NCG060102_Renewal Application_20170921

a Permit Coverage
Renewal Application Form
NCDENA National Pollutant Discharge Elimination System NPDES Permit Number
Stormwater Individual Permit NCS 114-�� E �,
Please provide your permit number in box in the upper right hand corner, complete the information in the space provided
below and return the completed renewal form along with the required supplemental information to the address indicated.
Owner Information
Owner/ Organization Name:
Owner Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Facility Information
Facility Name:
Facility Physical Address:
Facility Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Permit Information
Permit Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Discharae Information
Receiving Stream:
Stream Class:
Basin:
Sub -Basin:
Number of Outfalls:
Facility/Activity Changes Please describe below any changes to your facility or activities since issuance of your permit. Attached a
CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and belief
such informatio true,
comp ete a. daccurjte.
Signature Date f
31�\ r'ojkjA-Q M,) I P0 1­V�\-'J,AJ? 4- Q_
Print or type name of person signing above V Title
Please return this completed application form SW Individual Permit Coverage Renewal
Stormwater Permitting Program I�
and requested supplemental information to: 1612 Mail Service Center I IW
Raleigh, North Carolina 27699-1612

a
September 19, 2017
NCDEQ
Division of Water Quality
Storm Water Permit Coverage Renewal
Storm Water Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699®1612
Subject: Storm Water Permit Renewal
- Permit No. NCG 060102
Perdue Farms Inc. — Candor Feed Mill
Eagle Springs, Moore County, North Carolina
To: Regional Supervisor,
bEP,A,zLAIq QUALITY
M-MV'+AreN PERiv n'T'ING
Please find attached two copies of the completed Storm Water Renewal Application
Form for the Perdue, Candor Feed Mill.
If you need any additional information or have any,questions please do not hesitate
to contact me at (757) 7104436.
Respectfully Submitted,
Bruce Roberts
Regional Environmental Manager
[e-mail]