NCG070239_Application_20240715

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NCG07o2 3FOR AGENCY SEL�ONLY
Assigned to: - CAOV-
ARO FRO R RRO WARO WIRO WSRO >/
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCGO70000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC 32[Stone,Clay, Glass and Concrete Products],and like activities deemed by DEMLR
to be similar in the process and/or the exposure of raw materials,products,by-products,or waste materials.SIC
3273[Ready-Mixed Concrete]is spec fia gy excluded from coverage under this General Permit and is instead
covered under NCG140000. You can find information on the DEMLR Stormwater Program at deq.nc.gov/SW
Directions: Print or type all entries on this application. Send the original,signed application with all required
items listed in Item(6)below to: NCDENU Stannvmter Pn ram,1612 MSC,Rakish,NC 27699-1612. The
submission of this application does riot guarantee coverage under the General Permit Prior to coverage under
this General Permit a site inspection will be conducted.
1. Owner/ (to whom all permit correspondence will be mailed):
Na a of legal organizational a ty: Legally responsible person as signed in Item(7)below:
e ( G r11 ill r SWadhd l;nan;t
Street address: City: State: Zip Code:
53 "0 t, i II ►-d MOMc. tic
Telephone num Email address:
04 m ndf2 nine-lilt . '/.eon')
Type of Ownership:
Government
❑County ❑Federal ❑Municipal ❑State
Non-government
13
Business(If ownership is business,a copy of NCSOS report must be included with this application)
X Individual
2. Industrial Facility(facility being permitted):
F ility name: Facility environmental contact: I
z ntle ., Tile, Alod"d - Jnab z
Street address: City: State: Zip Code:
3 "Q- "orYtre �L agI► Z�
Parcel Identificatio umber(PIN): County:
Y1i0✓1
Telephone nu ber: Email address:
p'As 1 le Co
4-di it SIC code: Facility is: Date ope lion is to m or bega .
SIZE ^4 t ❑ New ❑ Proposed Existing
Latitude of entrance: Longitude of entrance:
cn 5 _ 3- a to
Brief description of the types of industrial activities and products manufactured at t s facility:
o I. n IZ v+Z
If the stdrmwater discharges to a municipal separate storm sewer system(MS4),nafhe the operator of the M54:
❑ N/A
Page i of 5

3. Consultant(if applicable):
Name of qo ultant: Consulting firm:
Street address: City: State: Zip Code:
Telephone number: Email address:
4. Outfalf(s)_At least one outfall is required to be eligible for coverage.
3-4 digit identifier: me of receiving water: Classification: This water is impaired.
j(- —I 1 —�j(p— /S n Cy'"L Ci ❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
3y . S - 32 -2-
Brief scription of the industrial activities that drain this outfa :
WSYtk 0 1 A / 2
Do Ve icle Maintenance,4ktivitles occur in the drainage area of this tfall? ❑Yes KNo
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfaff:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfag? []Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water. Classification: ❑This water is impaired.
❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water. Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
All outfalls must be listed and at least one outfall Is required.Additional outfalls may be added in the section
"Additional Outfalis"found on the last page of this NOI.
Page 2 of 5

S. Other Facility Conditions(check ali that apply and explain accordingly):
❑This facility has other NPDES permits.
If checked,list the permit numbers for all current NPDES permits:
❑This facility has Non-Discharge permits(e.g.recycle permit).
If checked,list the permit numbers for all current Non-Discharge permits:
❑This facility uses best management practices or structural stormwater control measures.
If checked, briefly describe the practices/measures and show on site diagram:
❑This facility has a Stormwater Pollution Prevention Plan(SWPPP).
If checked,please list the date the SWPPP was implemented:
❑This facility stores hazardous waste in the 100-year floodplain.
If checked,describe how the area is protected from flooding:
❑This facility is a(mark all that apply)
❑ Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked,indicate:
Kilograms of waste generated each month: Type(s)of waste:
How material is stored: Where material is stored:
Number of waste shipments per year: Name of transport/disposal vendor-
Transport/disposal vendor EPA ID: Vendor address:
❑This facility is located on a Brownfield or Superfund site
If checked,briefly describe the site conditions
6. Required Items(Application will be returned unless all of the following items have been included):
❑ Check for$120 made payable to NCDEQ
CYCopy of most recent Annual Report to the NC Secretary of State
❑'This completed application and any supporting documentation
A site diagram showing,at a minimum,existing and proposed:
a) outline of drainage areas
b) surface waters
c) stormwater management structures
d) location of stormwater outfalls corresponding to the drainage areas
e) runoff conveyance features
f) areas where industrial process materials are stored
g) impervious areas
h) site property lines
Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 3 of 5

7. Applicant Certification:
North Carolina General Statute 143-215.68(i)provides that: Any person who knowingly makes any false statement,
representation,or certification in any application,record,report,plan,or other document filed or required to be maintained
under this Article or a rule implementing this Article.. .shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that:
7 I am the person responsible for the permitted industrial activity,for satisfying the requirements of this permit,and for any
I'vil or criminal penalties incurred due to violations of this permit.
he information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,and complete based on
my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the
Information.
will abide by all conditions of the NCG070000 permit.I understand that coverage under this permit will constitute the
�}1ermit requirements for the discharge(s)and is enforceable in the same manner as an individual permit.
LUI hereby request coverage under the NCG070,0^00 General Permit. 1 Printed Name of Applicant: Sd S Ir.)J 5 /"I d`-1 C1 I-k�'Ytt y" 2 .
Title: QQ2YW/✓
sd -7I1 D �aN
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 4 of 5

Additional Outfalls
3-4 digit identifier: Name of receiving water. Classification: ❑This water is impaired.
❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: El This water is impaired.
❑This watershed has a TMDL
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
Page 5 of 5

L*bing rnap;
Hernandez Granite&Tile
Address: 523 Morgan Mill Rd, Monroe, NC 28110
Phone: [phone]
Hours
Monday- Friday 9:00 AM -5:00 PM
Granite 8 Tde!"
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Parcel Number 0 0 , p
09189018
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Owner 0 0
MORGAN 0 7 0 0 p 0 •��¢. 0
MILL LLC 'O
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O p 10 O p'.ID
Mailing Address o a p o
204-C WEST WOODLAWN RD 0 0 eO /' 9c
CHARLOTTE j 0
NC, 28217 O i 0 O /' 0
mt p p 0 0
tLL 0 0
Account Information
Land Value $1,099,600,00
Building Value $458,100.00 Description MORGAN MILL RD 537 HWY 74
Total Value $1,557,700.00 Situs Address 537 557 MORGAN MILL RD
Acreage 4.8870 Property Class COMMERCIAL
Sales Information
Sale Date Sale Amount Book&Page Grantor
04/12/2001 $815,000.00 1539 749 C W HORNE SAWMILL&
CHIP CO INC
OV11/2001 $725,000.00 1488 870 GRIFFIN FLORA D
Location Information
Municipal Monroe 12 Mile Service Area No
Administration
County Zoning Code CITY School School Assignment Information
Zoning Administration Monroe Census Tract Number 204.04
ETJ FEMA Panel 5445
Fire District Monroe FEMA Zone
Soils BuB
Building Information View Real Property Site
Total Living Area 00
Year Build 0
District Voting Assignments (Jurisdictions)
Polling Place WINCHESTER Scholl District 1 Congressional 9
COMMUNITY CENTER District
Precinct District #43 State House 55 Senate 29
District

0 BUSINESS CORPORATION ANNUAL REPORT --
rrAME OF BUSINESS CORPORATION: Hernandez Granite and Tile,Inc.
1428489 HiM Office Use Only
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC YY
REPORT FOR THE FISCAL YEAR END: 12/31/23 INA©
L
SECTION A:REGISTERED AGENT'S INFORMATION ffl~ ti ® Changes
1.NAME OF REGISTERED AGENT: ESdraS Jesus Madrid Hernandez
2.SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENTTO THE APPOINTMENT
3.REGISTERED AGENT OFFICE STREET ADDRESS&COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
523 Morgan Mill Road 523 Morgan Mill Road
Monroe, NC 28110 Union Monroe, NC 28110 Union
SECTION B:PRINCIPAL OFFICE INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS: Construction-Granite&Tile
2.PRINCIPAL OFFICE PHONE NUMBER: [phone] 3.PRINCIPAL OFFICE EMAIL: [e-mail]
4.PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILING ADDRESS M
O
523 Morgan Mill Road 523 Morgan Mill Road
Monroe,NC 28110 Union Monroe,NC 28110 Union
6.Select one of the following If applicable.(Optional see Instructions)
❑ The company is a veteran-owned small business
❑ The company is a service-disabled veteran-owned small business
SECTION C:OFFICERS(Enter additional officers in Section E.)
NAME: Esdras Jesus Madrid Hernandez NAME: NAME:
TITLE: President TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
3204 Old Monroe Marshvilie Rd
Wingate,NC 28174 Union
SECTION D:CERTIFICATION OF ANNUAL REPORT_ Section D must be completed in its entirety by a person/business
entity.
SIGNATURE DATE
Form must be signed by an otfim rrsted under Seclion C of M fi r
"J'"`PriiiforType Name ur019ar -- — print"Type Title or Oiflc �—
SUBMIT THIS ANNUAL REPORT WITH THE REQUIRED FILING FEE OF$25
MAIL-TO:Sevetaryofstaze. RUMI ss RegSuabw Divisiom Post O&ce Bo:29525,Ratetgn,MC2T626045

CA202315901852
SOSID:1421r489
Date.Filed:6W2023
.�,. ,,t, BU.SINFissCORPORATIONANNUALREP Elaine F.Marshall
r, 3 �4
North Carolina Secretary of State
coma CA2023 159 01852
NAME OF BUSINESS CORPORATION: Hernandez Granite and Tile,Inc.
1428489 muse
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC
Ordy
REPORT FOR THE FISCAL YEAR END: 12/31/22 N
L
SECTION A.REGISTERED AGENTS ng
INFORMATION Wy 4 Chaes
1.NAME OF REGISTERED AGENT: Esdras Jesus Madrid Hernandez
---`L SIGNATURE OF THE NEW REGISTERED AGENT: _--_- --- — -- _ _ -
SiG W 11URE CONSnnnES CONSENr TO THE APPONWNi
3.REGISTERED AGENT OFFICE STREETADDRESS 3 COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
3204 Old Monroe Marshville rd 3204 Old Monroe Marshville rd
Wingate, NC 28110 Union Wingate, NC 28110 Union
SECTION B:PRINCIPAL OFFICE INFORMATION
1.DESCRPnON OF NATURE OF BUSINESS: Construction-Granite&Tile
2.PRINCIPAL OFFICE PHONE HUMBER (7Q4)320-1201 3.PRINCIPAL OFFICE Elnn: P(iva Redaction
4.PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILINGADDREW
3204 Old Monroe Marshv8le rd 3204 Old Monroe Marshvgle rd
Wingate,NC 28174 Union Wingate,NC 28174 Union
6.Select one of the following if applicable.(Optional see instructions)
❑ The company is a veteran-owned small business
The company is a service-disabled veteran-owned small business
SECTION C:OFFICERS(Enter additional oRicers In Section E.)
NAME: Esdras Jesus Madrid Hernandez NAME: NAME
TITLE: President TITLE TITLE.
ADDRESS: ADDRESS: ADDRESS:
3204 Old Monroe Marshville Rd
Wingatp,NC 28110 Union .
SECTION D:CERTIFICATION OF ANNUAL REPORT. Section O must be completed in its entirely by a personibusiness
en�itY• —MQtAF1G n%d (/I.H U a3
SIGNATURE —� pATE
Fan must be signed by=ofica Gated wWwSedon C oraistm.
Esdras Jesus Madrid Hernandez x president
P"aType Nave of Ortwer Pda aTypeTdleel OH6rcr
- SUBMIT-THIS ANNUAL-REPORT WM4-rHERECIUIRED FILING FEE OF S25
NALTo:seaeUgorates Ru sRe*sftz ,MVMk .Post ofxe ens ZM%RWWA NC 27MO 9a

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CA202315901852
SOSfD: 1428489
Date Filed;6/8/2023
BUSINESS CORPORATION ANNUAL REP Elaine F.Marshall
North Carolina Secretary of State
CA2023 159 01852
NAME OF BUSINESS CORPORATION: Hernandez Granite and Tile,Inc.
1428489 use04
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC
REPORT FOR THE FISCAL YEAR END: 12/31/22 � IJ
L
SECTION A:REGISTERED AGENTS INFORMATION
Changes
1.NAME OF REGISTERED AGENT: ESdraS Jesus Madrid Hernandez
--2.SIGNATUREOF THE NEW REGISTERED AGENT:
SIGNATURECONSiiIUfES CONSERTO TIEAPPOfNT&RINT
3.REGISTERED AGENT OFFICE STREETAD13RESS S COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
3204 Old Monroe Marshville rd 3204 Old Monroe Marshville rd
Wingate, NC 28110 Union Wingate, NC 28110 Union
SECTION B:PRINCIPAL OFFICE INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS: Construction-Granite&Tile
2.PRINCIPAL OFFICE PHONE NUMBER. [phone] 3.PRINCIPAL OFFICE EMAIL:I Privacy Redaction
• .0
4.PRINCIPAL OFFICE STREET ADDRESS S.PRINCIPAL OFFICE MAILING ADDREW
3204 Old Monroe Marshville rd 3204 Old Monroe Marshville rd
Wingate,NC 28174 Union Wingatee,NC28174 Union
6.Select one of the following if applicable.(Optional see instructions)
❑ The company is a veteran-awned small business
❑ The company is a service-disabled veteran-owned small business
SECTION C:OFFICERS(Enter additional officers in Section E.)
NAME: Esdres Jesus Madrid Hernandez NAME: NAME: 71
-
TITLE: President TITLE TITLE:
ADDRESS: ADDRESS: ADDRESS:
3204 Old Monroe Marshville Rd
Wingate,NC 28110 Union -
SECTION D;CERTIFICATION OF ANNUAL REPORT Section D must be completed in its entirety by a person/business
entity.
SIGNATURE DATE
must be signed byar offices fisted miler Sedmn C dfNtm sfo .
�Esdras Jesus Afadrid Hermandez jr president
PdnlaT,pe Name0f0fi1 r PriterTweTaieaaear
�- —SUBMIT THIS ANNUAL REPORT-WITH THE REQUIRED FILING FEE OF$25——
HALTO:SmetWd8hft Buarras RapYRfm 6dsloA Posl o<iice aet a55xs.Ratigq NC a6 +25
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