NCG060453_Application_20240828

FOR AGENCY USE ONLY
NCG06Qt53 VDT v^
Assigned to: . C�
ARO FRO MRO R WARO WIRO WSRO ��� Joey O
Division of Energy, Mineral, and Land Resources Land Quality Section ;P0C
National Pollutant Discharge Elimination System
NCG060000 Notice of Intent
This General Permit covers STORMWATER DISCHARGES associated with activities under the following Standard
Industrial Classifications: SIC20[Food and Kindred Products],SIC21[Tobacco Products],SIC 283[Drugs],SIC284
[Soaps, Detergents, & Cleaning Preparations;Perfumes, Cosmetics, & Other Toilet Preparations],SIC 422[Public
Warehousing and Storage—except for 4226]. 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:
Counter Culture Coffee Cameron Heath
Street address: City: Durham State: Zip Code:
812 Mallard Ave NC 27701
Telephone number: Email address:
919.909.9037 cheath @counterculturecoffee.com
Type of Ownership:
Government
❑County ❑Federal ❑ Municipal ❑State
Non-government
♦a 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: Counter Culture Coffee Facility environmental contact:
Cameron Heath
Street address: City: State: Zip Code:
812 Mallard Ave Durham NC 27701
Parcel ldentifcat g-e3 r) cow County:Durham
Telephone number: Email address:
[e-mail]
4-digit SIC code: Facility is: Date operation is to begin or began:
❑ New ❑ Proposed Sd Existing 1 04/01/1995
Latitude of entrance: m °I'� Longitude of en�ran e: �,
jj
Brief description of the types of industrial activities and products manufactured at this facility:
Recivin Roasting, Packingand Shipping of Coffee
This facility processes meat: ❑Yes No
If the stormwater discharges to a municipal separate storm sewer system(MS4),name the operator of the MS4:
❑ N/A
Page 1 of 5

3. Consultant(if applicable):
Name of consultant: Consulting firm:
Street address: City: State: Zip Code:
Telephone number: Email address:
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.
lY�"I ❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
s.99T3�;I —TO - D 4
Brief description of the i dustrial 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. 5 6``f Longitude of outfall: �� I
Brief description of the indus rial act( i7 es that drat to this outfall
1.
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes X 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 Cutfalls"found on the last page of this N0L
Page 2 of 5

— —5.---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:
0 This facility uses best management practices or structural stormwater control measures.
If checked,briefly describe the practices/measures and show on site diagram:
fd This facility has a Stormwater Pollution Prevention Plan(SWPPP).
If checked,please list the date the SWPPP was implemented: 81
❑This facility stores hazardous waste in the 100-year floodplain. (J�`
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: , _ Ty'pe(s)of-waste:
How material is stored: Where material is stored: ,r
Number of waste shipments'peryear.— - Name of transport/disposal vendor:
Transport/disposal vendor EPA ID: Vendor address: v
❑This facility is located on a Brownfield or Superfund site r t
If checked,briefly describe the site conditions
6. Requ' ed Items(Application will be returned unless all of the following items have been included):
Check for$120 made payable to NCDEQ
Copy of most recent Annual Report to the NC Secretary of State
his 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)iIocation 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 143-215.613(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:
B 11 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.
9'rh—e 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
i rmation.
I will abide by all conditions of the NCG060000 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.
hereby request coverage under the NCG060000\G,en�er`\al Permit.
Printed Name of Applicant: CU�MQCayI 1 \`r-��T�
Title: ftnwc
ignatureofAppl(cant) _ �''�` - y (Date Signed)'
Mail the entire.packa`geto: DEMLR—StormwaterProgram
r f ,rDepartment of Environmental Quality i.. �._ r✓�
s 1612 Mail Service Center
._,fir_ •—s
Raleigh, NCC 27699699-161-2
Page 4 of 5

AdditionafOutfalls -- —
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 his a.TMDL.
Latitude of outfall: Longitude of outfall: — ;4
i
Brief description-of.the'industrial activities that drain to this outfall:
Do Vehicle kaintenance Actvities 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? y
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

BUSINESS. CORPORATION ANNUAL REPORT
usrzou
NAME OF BUSINESS CORPORATION: Counter Culture Coffee,Inc.
0360839 Ring
as Use Only
SECRETARY OF STATE ID NUMBER: STATE OF FORMATION: NC E-Filed Annual Report
0360839
REPORT FOR THE FISCAL YEAR END: 12/31/2023 CA202408605538
3/26/2024 02:30
SECTION A: REGISTERED AGENT'S INFORMATION ® Changes
1.NAME OF REGISTERED AGENT: CT Corporation System
2.SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS 8 COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
1601Mine Lake CtSte 200 160 Mine Lake Ct Ste 200
Raleigli, NC 27615 Wake County Raleigh, NC 27615
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Manufacturing and Distribution
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3.PRINCIPAL OFFICE EMAIL: Privacy Redaction
4.PRINCIPAL OFFICE STREET ADDRESS 5.PRINCIPAL OFFICE MAILING ADDRESS
812 Mallard Avenue 812 Mallard Avenue
Durham, NC 27701 Durham, NC 27701
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: Brett Smith NAME: Brett Smith NAME: Tommy Morton
TITLE: President TITLE: Secretary TITLE: Chief Financial Officer
ADDRESS: ADDRESS: ADDRESS:
812 Mallard Avenue 812 Mallard Avenue 812 Mallard Avenue
Durham,NC 27701 Durham, NC 27701 Durham,NC 27701
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in Its entirety by a person/business
eri%'ett Smith 3/26/2024
SIGNATURE DATE
Forth must be signed by an officer listed under Section C of this form.
Brett Smith President
Print or Type Name of Officer Print or Type Title of Officer
MAIL TO:Secretary of State, Business Registration Oivision.Post Office Box 29525.Raleigh,NO 2762MS25 T

SECTION E:ADDITIONAL OFFICERS
NAME: Brett Smith NAME: NAME:
TITLE: Chairman Of The Board TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
812 Mallard Avenue
Durham, NC 27701
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: Name:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:

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