NCG210516_Application_20240722

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FOR AGENCY USE ONLY
NCG21 0 5 i G JU!
Assigned to: Q,. CA Oit 1 Co
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Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
NCG210000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC 24 member Products, including Wood Chip Mills—except as specified below]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. The following activities are specifically excluded from coverage under this General
Permit:SIC 2434[Wood Kitchen Cabinets],SIC 2491[Wood Preserving], and SIC 2411[Logging]. You can find
information on the DEMLR Stormwater Program at deq.nc.gov/SW.
Directions: Print or type all entries on this application. Send the original,signed application with all required
items listed in Item (6) below to: NCDEMLR Stormwater Program, 1612 MSC, Raleigh,NC 27699-1612. The
submission of this application does not guarantee coverage under the General Permit. Prior to coverage under
this General Permit a site inspection will be conducted.
1. Owner/Operator(to whom all permit correspondence will be mailed):
Name of legal organizational entity: Legally responsible person as signed in Item(7)below:
Champion Home Builders, Inc Stephen Simms
Street address: City: State: Zip Code:
349 East Rail Road Street Pembroke NC 28372
Telephone number: Email address:
229-322-5129 [e-mail]
Type of Ownership:
Government
❑County ❑Federal ❑Municipal ❑State
Non-government
12 Business(If ownership is business,a copy of NCSOS report must be included with this application)
❑ Individual
2. Industrial Facility(facility being permitted):
Facility name: Facility environmental contact:
Champion Homes 042
Street address: City: State: Zip Code:
349 East Rail Road Street Pembroke NC 28372
Parcel Identification Number(PIN): County:
Robeson
Telephone number: Email address:
229-322-5129 1 [e-mail]
4-digit SIC code: Facility is: Date operation is to begin or began:
2451 ❑ New ❑ Proposed 0 Existing April 2022
Latitude of entrance: Longitude of entrance:
34 40' 39.24" North -79 10' 50.40"West
Brief description of the types of industrial activities and products manufactured at this facility:
Manufactured Home Construction
This facility will produce Wood Pellets: ❑Yes 0 No
If the Stormwater discharges to a municipal separate storm sewer system(MS4),name the operator of the MS4:
Cd N/A
Page 1 of 5

3. Consultant(if applicable):
Name of consultant: Consulting firm:
Michael Furfaro DECA Environmental &Associates, Inc
Street address: City: State: Zip Code:
410 1st Avenue NE Carmel IN 46032
Telephone number: Email address:
574-276-7652 [e-mail]
4. Outfall(s)At least one outfall is required to be eligible for coverage.
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
OF-1 Watering Hole Swamp WS-IV; Sw ❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
34.676217 -79.176710
Brief description of the industrial activities that drain to this outfall:
Storage of materials and movement of completed modular homes
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes 2 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.
OF-2 I Watering Hole Swamp WS-IV; SW ❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
34.67943 -79.08174
Brief description of the industrial activities that drain to this outfall:
Storage of materials and movement of completed modular homes
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes 2 No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑ This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
All outfalls must be listed and at least one outfall is required. Additional outfalls may be added in the section
"Additional Outfalls"found on the last page of this N01.
Page 2 of 5

S. Other Facility Conditions(check all that apply and explain accordingly):
❑This facility has other NPDES permits.
If checked,list the permit numbers for all current NPDES permits:
❑This facility has Non-Discharge permits(e.g. recycle permit).
If checked,list the permit numbers for all current Non-Discharge permits:
❑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):
42 Check for$120 made payable to NCDEQ
❑ Copy of most recent Annual Report to the NC Secretary of State(if applicable)
0 This completed application and any supporting documentation
Z] 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 outfalIs corresponding to the drainage areas
e) runoff conveyance features
f) areas where materials are stored
g) impervious areas
h) site property lines
42 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:
121 am the person responsible for the permitted industrial activity,for satisfying the requirements of this permit,and for any
civil or criminal penalties incurred due to violations of this permit.
0 The information submitted in this N01 is,to the best of my knowledge and belief,true,accurate, and complete based on
my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the
information.
01 will abide by all conditions of the NCG210D00 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.
01 hereby request coverage under the NCG210000 General Permit.
Printed Name of Applicant: Stephen Simms
Title: General Manager
7/10/2024
(SigndiureofApplicant) (Date Signed)
Mail the entire package to: DEMUR—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: ❑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