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HomeMy WebLinkAboutNCGNE0945_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 jenifer.carter@edenr.gov 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:(336)771-50001 Fax:(336)771-46301 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. 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Shaw Industries, Pit LP A- 4-0 97. ki�0 c7N IL Jf's V Tr �H-ne 52 U 'j P, 0.1 A- 02013 Microsoft Corporation 020.13�Nokia- littp://www.bing.com/maps/print.aspx?mkt=en-us&z=14&s=r&cp=3 5.92 7494,-8 0.23)60 52&... 5/3/201 J - , -- a Ul MC®ENR 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 jenifer.carter@ncdenr.gov 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:(336)771-50001 Fax:(336)771.4630 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:(336)771-50001 Fax:(336)771-46301 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 336.731.8803 Shaw Industries Group,Inc. Fax 336.731.1433 144 Welcome Center Court Mobile 336.926.9589 1 Lexington,NC 27295 Bill.Kilmer@shawinc.com �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(336)771-5000 Na Y.hCarolina Customer Service: 1-577-623-6748 Internet: www.ncwaterquality.org Fax(336)771-4630 ��atura!!lf An Equal Opportunity/Affirmative Action Employer—50%Recycled/]0%Post Consumer Paper l FEB 13 VAR lowillb"All"40 ,1 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 336 731-1425 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 (706) 275-2367 or (706) 275-2368. 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 (919) 733-5083 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(919)733-5083 Customer Service Internet: www.ncwaterquality.or Location: 512 N.Salisbury St. Raleigh,NC 27604 Fax (919)733-9612 1.877-623-6748 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. 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'1,i '��[ r,. � •�{er, •rn�ti�. `r'�h a� ���- €' � i�i' .f��r I.�/ �1 �\ Jt �r✓'�t� r /J J�)} 1'. tR�`-1 rd ,'�^r >•1il � +,-'rt'!� _ g tl J a *,r��: r i J �v .- ",���J_ 1 G.u (�rV r•1`-�J� 4i 1�.� r ��1�('�� :i�� 11�. _' J 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