Yes No NA NE
Does the site have a Stormwater Pollution Prevention Plan? e D D
#Does the Plan include a General Location(USGS)map? D ■ D D
#Does the Plan include a"Narrative Description of Practices"? D ■ D D
#Does the Plan include a detailed site map including outfall locations and drainage areas? D ■ D D
#Does the Plan include a list of significant spills occurring during the past 3 years? ❑ ■ D D
#Has the facility evaluated feasible alternatives to current practices? D ■ D
#Does the facility provide all necessary secondary containment? r l ■ D D
#Does the Plan include a BMP summary? D ■ D D
#Does the Plan include a Spill Prevention and Response Plan (SPRP)? D ■ D D
#Does the Plan include a Preventative Maintenance and Good Housekeeping Plan? D ■ D D
#Does the facility provide and document Employee Training? D ■ D D
#Does the Plan include a list of Responsible Party(s)? ❑ ■ 0 D
#Is the Plan reviewed and updated annually? D ■ D
#Does the Plan include a Stormwater Facility Inspection Program? 0 ■ 0 D
Has the Stormwater Pollution Prevention Plan been implemented? D ■ D D
Comment: Please refer to the attached inspection summary letter.
Qualitative Monitoring Yes No NA NE
Has the facility conducted its Qualitative Monitoring semi-annually? ❑ ■ 0 0
Comment: Please refer to the attached inspection summary letter.
Analytical Monitoring Yes No NA NE
Has the facility conducted its Analytical monitoring? D ■ D D
#Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas? ❑ ■ ❑ D
Comment: Please refer to the attached inspection summary letter.
Permit and Outfalls Yes No NA NE
#Is a copy of the Permit and the Certificate of Coverage available at the site? ■ D D ❑
#Were all outfalls observed during the inspection? ■ D 00
#If the facility has representative outfall status, is it properly documented by the Division? D D ■ D
#Has the facility evaluated all illicit(non stormwater)discharges? D ■ D D
Comment: Please refer to the attached inspection summary letter.
Page: 3

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6/2/2011
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Inspection ` •
E` WINSTOW �`=
. SALEM For • • • Distribution Inc.
cyi4r.
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FAX
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The objective of this SWPPP is three-fold:(1) Identify potential sources
Z
of pollution at Grace food distribution Describe bestnot limited to, a facility inspection, site compliance evaluation, record
3'
management practices (BMPs) (3) Provide other elements such as, but
F �+
keeping • reporting program review that will help Grace food ✓ �
E'er distribution Inc. with the terms an• conditions of • z
discharge t'yl�
�7
x� Report By s. • /n-Salem Stormwater Inspector
t7L;
j
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.! ..._ �:i�?:�`�2`�.c� z1 T�;�. .��a kin'�x.J�..���,`��.', ' �-1�.. z � "�"�"�Xn'V::.,1:.0 a..u�w.�,{�.. �._ 7 _-.Kz..'' iml•r.F!X't'�_x ,..."�Lw -'�,

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City of Winston-Salem
Stormwater Division
Surface Water Inspection for Industrial Sites
Part 1 — General Informations
A. official Company Name: Grace Food Distribution Inc.
B. Physical Address: 5646 Shattalon Drive, Winston-Salem, NC 27105
C. Telephone Number: 336.661.0291
D. Mailing Address, If different from above address: Same
E. Primary contact who is authorized to represent company in environmental regulatory issues:
a. Name: Robert Smith
b. Title: operational Manager
cis Contact Number(s): 336-661-0291
d:� Email: [e-mail] .n _
F. SIC�Code number of business: 5141014 1 r
G. NC.Stormwater NPDES Pi mit Number:1jCG060313
vat. ,Facilrt T e: Food Products`Distribution Warehousin
H.'"Any:other control authoyrity Permits) (air quality cantrol,wastewater,.hazardouswaste)&
riumber(s)-Mone tj L3Li U
I: '' Brief descriptiom oflndustrial activities that occur on-site: Grace Food Distribution,.Inc-engages
in=the,wholesale distribution of Chinese food products. .
ecei ing Water(s)'%'#MS4: Mill Creek, Winston-Salem MS4
P,.art1� Stormwater�;Control
1. Best management Practices
A. List the non/structural controls employed by the facility:
1.Currently they do not have any inplace.
B. Are the BMPs reasonable &appropriate for the facility: Yes No^x zz
C. Are BMPs installed correctly, maintained, and effective operation condition: Yes No x-x-xl
2. Provide a brief description of other controls that manage/prevent/minimize stormwater
runoff(e. g., erosion and sediment controls, inlet protection/control at storm drains, diversion
structures):
1.Comments.

f
Pa_rt:� Miscellaraeaus
1. Any evidence of discharge to receiving waters/MS4? (e.g., stormwater runoff, dry weather
discharge, co-mingling of process wastewater): xxx Yes No
i. NOV was issued for washing of raw meat waste and bleach into the storm water
drainage system.
2. Do the stormwater outfalls on-site correspond with those listed on the site map and in
SWPPP? Yes No xxx N/A
i. There is currently no map of the facility
Part'3, SIIUPPPaRe�iew {cant;becompletediri office)
General
1 Is there a SWPPP? Yes No
2) Does SWPPP identify a specific position(s)•for responsible
party purposes{e'g)dverall coordination, development, �' SiqD --` - V ��
implementation;&prevision a Yes Now
q `t �`'
3) Does SWPPPYdesigrtatetfacility:personnel responsible forty
implemeritin �SRP? Yes O."No.
4 Does SWPPP"include=atcer.tification statement? Y e s S Nod
5) Are employee training°records regarding stormwater pollution
reventi n topics included in=S,WPPP? Yes No
...fir-�J'.
Comments .-
Site Map NOTES
1 is there a site map? Yes No
2 Drainage patterns/outfalls Yes No
3) Identification of potential pollutants likely to be
discharged from each drainage area? Yes No
4 Narrative description and locations of (check if present):
1. Storage practices
2. Unload in /Load ing activities
3. Outdoor processes
4" Particulate generating/control processes

R
5. Waste Disposal
5 Name of receivtg.waters or MS4's listed? Yes No
6) Locations of significant materials exposed to
stormwater? Yes No
7) Locations and descriptions of major spills occurring within the
the 3 previous years (wl corrective actions to prevent future
spills)? Yes No
Stormwater Controls
NOTES
1) Does the SWPPP describe the non-structural
controls that will be used to prevent/reduce
discharge of pollutants in stormwater runoff? Yes No
2) Does the SWPPP describe the structural controls
that will be used to prevent/reduce discharge of
pollutants in stormwater runoff? Yes No
3) Does the SWPPP�describe other controls that will be ,�
used to prevenUrbd ce,off-site tracking or blow ng7of
sediment dust , r'aw final or waste products or
other solid materials'an'd fl`oatin tlebris. ' °
? '�
4) Does the..-SWPPP incorporate the 8zbaseline controls ` 1=
(good housekeeping,_BMP�summ4ary feasibiIi turfy, L �
K--'
PM, SRP procedCjres,.facility inspections, and O o
comprehensive.site evaluation employee training,
seconds .containment,-,and sediment control? Yes No
5) Does the•SVVPPP'describe-the pollutant or activity to
be controlled by`BMPs'and assessed the need of
im lementatibnI roug6ata collected? Yes No
6) Does the SWPPP describe the pollutant or activity
to be controlled by BMPs and assessed the need
of implementation through data collected? Yes No.
Non-stormwater Discharges
NOTES
1) Certification that the facility has been tested for non-
stormwater discharges from the site? Yes No
2) Description of testing method, drainage points,
observed results, date, and signature? Yes No

Monitoring
1) Are samples collected within 30 minutes of
measurable weather events occurring 72 hours after Yes No
previous measurable weather event?
2) Were samples collected and preserved in
accordance with 40 CFR 136? Yes No
3) Was proper chain-of-custody procedures
followed? Yes No
4) Was analytical and qualitative monitoring
complete? Yes No
5) Any exceedences of pollutant parameters in
regards to benchmark values? Yes No
Part 4=iRequiretl Actions fo be c_omt `lep _tedt%y.Facility":
v, _ �. - - -
1. Update', WPPP to reflect permit requirements (i.e. feasibility study, site map to scale, Lat/long
of utfalls za etc.) q 1 111
2. Site map,heed to be doneao-scale,with Eat/long for each outfall that needs to e,annotated,
percentage of:impervious area,need.to'be annotated, potential pollutants-likely to}b�
. �. �; 1 ):x� 1RS �� �
��dascharged needsao be marked for each drainage,bAin„and thelMS4 that is used need to be
�listed�o_ site map. L-i Li R
3 'SWPPP.-need=nbt:be,in general and needs to address specific, implemented'BMPs
_ ._. (41
4: Training'cecords forrspill response and prevention are needed; please submit to thOStormwater
Divis on once.traaining has been accomplished.
1�,5„> A'updated�sig6 ertification statement validating your SWPPP, Spill response training logs, a
`statement,that,no significant spills have occurred on site for the past 3 years, preventative
maintenance records, a non-stormwater discharge certification statement, and a narrative
description of potential pollutants which could be expected to be present in stormwater
discharge for each outfall.
6. Monitoring needs to be performed. Both analytical and qualitative must be in a six month
intervals according to the permit, 2010 monitoring was absent.
7. No qualitative monitoring has been accomplished.
8. Conduct Training and document training, there has not been any conducted.
9. Signed certification statement of SWPPP
10. Conduct feasibility study for the temporary storage tank, which is in the maintains shop a
economic feasibility study for improving that includes inclosing, containing potential spills,
managing spills and 'improving handling of the oil tank.
11. Develop SOPS for delivery personal of how to unload goods, and action that needs to be
emplace in case of a spill, and document that they understand the SOPS and will comply your
established SOPs

The City of Winston-Salem Stormwater Division is requiring that Items#1-11 to be completed. Grace
Foods Incorporated shall keep the Stormwater Division updated on milestones and activities completed
in its progression to comply with these required actions this will be done on a monthly basis. The
Stormwater Division may conduct follow-up inspections in order to ensure completion of mandated
activities.
Educational Resources:
1. NC Stormwater Manual for Industrial lasers:
a. http://h2o.enr.state.nc.us/su/storm water.html.
b. http://portal.ncdenr.org/web/wq/ws/su/bmp-manual
Company Representative(s) that participated in inspection name and title(s): Loy Lee Vice President;
Robert SmithAperation Manager
Start of Inspection: 1:30 PM
: .
CompletEonf I onspec �#ion: 3:15' ' , _ Q
o ,
1
Date of nspec6on,.V6 2- 2011 : , F f
r �- ,. ` . LQJ
Signature-of'Storrriwate.r•Inspector and title: William D. Baugher, Stormwater Inspector 4
n In
V s

Pruitt, Rose
From: Pruitt, Rose
Sent: Monday, July 27, 2009 9:58 AM
To: Larsen, Cory
Subject: RE: Grace Food Distribution NCG060313
Go ahead and issue this permit. They are no longer washing out trucks at the site.
*** My email has changed to Rose.Pruitt @ncdenr.gov
Rose Pruitt
NCDENR-DWQ Winston-Salem Regional Office
Division of Water Quality, Surface Water Protection
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
From: Larsen, Cory
Sent: Wednesday, July 22, 2009 3:32 PM
To: Pruitt, Rose
Subject: Grace Food Distribution NCG060313
Rose,
Grace Food has applied for coverage under NCG06. The application is complete. Any comments from your Region on
this facility? Thanks.
Cory
Cory Larsen
Environmental Engineer
NCDENR I DWQ I Stormwater Permitting Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
512 N. Salisbury St, Raleigh, NC 27604
Phone: [phone]
Fax: [phone]
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
1

rt
FOR AGENCY USE ONLY
Division of Water Quality/Surface Water Date Received
Year Month Da
Protection Section 0- L
Certificate ofCDveraee
r
K'""EM
National Pollutant Discharge Elirninadon System hecckk# I A omt
' r.�v,x Yr.+*a[u Maws.ra-a.rt:ra NCG060000 Perini:Assiened ro
arsy-
NOTICE OF INTENT
National Pollutant Discharge Elimination System application for coverage under General Per ' 7
NCG060000: m a --�-
9�"1 I 1.
STORMWATER DISCHARGES associated with activities classified as: 1'z
SIC(Standard Industrial Classification)20 Food arld Kindred Products
SIC 21 Tobacco Products
»
SIC 283 Drugs
9 -
SIC 284 Soaps, Detergents, & Cieaning Preparations; Perfumes, Cosmetics, &Other Toilet; arms s
Lo
SIC 422 Public Warehousing and Storage (except 4226) — L
f For questions,please contact the DWQ Regional Office for your area. Seepage
(Please print or type) _
1) Mailing address of ownerloperator(address to which all permit correspondence will be mailed
Name _- 611A CP I" d r'
Street Address
City State_-, PJ,_( ZIPCode
Telephone No. 4a'1..n2 4'! Fax: ��G=. ez-1-Ladl
2) Location of facility producing discharge: (Cell 917-4(,D- /7 3,Z
Facility Name `� �-
zr
= '
Facility Contact �jps � Q. L,�,g
Street Address
City toi State Al. <- _Z1P Code _?7ICJ— mm_
County -
Telephone No. �_ (�I'- Fax:
Email C C-fl 9/7, 660- /7.3.2 �o;F. �
3) Physical Location Information:
Please provide a narrative description of how to get to the facility(use street names, state road numbers, and
distance and direction from a roadway intersection). - .z 'd 6Qk 11-r a.
; 'Pe—
(A copy of a county map or USGS quad sheet with the facility clearly located must be submitted with this application-}
It p i r!
4) Latitude 110V[19.- f A� Longitude 1'7't . ©0(deg, min, sec)
i
5) This NPDE Permit Application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
Existing
Pagel of 4
S W U-221-071408 Last revised 7/14/07

NCG060000 N.O.I.
6) Standard Industrial Classification:
Provide the 4-digit Standard Industrial Classification code (SIC code) that describes the primary industrial
activity at this facility.
SIC code: -.7- 'z
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: -' G
8) Discharge points 1 Receiving waters:
How many discharge points (ditches, pipes,channels, etc.)convey stormwater from the property?
What is the name of the Ain
00or bodies of water(creek, stream, river, lake, e e:)-t;at the facility stormwater
discharges end up in?
Receiving water classification:
Is this a 303(d) listed stream? rt0 Has a TMDL been approved for this watershed?
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer).
9) Does this facility have any other NPDES permits?
IdNo
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this faeil�ty:
10) Does this facility have any Non-Discharge permits(ex: recycle permit)?
V'No
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
11) Does this facility employ any best management practices for stormwater control?
lit No
❑ Yes (Show any structural BMPs on the site diagram.)
If yes, please briefly describe:
12) Does this facility have a Stormwater Pollution Prevention Plan?
C�No
❑ Yes
If yes, when was it implemented?
13)Ara vehicle maintenance activities occurring at this facility?
❑ No - Aes
14) Hazardous Waste: y
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
If No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
MeNo ❑ Yes
Page 2 of 4
SWU-221-071408 Last revised 7/14107

NCG060000 N.O.I.
c) Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
®[No ❑ Yes
d) Is hazardous waste stored in the 100-year flood plain?
No ❑ Yes If yes, include information to demonstrate protection from flooding.
e) If you answered yes to questions b.or c., please provide the following information:
Type(s) of waste:
How is material stored: _
Where is material stored:
How many disposal shipments per year:
Name of transport/disposal vendor:
Vendor address:
15) Certification:
North Carolina General Statute 143-215.6B (€) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report,
plan,or other document ailed or required to be maintained under this Article or a rule implementing this Article; or who
knowingly makes a false statement of a material fact in a rulemaking proceeding or conlested case under this Article;or
who falsifies,tampers with,or knowingly renders inaccurate any recording or monitoring device or method required to be .
operated or maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2
misdemeanor which may include a fine net to exceed ten thousand dollars($10,000)-
hereby request coverage under the referenced General 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.
certify that I am familiar with the information contained in this applicatiori and that to the best of my
knowledge and belief such information is true,complete, and accurate.
Printed Name of Person Signing: J�X'E _iD, L_1 p r A
Title: /—/eef /Jfi,7A4�v
(Signature of AppGcan (Date Signed)
This Notice of Intent must be accompanied by a check or money order for$100.00, made payable to:
NCDENR
Page 3 of 4
SWU-221-071408 Last revised 7/14107

NCG060000 N.O.I.
Final Checklist
4
This application will be returned as incomplete unless all of the following items have been included:
19 Check for$100 made payable to NCDENR,
❑ This completed application and all supporting documents.
❑ A site diagram showing, at a minimum, (existing or proposed):
(a)outline of drainage areas, (b) stormwater management structures, (c) location of stormwater outfalls
corresponding to the drainage areas, (d) runoff conveyance features, (e) areas where materials are stored,
(f) impervious areas, (g) site property lines.
❑ Copy of county map or USGS quad sheet with the location of the facility clearly'marked on the map..
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee coverage under the General Permit.
For questions,please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
r
Asheville Office ...... [phone]
Fayetteville Office ... [phone]
Mooresville Office ... [phone] ,
Raleigh Office ........ [phone]
Washington Office ...[phone]
Wilmington Office ... [phone] � Il �, t
Winston-Salem ...... [phone] r
Central Office .........[phone]
Y ngipn
.f
Page 4 of 4
SW U-221-071408 Last revised 7114107

i \� r Mi��'.,ua -tx •ry 4 i � c }'x"s`.iPs'i ,r,.'_ - 'sz-.r�f
T OF41y ! \ Scott Services Inc 1:►"=• ^'
Clyf J� D.B. 2314, Pg. 1619
M<< 0 �s + 1J �� Block 3452, Lots 204C, 205E, ord 205E II.cC -«.
`� 4) RFL�;rCENT�,R ; Pin # 6818-91-3647.00 1 Pir, s 5-
s Sp 17', J 5 Shattalon Or 552C =
- Zoned LI
�4 eRE-z� (PROPER ENT=R OF #AIL S=T `food 1vu� L; "- '-
522.94' N 14.59'25"E
EXISTING GRAVEL AREA
fr' '` f f f �. --�--•-- Sys„ a TFiNK
ACATION Ew SHELTErZ: ' '>, Yr ,tr n� Stiu a4W {c �.� '
GAS , k00, x to0'� ''. RAYE1,`of ,r fr 1
}— , s 1��} - hq zl _ 3 t1 1 Y Eli
N
! earrCOCREIE
100 Y - r ? {
1, 11QQ Line,
qa r " 1, STORY METAL r�_Ulf D1f3G + } N M
► Q�?�' �t.� z �f3LOCK r r....,r-� r� �r'r•,..!S-i z .- .�;--�• �y '
r 1 ! PP M3
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r o�� ��. .. ETe .,. ce.'`-i00�Year='Ftno-d. Lit1e.-. _: , - -• .�1`n.
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Ding Inc FW C7 B ASPHALT P. �IEQ_AREA
76 GAS LINE rt !
360 EQUIPMENT , a IF i r— S 15.32'21"W 550.68 IF t0.0i�
1114 APPROXIMATE LOCATION
j u7 GAS LINE
i o Arid Martin; BeJ
it j _ �rn D.B. 2446, Pc. 27
,n 1 Pin # 6828-02-12�'
+ '`J " `� j v Etcck 6409, Lot e
t f- J
t ' ! I f 1E Moore 01
r ¢ .�?-17
ka j 5 1 1_-,Q'47"W
o5"W 34094r 1 N0 BASES OF REED
k �
PLACED
F TREE
Modern Investments LLC \
D.B. 2450, Pg. 2728
Block 6409, Lot 101
Pin # 6828-01-3505.00
54's 5 Kelley-Moore Dr
Zoned LI
i
r T:is
`e a�*er>sr:.1c s are
da:�t reGr,ue a buffer
i to-uva TyCe[V 5uffe
Bufferyards. Note tha
southern and southwe
The owners of the Prc
inspector to visit the s

7 ` e
iT
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r _
+a�`. _ � �'=—t "`-. ice- -....�(�,s _� •��gi� � � / /'�. � .� , .��f_.•, ., r
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�• � • '� � ° Grace Food Distribution
• s , ``ti r 4
t�"�f+ Y/ yF-• � I,' •J__.r'- � �`••1� ' �F � �I 1. .�� ��. ��t �� f �:ai'L.
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• .r, C �I •� ♦ ti. � k� • ,ate- / 11 a• �,. � lll--,__---���♦•.
NCG060313 Grace Food Distribution, Inc.
Latitude: 360 10' 08" N
Longitude: 800 17' 14" W
County: Forsyth
Receiving Stream: Mill Creek
Stream Class: C
Map le 1:20,000 Sub-basin: 03-07-04 (Yadkin Pee-Dee River Basin) Facility Location

'�'ti a!sy'':3) } ~r�..i #�4'x,�� y" - P ,� n �s,y .� j � ,a ti a '+ � { -' •
?T a ,4
- RECEIVE_Q
E}eot.OfFcr. �
MAR 18 2M .
Win-iton-Salem
Regional Ica
GPACE FOOD DISTRIBUTION
5646A Shattaion Dr., Winston-&Icm,N.C. 27105
046)�t�zs►t
Dade: Avrah iI,2€DOg
To Whom it May Cotwwn:
This lstW is to inform thw city of VftoWn-Selem public vaster works
that Cram Food Dist.will take the following action to eliminate or control
and rnoeKared pollution sourcm from g the wa tm of tine state_
Cry Food Dist has created and knpleniGnted a petuanent t40 of sidlon
In order to establish a pollution pmm mtkm plan,to conduct good house
ks eong to avoid tiood matters or othet..rel&W iftom hom wing the
=W*, by educating the employ and i~Mg a wash pit and
containment area fet all c1mming gemr and-psoducts and tools.
Grace Faced Dist has opcAen with Rick Matdwvm Of Long
Construction Company to afsa help us knpMr xmt cet+tein pleas and
procedums to stop sad aanf wemiige acgom being WAW against Greve Fond
This is base-i of Grace Food Dist intended course of acts is eider
to prevent the Fecurromm of similar situations. Thank You
f
Sincerely

/I/OU
'r
. Y
AgA
S
NCDENR s
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 10, 2009
Grace Foods Dist. Inc
Mr. Loy Lee
5646-A Shattalon Dr
Winston Salem,NC 27105
Subject: NOTICE OF VIOLATION
And Recommendation to Enforce
Grace Food
Forsyth County.
Dear Mr. Lee: -
A complaint investigation was conducted at the Grace Food Dist. facility located at 5646 A Shattalon Drive in Winston
Salem NC'on February 24, 2009 by Rose Pruitt of the North Carolina Department of the Environment and Natural
Resources Division of Water Quality, Winston-Salem Regional Office and Keith Huff,Don Donadio and John Spainhour .
with the City of Winston Salem Stormwater Division. Loy Lee,Vice President and Joey DeLuca,Fleet Manager with
Grace Food Dist. were present at the inspection. During the investigation it was noted that this facility was operating
without required NPDES wastewater or stonmvater permits. A vehicle wash station had been set up where detergents
were used to wash and rinse out trucks that contained leachate and food waste. This waste water flowed to a storm drain
to Leak Fork Creek, a class C water in the Yadkin-Pee-Dee River Basin.
Serious compliance issues and violations were noted as follows.
h (1) Operating without a permit. f 5
The Division of Water Quality issues a General Permit No.NCG060000 to discharge stormwater under the
National Pollutant Discharge Elimination.System. Coverage under this general permit is applicable to all owners;- ,
of stormwater point source discharges associated with activities that are classified as.establishments primarily
engaged in activities classified as Food and Kindred Products (standard industrial classification(SIC)20... and
Public Warehousing and Storage(SIC 4221-4225). I have enclosed information about this permit and a Notice of
Intent or application for coverage under General Permit NCG060000, You trust make application for this permit
immediately.
(2) Making an illicit outlet to the waters of the state in violation of North Carolina General Statute 143-215.1:
§ 143-215.1. Control of sources of water pollution; permits required.
(a)Activities for Which Permits Required.—No person shall do any of the following
things or carry out any of the following activities unless that person has received a permit from
the Commission and has complied with all conditions set forth in the permit:
(1)Make any outlets into the waters of the State.
(2) Construct or operate any sewer system, treatment works, or disposal system
within the State. 5
North Carolina Division of Water Qualfty,Winston-Salem Regional Office
Location:585 Waughtown St.Winston-Salem,North Carolina 27107 One
Phow 336-771-5000 4 FAX:[phone] Customer Service:1-877-623-6748 North Carolina
Internet:www.ncwaterquality.org '�' "atura l ff
An Equal Opportunity 1 Affirmative Action Employer �/ y

1
(6) Cause or permit any waste, directly or indirectly, to be discharged to or in
any manner intermixed with the waters of the State in violation of the water
quality standards applicable to the assigned classifications or in violation of
any effluent standards or limitations established for any point source,unless
allowed as a condition of any permit, special order or other appropriate 5
instrument issued or entered into by the Commission under the provisions of this Article.
An illicit discharge of waste water was observed at the time of the inspection.
A vehicle wash station had been set up where detergents were used to wash and rinse out trucks that contained
leachate and food waste. This waste water flowed to a storm drain to beak Fork Creek, a class C water in the
Yadkin Pee-Dee River Basin,
This Office requires that violations,as stated above, be abated immediate. Also please note, these violations and
any future violations are sub'ect to civil penalty assessments of up to$25 000.00 per day, per violation.
This Office requests that.y6u respond to this letter, in writing,within 20 days of receipt of this Notice. Your
response should address the following items:
(1) You must immediately cease the illicit discharges of process waste water from your facility.
-This Office will require documentation of all remedies.
(2) You must immediatelv begin the application process for General Permit No.NCG060000 to
discharge Stormwater under the National Pollutant Discharge Elimination System. (This is not
apermit to discharge process wastewater.) Send a completed copy of your Notice of In_ten_t to
this office as well as the Raleigh office indicated on the enclosed forms.
(3) Please clearly discuss your efforts to abate/stem impacts to surface_waters.
Thank you for your immediate attention to this matter.This office is considering sending a recommendation for
enforcement to the Director of the Division of Water Quality. Your response to this correspondence will be considered in
this process. Should you have any questions regarding this matter, please contact Rose Pruitt at(336) 771-5000.
ASInce ,. Tedder
Water Quality Regional Supervisor
Winston-Salem Region
Division of Water Quality
Attachments
Cc: Central Files
W SRO
Brock Turner,Forsyth County Health Dept
Keith Huff, Winston Salem Stormwater Division
NPS Compliance and Assistance Unit
Bradley Bennett, Stormwater Permitting Unit

J
WA �aG Incident Report
r
Report Number: 200900632
Incident Type: Complaint On-Site Contact:
Category: Surface Water First/MidlLast Name: Joey Deluca
Incident Started: 02/23/2009 . Company Name: Grace Foods
County: Forsyth Phone: [phone]
City: Pager/Mobile Phone: 1
Farm#:
Responsible Party: Reported By:
Owner: First/Mid/Last Name: Brock Turner
Permit: Company Name:
Facility: Address:
First Name: Loy Fc Flealth'Dept
Middle Name: City/State/Zip:
Last Name: Lee Phone: [phone]
Address Grace Foods Pager/Mobile Phone: 1
5646 A Shattalon Dr
City/State/Zip: Winston Salem NC 27105
Phone: [phone]
Material Category: Estimated Qty: UOM Chemical Name Reportable Qty. lbs. Reportable Qty. kgs.
DD:MM:SS Decimal Position Method: •
Latitude: Position Accuracy:
Longitude: Position Datum:
Location of Incident: Grace Foods
Address: 5646-A Shattalon Dr
City/State/zip Winston Salem NC 27105
Report Created 03/10/09 07:57 AM Page 1

Cause/Observation: Directions:
Owner contacted Health dept for well permit. Wanted well to
wash out chicken delivery trucks to storm drain.
Action Taken: Comments:
Site visit 02/24/2009 @ 10A5-11:45 am with City of WS Met with Loy Lee,Joey DeLuca with Grace Foods. Site is unpermitted
Stormwater Keith Huff Don Donadio,John Spainhour. (SW)food warehousing and distribution site with on site vehicle
maintenance using>55 gallmo of motor oil. Wash area set up to rinse
out delivery trucks with detergent and water drains to stormwater drain.
Site has streams on 3 sides and wetland area.
Incident Questions:
Did the Material reach the Surface Water? Yes - Conveyance: Storm Drain
Surface Water Name? Leak Fork
Did the Spiil result in a Fish Kill? Unknown Estimated Number of fish?
If the Spill was from a storage tank indicate type. (Above Ground or Under Ground)
Containment? Unknown
Cleanup Complete? Unknown
Water Supply Wells within 1500ft: Unknown Groundwater Impacted : Unknown
Event T' pe Event Date Due Date Comment
Irv�iaent closed
Requested Additional Information
Report Entered 2009-03-10 08:48:00
Inspection or Site Visit Conducted 2009-02-24 10:45:00 discussed alternatives for truck wa
Report Created 03/10/09 07:57 AM Page 2

Report Received 2009-02-23 08:15:00
Referred to Regional Office-Primary Contact 2009-02-23 08:15:00
Incident Start 2009-02-23 0&12:00
Standard Agencies Notified:
Agency Name Phone First Name M.I. Last Name Contact Date
Other Agencies Notified:
Agency Name Phone First Name M.I. Last Name Contact Date
City of WS Stormwater [phone] EA. John Spainhour 2009-02-24 10:45:00 AM
DWQ Information:
Report Taken By: Report Entered By: Regional Contact:
Rose Pruitt Rose Pruitt Rose Pruitt
Phone:
DaterTime: 2009-02-23 08:15:00 AM 2009-03-10 08:48:00 AM 2009-02-23 08:15:00 AM
Referred Via: Phone Phone
Did DWQ request an additional written report?
If yes,What additional information is needed?
Report Created 03/10/09 07:57 AM Page 3

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2666 7 2780 �" '
56627693 �i�✓• 7516 - r
4fi44 7516
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T 24588T, go' 1 "'� a' _ .� � ..- A,1Q �r i
4359 6376 8417
;a; qi g .r w 9332. 6215 7"
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�7075 _ "y y 6084
681•7
PIN 6818-91-6360.00 Current Deed Stamps $1,190
Property Address 5650 Shattalon Dr Map Number 618878
Block Lot 3452 114 Assessment Method Income and Expense
Additional Lots WIP No
Tax Jurisdiction Winston-Salem Land Value $194,704
Anx N Dwelling Value
Taxable Owner Name W S Real Estate Holding Inc Commercial Value $450,827
Taxable Owner Name2 Industrial Value
Taxable Owner Address 5646 Shattalon Dr Misc Imp Value $32,791
Taxable Owner City St Zip Winston-Salem, NC 27105 Total Value(2005 renal) $705,400
Taxable Deed Bk-Pg 1967-376 Acreage 13.59
Taxable Deed Date 10/1/1997 Sq Ft Living Area(Res)
Taxable Deed Stamps $1,190 Gross S-q Ft(Com) 30000
Current Owner Name 1 W S Real Estate Holding Inc Year Built(Res)
Current Owner Name2 Year Built(Com) 1990
Current Owner Address 5646 Shattalon Dr Census Tract 27.02
Current Owner City St Zip Winston-Salem, NC 27105 Zoning LI
Current Deed Bk-Pg 1967-376 Last Qualified Sale Price S595,000
Current Deed Date 10/1/1997
Disclaimer:Forsyth County cannot guarantee the accuracy of this information, and the Map Scale
County hereby disclaims all warranties, including warranties as to the accuracy of this 1 inch=636 feet
information. `
01,
6t ,
1 of 1 2/23/2009 8:28 AM

North Carol kpa Secretary of State htrp://www.secretary.state.ne.us/corporations/Corp.aspx?Pitemld=47...
North Carolina
Elaine F. Marshall DEPARTMENT OF�THE
zP SECRETARY of STATE
Secretary .
PO Bax 29622 Raleigh,NC 27626-0622 [phone]
CORPORATIONS Date: 2/23/2009
Corporations Home Click here to:
Search By Corporate Name View Document Filings I Sign Up for E-Notifications i
Search For New&Dissolved Print apre-populated Annual Report Form i Annual
Search By Registered Agent Report Count i File an Annual Report I
Important Notice
Corporation Names
Resale of Tickets Online
Corporations FAQ Name Name Type
Homeowners' Association FAQ NIC Legal '
Tobacco Manufacturers WINSTON-SALEM
Unincorporated Non-Profits REAL ESTATE
Dissolution Reports HOLDING, INC.
Non-Profit Reports Business Corporation Information
Verify Certification
SOSID: 0436521
Online Annual Reports
Status: Current-Active
LINKS&LEGISLATION
Date Formed: 9/25/1997
KBBE B2B Annual Reports
.SOSID Number Correction Citizenship: Domestic
2001 Bill Summaries State of Inc.: NC
1999 Senate Bills Duration: Perpetual
Annual Reports 1997
Registered Agent
Corporations 1997 -
Register for E-Procurement Agent Name: Chiu, Kuong Chung
Dept. of Revenue Registered Office 5732 Shattalon Drive
ONLINE ORDERS Address: Winston Salem NC 27105
Registered Mailing 5732 Shattalon Drive
Start An Order Address: Winston Salem NC 27105
New Payment Procedures Principal Office 5646a Shattalon Dr
CONTACT US Address: Winston Salem NC 27105-1331
Corporations Division Principal Mailing 5646a Shattalon Dr
Address: Winston Salem NC 27105-1331
TOOLS Stock
Secretary of State Home
Secretary of State Site Map Class Shares No Par Value Par Value
Printable Page COMMON 100 1
1 of 1 2/23/2009 10:16 AM

•, SOSID: 0.138521
Date Filed: 2/26/2007 8:05:00 AM
Elaine F. Marshall
CD=479.(50) Business Corporation North Carolina Annoy North Carolina Secretary'of State
1>>`19-06 2007 057 02973
This report may be filed online at the Secretary of State websitd:
Name of Business Corporation: W?NSTON-SALEM R AL ESTATE HOLDING T
Fiscal Year Ending: 12/31/06 State of Incorporation: NC `
MontnfDaylYear
Secretary of State AID Number.
I hereby certify that the information requested below (required by NCGS 55-1fi-22) has not changed since the most recently filed annual
report-and is therefore complete.
Nature ofBusiness:
r Registered Agent: 4
Registered Office flailing Address:
x x -'C'ourity: City[ '' v rSlate_. . Zip Coder
. .
Registered Office Street Address:
County: State: Zip Code:
Signature of New Registered Agent:'
constduies'cansent to She appoinimenq
Principal Office Telephone NumbeF-
Principa( Office Mailing Address:. 5646N1A ,SHAPTALON DRIVE
r
_ City: WIN-STON-.SALiM State: -N(2 'Zip Code: 27305
Principal Office Street Address: 5646;A' SH.A TALON DRIVE
:Y City;r'. WINSTON=SALEM State '•NC Zip Code: 27105
Name,Title, and Business Address Principal Officers:."
Name: BF-IN K.0`, CHI ' Title: PRESIDENT k
Address: 8 NORTH 1ST
C., City: BROOKLYN` t" Stale: NY ZIP: 11211
: Name: xC ~` • . Title" .?
Address:
City: State: ZIP:
Name: 'Title:
Address: i
City: "' State: ZIP:
Certification of arnt]af report(Must be corii I&ed by all Business.Corporations).
'. Signature(F erh st be s'peCjtiy:an o4icer of corporation) 'Dale
Type or Print Name
NCCZ050i 11f13U '
rS 4.' a• T
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