NCGNE0945_COMPLETE FILE - HISTORICAL_20130521

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V
DOC TYPE Q/HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ �������
YYYYMMDD

MCDESNR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakiid, P.E. John E.Skvaria, III
Governor Director Secretary
May 21, 2013
Shaw Industries Group, Inc.
Attu: Mr. Brett Owen
Mail Drop WD-53; P.O. Drawer 2128
Dalton,GA 30722
Subject: .No-Exposure Certifications NCGNE0945
Rescission of Permit NCGO50356 #
Shaw Industries Group,Inc.; Plant LP i
Davidson County I
Dear Mr. Owen:
The Division has reviewed your submittal of the application for No-Exposure Certification for exclusion from NPDES
stormwater permitting. Based on a recent inspection, and your submittal and signed certifications of no exposure at the
above referenced facility, the Division is granting your conditional exclusion from permitting as provided for under 40
CFR 122.26(g), which is incorporated by reference in North Carolina regulations. We are also hereby rescinding the prior
owner's Certificate of Coverage, NCG050356.
Please note that by our acceptance of your no-exposure certification, you are obligated to maintain no-exposure conditions
at the facility. If conditions change such that the facility can no longer qualify for no-exposure exclusion, you are
obligated to immediately obtain NPDES permit coverage for any stormwater discharge(s). Otherwise, the discharge(s)
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. The annual self re-certification statement does not need
to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does not affect the facility's legal requirements to obtain environmental
permits that may be required under other federal, state,or local regulations or ordinances.
If you have any questions or need further information, please contact Jenifer Carter at (336) 771-4957, or at j
[e-mail] I
Sincerely,
i
& i
W. Corey Basinger #
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: cW,..SRO-files 1
SWP Central Files I
Stormwater Permitting Unit: No-Exposure File
Fran McPherson—Budget Office
Mr. Bill Kilmer(Shaw Industries Group, Inc. Plant LP; 144 Welcome Center Court;Lexington, NC 27295)
North Cardina Division of Water Quality,Winston-Salem Regional Office One
'
Location:585 Waughtown Street,Winston-Salem,NC 27107 Nrt
hCarolina
Phone:[phone] Fax:[phone] Customer Service:1-877-623-6748
Intemet:hfp://portat.ncdenr.org/web/wq
An Equal Opportunity 1 Affirmative Action Employer

FkAY�
���t3f'i a. qq c.•,•n r�J J
li�SlUR J31�fT1 FOR AGENCY USE ONLY
Date Reccivcd
Division of Water Qualit"y_FIES+iicfdr&'r atCr Protection Ycnr Mnmh Day
NCDENitNatlonal.,PolIutant Discharge Elimination-System , Certificate nrcovcnigc
`kkTN C�_r��En a NO EXPOSURE CERTIFICATION for Exclusion N
NVR: W',VT M V Hu ,rq'16FRS '
NCGNE0000
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 facilities in North Carolina, DWO 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. "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 NPDES 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 122.26(g).
You are required to self re-certify your No Exposure Exclusion annually.
For questions,please contact the DWQ 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):
Name C23uAW �n)DUS'�R1 5�Ca�,D��r'�r 'nK-• _
Contact g nl
Street Address ,MAID 1]tpp w❑-53 o. nRAi++rER. 21'L$
City or4 State t,A ZIP Code 22
Telephone No. -76t,e $4 Fax:
Email bfe t- ry1MP�n�st,aWihG.Go,r� r
0 LS @[9 V
Page 1 of 7 k!AY 9 2013
SWU-NE-12Aug2010 Q - WATER UALITY
Wands w ,_Wp wa*,e Branch

r ,
NCGNE0000 No Exposure Certification
2) Location of facility producing discharge: �}
Facility Name 11AW INDuS-rWES 414�P. We- k LA4T ,_-
Facility Contact 9%u_ 9iUV<'_P,
Facility Street Address 14 ei r_ome Ce&rerz Coo?,T
City LeYrNGcrgr4 State_ham ZIP Code 7.7 2 9 S
County _ A_gttSor4
Telephone No. astp_ - I Fax:
Email bill- �erS� S 1�•Loryl
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). Uwy !!7.-15" anlTb oW US 52. - Togs_
LW oLma_- JF}��bM& Ci. - &Jeg -ro t- -r 8Lp4 IN !NI)u6TWIh. DA2y- is Ste+-0.
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands? ❑ Yes ZNo
5) Is this a Federal facility? ❑ Yes l(No
6) Latitude -W 551 39.iI'r Longitude -V 141 9•$��� (deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
0 New or Proposed Facility Date operation is to begin
Existing Date operation began 9�ZOOrj
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? Yes ❑ No
If yes, what is the NPDES Permit Number?��D5o35Cp
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code:?
10) Provide a brief description of the types of industrial activities and products produced at this facility:
VacCESS A 49, cx 'M I ? v A[Td
e7r, .AW40AP►r FCPowa4
11) Does this facility have any Non-Discharge permits(ex: recycle permits)?
I/No
❑ Yes
If yes, list the permit numbers for all current•Non-Discharge permits for this facility:
- i_
Page 2 of 7
SWU-NE-1 Mug2010

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 ❑ Yes VNo
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 VN0
c. Materials or products from past industrial activity ❑ Yes I(No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes 'No
e. Materials or products during loading/unloading or transporting activities © Yes GTINo
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes R/N0
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, ❑ Yes VNo
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes O/No
the discharger
i. Waste material (except waste in covered, non-leaking containers [e.g., dumpsters]) ❑ Yes AN
j. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes 2No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes WNo
otherwise regulated (Le., under an air quality control permit) and evident in the
stormwater outflow
1. Empty containers that previously contained materials that are not properly stored ❑ Yes o'No
(Le., 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 2rNo
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 dyes ❑ No ❑ N/A
deterioration, or evidence of leaks? /
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any i�Yes ❑ No ❑ N/A
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SWU-NE-12Aug2010

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 2Yes ❑ No ❑ NIA
containers (including drums, barrels, etc.)with a capacity of more than 660-
gallons?
b. Is secondary containment provided for above ground storage containers stored I/Yes ❑ No ❑ NIA
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 ❑ No ❑ NIA
Amendments and Reauthorization Act (SARA) water priority chemicals'?
d. Is secondary containment provided for hazardous substances—designated in 40 L�'Yes ❑ No ❑ NIA
CFR §116?
e. Are release valves on all secondary containment structures locked? eYes ❑ No ❑ NIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes ZNo
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes O'No
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes JZ/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:_ N A_ _
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 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-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 of the site circumstances may be required. , W q} a nY
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? , 'Yes ❑ No 0/1k 4-1V
-- D 9—,
b. Does your facility have coal piles on site? ❑ Yes ;Z'No
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes ZNo
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: f oc.C&Sr j pAF6R, oAq_nR. -6P lnI LAM11406 jggAQ$
e. If you answered xes to d., are those emissions permitted by an Air Quality Permit? d7Yes ❑ No ❑ NIA
Please specify: YP_Q-r4rf A OTR 0 9N D
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: aal
Permit: Program: 4La Lke ed ` V
Permit: Program:
po I,- 'S
Permit: Program:
. his 6ee11
Permit: Program:
rt�olud-
Permit: Program: r ©4
Page 5 of 7
SW U-NE-12Aug2010

NCGNE0000 No Exposure Certification
17) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of"no
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 identified in this document(except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to annually self re-certify No Exposure and, if requested, 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). I understand that 1 must allow the North Carolina Division of Water Quality, or MS4 operator where the
discharge is into the local MS4,to perform inspections to confirm the condition of no exposure and to make such
inspection reports publicly"available upon request.
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 prior Van y point source dischar6'of stormwater from the faciYy.Additionally, I certify under penalty of
law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is to the best of my knowledge and belief true,accurate and complete. I am aware
that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief
such information is true,complete, and accurate. I '
Printed Name of Person Signing: W l"j A M k i LMER
Title: LRNT A NJI C—fR-
-0 �"M 23 i3
(Signature of Applicant) (Datl Sig d)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional 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 any time in the future for compliance with the No Exposure Exclusion.
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement,representation,or certification in any application,record,report, plan,or other
document filed or required to be maintained under this Article or a rule implementing this Article;or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested 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
[Environmental Management]Commission implementing this Article shall be g0ty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($10,000).
There is currently no fee for a No Exposure Exclusion.
Page 6of7
SWU-NE-12Aug2010

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North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P.E. John E. Skvarla, III
Governor Director Secretary
May 21, 2013
Shaw Industries Group,Inc.
Attn: Mr. Brett Owen
Mail Drop WD-53; P.O. Drawer 2128
Dalton,GA 30722
Subject: No-Exposure Certifications NCGNE0945
Rescission of Permit NCG050356
Shaw Industries Group,Inc.; Plant LP
Davidson County
t
i
I
Dear Mr. Owen:
The Division has reviewed your submittal of the application for No-Exposure Certification for exclusion from NPDES
stormwater permitting. Based on a recent inspection, and your submittal and signed certifications of no exposure at the
above referenced facility, the Division is granting your conditional exclusion from permitting as provided for under 40
CFR 122.26(g), which is incorporated by reference in North Carolina regulations. We are also hereby rescinding the prior
owner's Certificate of Coverage,NCG050356.'
Please note that by our acceptance of your no-exposure certification, you are obligated to maintain no-exposure conditions
at the facility. If conditions change such that the facility can no longer qualify for no-exposure exclusion, you are I
obligated to immediately obtain NPDES permit coverage for any stormwater discharge(s). Otherwise, the discharge(s)
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. The annual self re-certification statement does not need
to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does-not affect the facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jenifer Carter at (336) 771-4957, or at I
[e-mail]
Sincerely,
W. Corey Basinger D
Surface Water Regional Supervisor
Winston-Salem Regional Office - }
Division of Water Quality FmAY 2, 20 3 1
cc: WSRO files
NR SWP Central Files w - w� �llq�f�1.
s�` atee Branch
Si tormwater Permitting natU No;Exposuie,Fil
Fran McPherson—Budget Office
Mr.Bill Kilmer (Shaw Industries Group,Inc. Plant LP; 144 Welcome Center-Court; Lexington, NC 27295)
i
North Carolina Division of Water Quality,Winston-Salem Regional Office ne
Location:585 Waughtown Street,Winston-Salem,NC 27107 N09crthcarolina.
Phone:[phone] Fax:[phone] i Customer Service:1-877-623.6748 tm"w1l
Internet:http:llportal.nedenr.org/weblwq
An Equal Opportunity 1 Affirmative Action Employer

_5
�CDEHR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P.E. John E. Skvarla, III
Governor Director Secretary
March 27, 2013
Shaw Industries Group, Inc.
Mr: Bill Kilmer
144 Welcome Center Court
Lexington,NC 27295
Subject: Compliance Evaluation Inspection
Certificate of Coverage#ENCG050356
Shaw Industries Group, Inc; Plant LP
Davidson County
Dear Mr. Kilmer:
A Compliance Evaluation Inspection was performed at Shaw Industries in Lexington, North Carolina on
February 28, 2013 by Jenifer Carter of the Winston-Salem Regional Office. You were present for the inspection.
The purpose of the inspections was to review compliance with the National Pollutant Discharge Elimination System
(NPDES) General Stormwater Permit. The following are the findings from the subject inspection:
• A Stormwater Pollution Prevention Plan (SPPP)has been developed and properly implemented.
• Qualitative monitoring has been conducted and recorded in accordance with permit requirements.
• Analytical monitoring is not required since no vehicle maintenance is performed on site.
• There were no residuals from spills or leaks observed on the ground, nor in or near surface waters.
• There was no evidence of use of, or cleaning of industrial machinery or equipment outdoors.
• 3 outfalls are being monitored.
• The facility qualifies for No Exposure Certification. An application is enclosed should you choose to apply for it.
The Division greatly appreciates your efforts to maintain compliance. Should you have any questions, please contact
Jenifer Carter at(336) 771-495T
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
CC" WSRO Files
SWP—Central Files
NPS ACO Unit
North Carolina division of Water Quality,Winston-Salem Regional Office One
Location:585 Waughtown Street,Winston-Salem,NC 27107 NO Carolina F
Phone:[phone] Fax:[phone] Customer Service:1-877-623-6748 U�lfPa��l,f l
lntemet:http:llportal.nodenr.org/wehlwq '
An Equal Opportunity 1 Affirmative Action Employer

I
1 qff
Bill Kilmer
Plant Manager-LP
' Hard Surfaces Division Tel [phone]
Shaw Industries Group,Inc. Fax [phone]
144 Welcome Center Court Mobile [phone]
1 Lexington,NC 27295 [e-mail]

�OF W A rF9Q Michael F.Easley,Governor
William G.Ross Jr.,Secretary
7 North Carolina Department of Environment and Natural Resources
Q Coleen H.Sullins,Director
Division of water Quality _
January 8, 2009
Mr. Bill Kilmer
Shaw Industries Group, Inc; Plant LP
144 Welcome Center Court
Lexington,NC 27295 t
Subject: Compliance Evaluation Inspection
Certificate of Coverage ##NCG050356
Shaw Industries Group, Inc; Plant LP
Davidson County
Dear Mr. Kilmer:
A Compliance Evaluation Inspection was performed at Shaw Industries in Lexington, North Carolina on
December 17, 2008 by Jenifer Carter of the Winston-Salem Regional Office. Mr. Wendell Hardnett was present
or the inspection. The purpose of the inspections was to review compliance«nth the National Pollutant Discharge
Elimination System (NPDES) General Stormwater Permit. The following are the findings from the subject
inspection:
• A Stormwater Pollution Prevention Plan (SPPP)has been developed and properly implemented.
• Qualitative monitoring has been conducted more often than required (quarterly) and recorded in accordance
with permit requirements.
• Analytical monitoring is not required since no vehicle maintenance is performed on site.
• There were no residuals from spills or leaks observed on-the ground, nor in or near surface waters.
• There was no evidence of use of, or cleaning of industrial machinery or equipment outdoors.
• 12 outfalls are being monitored, though marry of them may be interconnected. You are only required to
monitor the points where stormwater leaves the facility's property. You can, of course, continue to monitor
all stormdrains if you choose, or investigate which ones are connected to each other and only monitor the ones
that direct the flow off of the property.
The Division greatly appreciates your efforts to maintain compliance. Should you have any questions, please
contact Jenifer Carter at(336) 771-4957.
Sincerely,
(Steve W. Tedder
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: Wr SRO Files_
SWP—Central Files
NPS ACO Unit
North Carolina Division of water Quality 585 Waughtown Street;Winston-Salem,NC 27107 Phone[phone] Na Y.hCarolina
Customer Service: 1-577-623-6748 Internet: www.ncwaterquality.org Fax[phone] ��atura!!lf
An Equal Opportunity/Affirmative Action Employer—50%Recycled/]0%Post Consumer Paper
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WtyonysOce Where Great Floors Begirf
INCIDENT INVESTIGATION FORM
Facility: Plant Name Shaw Industries Plant # LP CC# 01705
Address 144 Welcome Center Court
City Lexington State NC Zip 27295-
Phone [phone]
Employee: Name ❑ Male ❑ Female
Address
City State Zip
EM# Phone - Base Pay Rate- Date of Birth 1 /
Age Marital Date of Hire
Status
Time on Present Job # of Dependents
Job Job Title Job #
Description Dept Name Dept #
Shift Hours ❑ am ❑ pm to ❑ am ❑ pm Work Overtime ❑ Yes ❑ No
Employee on regular job? ❑ Yes ❑ No If no, explain:
# of days scheduled to work week of incident: Paid for full shift? ❑ Yes ❑ No
Incident Exact Location (be specific)
Date of Incident I I Time of Incident ❑am ❑ pm
Date Reported / 1 Lost Time ❑ Yes D No ❑ Unknown
Injury/Illness
Body Parts Affected Type of Injury/Illness
How did Injury/Illness Occur?
Was Employee on Premises? ❑ Yes ❑ No Reported To
Witnesses
Treatment Provided By ❑ Emergency Room ❑ Doctor ❑ Plant Nurse ❑ Supervisor ❑ No One
If First Aid, Given By
Describe First Aid Treatment
Name &Address of Physician or Health Care Professional:
Was Patient Hospitalized Overnight as an In-Patient? ❑ Yes ❑ No Lost time? ❑ Yes ❑ No ❑ Unknown
OSHA Recordable? ❑ Yes OSHA # ❑ No ❑ Unknown Fatality? ❑ Yes ❑ No Date: 1
Incidents Without Injuries Chemical Property Loss Securi Fire etc.
Person Reporting Edward Mahoney Job Title First Shift Supervisor
Type of Incident Contaminated Storm-water/Non Storm-water accidental discharge
Cause Tank farm flooded and was tested and pumped to stream and-then some contamination was found
Was There Any Property Damage? ❑ Yes ® No Type of Damage
Estimated/Actual Cost Local Emergency Services contacted? ❑ Yes ® No Specify:
Completed By Edward Mahoney Date 02/0512007
Distribution: Top Copy: Must be completed on the shift in which the incident occurred. If the incident required medical
attention (i.e. to doctor/ER),top copy must be forwarded to Worker's Compensation, Mail Drop ORW-24 or
Faxed to WC Dept [phone] or [phone]. States not handled by Shaw WC Dept need to
immediately phone the claim in to Zurich at 1-800-553-2671 as well.
Follow-up: Supervisor's follow-up investigation must be completed within 48 hours of the
incident and sent to the Plant Manager. All incidents which involve lost time cases, chemical
releases, or property damage in excess of $5,000 must be photocopied and forwarded to
Corporate Safety, Group Director Director of Distribution and Vice President of Distribution.
SAFF008.1.0 1

111hhh'ATIo R,
Where Great Floors Begirt
PLEASE TYPE OR PRINT CLEARLY
Employee's statement of what occurred and suggestions for preventing this incident from
W occurring again:
>- Z
O 0
a �
W Q Signature of Employee:
Describe clearly what occurred (how, what, when, where). Include diagrams if needed (include
witness statement, if applicable). At 0600 it was discovered that the water hose-going to the -
= pressure washer had busted. The tank farm was flooded with city water from water running for
G about one and half days. Water was tested pH was 7.25 and the RI was 1.3327 this test was in
P
CL the safe range. IFA Operator then started pumping the water to storm drain. At about 1100 the
maintenance supervisor noticed that there was a white cloud in the water that was remaining in
Wthe tank farm. The pump was shut off and the water was then tested at the exit point in the
o covert. The test was done in two locations the covert and the stream that the run off leads to.
The test results were DH 7.35 and RI 1.327 at covert and the stream was pH 7.45 and RI
1.3331,
Describe the hazard (unsafe act or condition) that caused the incident. Materiel Failure
Describe the root cause of the hazard stated above. Human error
CA Is this hazard covered in the ]HA? ❑ Yes ® No If no, submit one.
�n Was)HA reviewed with employee after the incident? ❑ Yes ® No
aEmployee's suggestion on what could be done to prevent this incident from recurring. Ensure
Z water has been turn off and good housekeeping ( Resin came from MF60%Tank #2 mess left
AC on deck after tank was empted last week)
What actions have been or will be taken to prevent recurrence? Completion Date
1) Prompt clean-up of tank farm after maintenance work is done— On going
especially if resin is spilled onto the concrete.
Z 2} More comprehensive daily inspections of the tank farm. On aoina
w
Z3) Better communication between maintenance personnel and 1 I
> production personnel with regards to the impacts of maintenance
W activities in the tank farm containment area.
oC
a 4) 1 /
5} 1 I
Supervisor C" Date Safety Mgr Date /
Signatur Signature
Department Head Date Plant Manager Date
54n&4t Signature
The incident investigation has been reviewed with me including all preventative actions.
SAFF008.1.0 2

O�OF \N A T'RQG Michael F.Easley,Governor
William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
/YG ycfh�
Alan W.Klimek,P.E.Director
Division of Water Quality
February 9, 2007
RECEIVED
Mr. Bill Kilmer ?5
Shaw Industries Group, Inc; Plant LP FEB 12 2007
144 Welcome Center Ct.
Lexington,.NC 27295 Regional�'ce
Subject: General Permit No. NCGO50000
Shaw Industries Group, Inc; Plant LP
COC NCG050356
Davidson County
Dear Mr. Kilmer:
In accordance with your application for a discharge permit received on January 22, 2007, 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 May 9, 1994 (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. Please also note the requirement to have a Stormwater Pollution
Prevention Plan and to comply with the cut off concentrations listed in the permit. This plan should
address all of the items listed in the permit including a method to mitigate possible future releases from
your concrete containment area as occurred on February 5, 2007. You will be contacted in the near future
for an inspection by our regional office.
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 Kelly Johnson at telephone
number [phone] ext. 376..
Sincerely,
- r
Alan W. Klimek, P.E.
cc: Winston Salem RegionalOffice, Jenifer Carter '.
Central Files
Stormwater Permitting Unit Files
NorthCarolina
,lValrrrally
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh,NC 27699-1617 Phone[phone] Customer Service
Internet: www.ncwaterquality.or Location: 512 N.Salisbury St. Raleigh,NC 27604 Fax [phone]
An Equal Opportunity/Affirmative Action Employer—50%Recyded110%Post Consumer Paper

i
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCC050000
CERTIFICATE OF COVERAGE No. NCGO50356
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,
Shaw Zndustries,Group, Inc; Plant LP
is hereby authorized to discharge stormwater from a facility located at
Shaw Industries Group, Inc; Plant LP
144 Welcome Center Court
Lexington
Davidson County
to receiving waters designated as Cain Creek, a class WS-III water in the Yadkin River Basin, in
accordance with the effluent limitations, monitoring requirements, and other conditions set forth
in Parts 1, I1, III, IV, V, and VI of General Permit No. NCG050000 as attached.
This certificate of coverage shall become February 9, 2007.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this 9`h day of February 2007. i
= w"Z`_EY BENNIE'[7
for Alan W. Klimek, P.E., Director
Division of Water Quality
By the Authority of the Environmental Management Commission

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Latitude: 35055'51" N
NCG050356
Facility ,. R.
Longitude: 80014'8"W
Shaw Industries
County: Davidson Location
Stream Class: WS-III Group, Inc; Plant LP
Receiving Stream: Cain Creep
Sub-basin: 03-07-07 (Yadkin River Basin) [NO�tft Not to scale