NCG050413_Application_20131107

�� : • Division of Water Quality / Water Quality Section
FRUNRNational Pollutant Discharge Elimination System
NDrerrl CA oU" DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
NCG050000
NOTICE OF INTENT
FOR AGENCY USE FNLY
Date Received.
Year
Month
Da
Certificate of Coverage
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C eck # Amount
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P rmit Assi ed to
National Pollutant Discharge Elimination System application for coverage under General Permit
NCG050000:
STORMWATER DISCHARGES associated with activities classified as:
SIC' 23 Apparel and Other Finished Products Made from Fabrics and Similar Materials
SIC' 266 Paperboard Containers and Boxes
SIC' 267 Converted Paper and Paperboard Products
SIG' 27 Printing, Publishing and Allied Industries
SIC' 30 Rubber and Miscellaneous Products (except as specified below)
SIC' 31 Leather and Leather Products (except as specified below)
SIC' 39 Miscellaneous Manufacturing Industries
SIC* N/A Like activities deemed by DWQ 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' 301 Tires and Inner Tubes
SIC' 311 Leather Tanning and Finishing
* Standard Industrial Classification Code
(Please print or type)
1) Mailing address of owner/operator (address to which all permit correspondence will be mailed):
Name Leggett & Platt Components Company, Inc
Street Address 178 Orbit Road
City Statesville State NC ZIP Code 28677
Telephone No. 704-873-1086 Fax: [phone]
E-mail Address bill.dotsontlleggett.com
2) Location of facility producing discharge:
Facility Name Sackner NC
Facility Contact Bill Dotson
d
Contact E-mail bill.dotson(),h
legQett.com („ > �.�y ; ,, Z its
Street Address 178 Orbit Road
City Statesville State NC ZIP Code 28677
County Iredell
Telephone No. 704-873-1086 Fax: [phone] '-,
3) Physical Location Information:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). From 140 take exit 144 for Old Mountain Road. Turn
south on Old Mountain Road drive .1 miles and then turn east onto Orbit Road. The facility is located .3 miles
down on the south side of the road.
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required with this application)
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NCGO50000 N.O.I.
4) Latitude 350 46' 25.2221" Longitude -800 59' 28.2714" (degrees, minutes, seconds)
b) This NPDES Permit Application applios to which of the following:
❑ New or Proposed Facility Date operation is to begin
X Existing
6) Standard Industrial Classification:
Provide the 4 digit Standard industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 2 3 9 9
Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: Facility manufactures braided welt cord — UFAC and non-UFAC. Also manufactured are
extruded plastic covered wire, poiv rod, and foam welt.
7) Discharge points:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? 2
8) Receiving waters:
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? Catawba Rlver
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer). NA
19j Does this facility have any other NPDES permits?
X No
❑ Yes
If yes, list the permit numbers for all current NPDES permits for this facility:
10) Does this facility have any Non -Discharge permits (ex: recycle permits)?
X No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:.
'11) Does this facility employ any best management practices for stormwater control?
❑ No
X Yes
If yes, please briefly describe: Wooden pallets are the only materials stored outdoors.
A;1 ) Does this facility have a Stormwater Pollution Prevention Plan?
X No
❑ Yes
If yes, when was it implemented?
13) Are vehicle maintenance activities occurring at this facility?
X No ❑ Yes
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14) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
X No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
❑X No ❑ Yes
c) Is this facility a Large 0uantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
❑X No ❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport / disposal vendor:
Vendor address:
15) Certification:
North Carolina General Statute 143-215.6 b (1) 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 11$10,000).
I hereby request coverage under the referenced General 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.
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: 0 P e �� ®�� O'V
Title: ewe t M4,vd�e�z
/ I
(Signature of Applicant)
i0 JaiY1
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to NCDENR.
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Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
❑ Check for $100 made payable to NCDENR
❑ This completed application and all supporting documents
❑ Copy of county map or USOS quad sheet with location of facility clearly marked on map and nearby `,craters
Flail the entire package to:
Stormwater and General Pei mits Unit
Division of Water Quality,
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of an NFDES permit.
For questions, please contact the DWQ Central Office or Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office ......
[phone]
Fayetteville Office...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
(919) 791--4200
Washington Office ...
[phone]
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........
[phone]
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