NCG060231_ROS Request Record_20190124

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Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
REPRESENTATIVE OUTFALL STATUS (ROS)
REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
If a facility is required to sample multiple discharge locations with very similar stormwater discharges, the
permittee may petition the Director for Representative Outfall Status (ROS). DWQ may grant Representative
Outfall Status if stormwater discharges from a single outfall are representative of discharges from multiple
outfalls. Approved ROS will reduce the number of outfalls where analvtica! sampling requirements apply.
!f Representative Outfall Status is granted, ALL out are still subject to the qualitative monitoring
requirements of the facility's permit —unless otherwise allowed by the permit (such as NCG020000) and DWQ
approval. The approval letter from DWQ must be kept on site with the facility's Stormwater Pollution
Prevention Plan. The facility must notify DWQ in writing if any changes affect representative status.
For questions, please contact the DWQ Regional Office for your area (see page 3).
(Please print or type)
1) Enter the permit number to which this ROS request applies:
Individual Permit (or) Certificate of Coverage
N C 5 I I I N C G 0 6 0 2 3 1
2) Facility Information:
Owner/Facility Name Santa Fe Natural Tobacco Company
Facility Contact Kelly Fie
Street Address 3220 Knotts Grove Road
City Oxford State NC_.. ZIP Code 27565
County Granville E-mail Address [e-mail]
Telephone No. [phone] Fax:
3) List the representative outfall(s) information (attach additional sheets if necessary):
Outfall(s) 1 is representative of Outfall(s) 1.2, 3
Outfalls' drainage areas have the same or similar activities? x Yes : No
Outfalls' drainage areas contain the same or similar materials? x Yes ;: No
Outfalls have similar monitoring results? x Yes No © No data*
Outfall(s) is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities? o Yes No
Outfalls' drainage areas contain the same or similar materials? 0 Yes No
Outfalls have similar monitoring results? ri Yes No L No data*
Outfall(s) is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities? o Yes No
Outfalls' drainage areas contain the same or similar materials? ❑ Yes No
Outfalls have similar monitoring results? ❑ Yes No ❑ No data*
*Non-compliance with analytical monitoring prior to this request may prevent ROS approval. Specific
circumstances will be considered by the Regional Office responsible for review.
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SWU-ROS-2009 Last revised 12/30/2009

Representative Outfall Status Request
4) Detailed explanation about why the outfalls above should be granted Representative Status:
(Or, attach a letter or narrative to discuss this information.) For example, describe how activities and/or
materials are similar.
Please see attached narrative discussion of the stormwater outfalls
5) Certification:
North Carolina General Statute 143-215.6 B(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; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case
under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device
or method required to be operated or maintained under this Article or rules of the [Environmental Management]
Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed
ten thousand dollars ($10,000).
I hereby request Representative Outfall Status for my NPDES Permit. I understand that ALL outfalls are still
subject to the qualitative monitoring requirements of the permit, unless otherwise allowed by the permit
and regional office approval. I must notify DWQ in writing if any changes to the facility or its operations take
place after ROS is granted that may affect this status. If ROS no longer applies, I understand I must resume
monitoring of all outfalls as specified in my NPDES permit.
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: <! rie,
Title:
E - J�f V aa/7
(Signs ure of Applicant) (Date Signed)
Please note: This application for Representative Outfall Status is subject to approval by the
NCDENR Regional Office. The Regional Office may inspect your facility for compliance with the
conditions of the permit prior to that approval.
Final Checklist for ROS Request
This application should include the following items:
d This completed form_
,pr Letter or narrative elaborating on the reasons why specified outfalls should be granted representative
status, unless all information can be included in Question 4.
d Two (2) copies of a site map of the facility with the location of all outfalls clearly marked, including the
drainage areas, industrial activities, and raw materials/finished products within each drainage area.
d Summary of results from monitoring conducted at the outfalls listed in Question 3.
1:1 Any other supporting documentation.
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SWU-ROS-2009 Last revised 12/30/2009