NCG070022 -

Permit Coverage
*' ` Renewal Application Form
NCD€NR National Pollutant Discharge Elimination System
Stormwater Individual Permit
�c6-0rl60 ,c;_
NPDES Permit Number I
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:
Facilitv 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:
Discharge Information
Receiving Stream:
Stream Class:
Basin:
Sub -Basin:
Number of Outfalls:
�RECFIVED
� JUN 07 2098
/� • / ///mm
DENR-LAND QUALITY
STORMWATER PERMITTING
V
Facility/Activity Chances Please describe below any changes to your facility or activities since issuance of your permit. Attached a
separate sheet if necessary.
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 information is true, complete and accurate.
Signature
to
l AW.5o n W. i3aks
Print or type name of person signing above Title
Please return this completed application form SW Individual Permit Coverage RenewalStormwater Permitting Program
and requested supplemental information to: 1612 Mail Service Center
Raleigh, North Carolina 27699-1612

Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Permit No.: N1C101ZId/ dQ1-1-1 or Certificate of Coverage No.: N/C/G/O/z/6/6/?./ ,(
Facility Name: 4 e d7� n
County: Phone No. 2,
Inspector: T�.
Date of Inspection:
Time of Inspection: Z 3 (7 $M _
Total Event Precipitation (inches):
Was this a Representative Storm Event? (See information below) ® Yes ❑ No
Please check your permit to verify if Qualitative Monitoring must be performed during a representative
storm event (requirements vary).
A "Representative Storm Event" is a storm event that measures greater than 0.1'inches of rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
1. Outfall Description:
Outfaii No. -S.T^ Structure (pipe, ditch, etc.)
Receiving Stream: -L -L -
Describe the industrial activities that occur we ouffall drainage area:
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: __.:/,- .___.._ --
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): Nom _ _^
Page l of 2

4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
l 2. 0 4 5 6
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where l is no solids and 5 is the surface coveted with floating solids:
O 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
( 2 3 4 S
7. is there any foam in the stormwater discharge? Yes No
S, is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
ottni 1A1_n;t'inR

STORM WATER POLLUTION PREVENTION PLAN
DEVELOPMENT AND IMPLEMEIVTA'T10N
CERTIFICATION
North Carolina Division of Energy, Mineral, and Land Resources - Stormwater Permitting
Facility Name:
Permit Number:
Location Address:
County:
"I certify, under penalty of law, that the Stormwater Pollution Prevention Plan (SPPP) document and all
attachments were developed and implemented under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gather and evaluate the information required by the SPPP.
Based on my inquiry of the person or persons who manage the system, or those persons directly responsible
for gathering the information, the information gathered is, to the best of my knowledge and belief, true,
accurate and complete."
And
"I certify that the SPPP has been developed, signed and retained at the named facility location, and the SPPP
has been fully implemented at this facility location in accordance with the terms and conditions of the
stormwater discharge permit."
And
"I am aware that there are significant penalties for falsifying information, including the possibility of fines and
imprisonment for knowing violations."
ISign (according to permit signatory requirements) and return this Certification. DO NOT I
SEND STORMWATER POLLUTION PREVENTION PLAN WITH THIS CERTIFICATION.
Signature —Mia V • ,,i
Print or type name of person signing above
Date 6 " j-- %Y
Title
SPPP Certification 10/13