NCG210470_NOI Application_20190502

Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental . NCG210000 1+�
Quality I'Ay 02 gn
NOTICE OF INTENT 0�'� -
S�op'v1iR � �� QUgI l
National Pollutant Discharge Elimination System application for cover t �l� �e raI Permit
NCG210000:
For STORMWATER DISCHARGES associated with activities classified as:
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
?,��
05
0Z
Certificate of Covera e
NCG2 1 c� a
Ch ck #
Amount
$too
Permit Assign ed to
s • s`i-(i
SIC' 24 Timber Products (except as specified below), including Wood Chip Mills;
And, Like activities deemed by DEMLR 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:
• Wood Kitchen Cabinets (SIC 2434)
• Wood Preserving (SIC 2491)
• Logging (SIC 2411)
Standard Industrial Classification Code
(Please print or type)
MAP
1) Mailing address of owner/operator (address to which official permit correspondence will be mailed):
Namo Vij ! l_C
Owner Contact (a person) ; -
Street Address 1, C �,.w\,`.� '� 6
City Kva.-- L-' State ►J � ZIP Code
Telephone No. `6 6 `r-- t�S Fax:
E-mail Address
2) Location of facility producing discharge:
Facility Name
Facility Contact (a person)
Contact E-mail
Street Address
City
County
Telephone No.
3) Permit Contact
Permit Contact (a pel
Contact E-mail
Contact phone numb,
4) Physical Location Information:
State ZIP Code
Fax:
Please provide a narrative description of how to get to the facility (use street names, state ro numbers, and
distance and directtiion from a roadway intersec ion)).. '4 4�
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required to be submitted with this application)
�.� �,
5) Latitude 3 s 3`� �? ,3 Longitude l,l0 3i `i (degrees, minutes, seconds)
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NCG210000 N.O.I.
f<? This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility Date operation is to begin
�19 Existing
7) Standard Industrial Classification (SIC):
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code:
8) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: P.'� 1, ; � vim. , t" ,. , Q �V" . De„_"
9) Discharge points / Receiving waters:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property? Q
List discharge points (outfalls) that convey discharge from the site (both on -site and off -site) and location
coordinates. Attach additional sheets if necessary, or note that this information is specified on the site plan.
Stormwater Outfall No. f
i c�
Latitude (degrees/minutes/seconds): 39 J"'t N
Longitude (degrees/minutes/seconds):' `��� �' 31.4 W
Stormwater Outfall No. _Q__
S� �i
Latitude (degrees/minutes/seconds): S`� N
Longitude (deg rees/minutes/seconds):"t 3i W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
Stormwater Outfall No.
Latitude (degrees/minutes/seconds): N
Longitude (degrees/minutes/seconds): W
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NCG210000 N.O.I.
cformwater Outfall No.
Latitude (degrees/minutes/seconds): _
Longitude (degrees/minutes/seconds):
10) Receiving waters:
N
W
What is the name of the body or bodies of water (creek, stream, river, lake, etc.) that the facility stormwater
discharges end up in? C-;14 , —N, - 9""" ,
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).
11) Does this facility have any other water quality permits?
No
❑ Yes
If yes, list the permit numbers for all current water quality permits for this facility
12) Does this facility have any Non -Discharge permits (ex: recycle permits)?
�© No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
13) Does this facility employ any best management practices for stormwater control?
No
❑ Yes
If yes, please briefly describe:
14) Does this facility have a Stormwater Pollution Prevention Plan?
N o
❑ Yes
If yes, when was it implemented?
15) Does this facility have exposed accumulations of sawdust, bark, mulch, wood chips, or similar size
woody material on -site for longer than seven (7) days? (Exposed directly to rainfall or to run-on from
other areas of the facility.)
LJ No Yes
16) Are vehicle maintenance activities occurring at this facility?
"�`© No ❑ Yes
17) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
No ❑ Yes
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NCG210000 N.O.I.
c) Is this facility a Large Quantity Generator (1000 kg, or more of ,hazardous waste generated per month) of
hazardous waste?
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:
18) 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 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: rlf ✓���rv` �.,,
Title:
(Signature of of Applicant)
(Date
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDEQ
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NCG210000 N.O.I.
Final C"ew „!ist
This application will be returned as incomplete unless all of the following items have been included:
>9 Check for $100 made payable to NCDEQ
This completed application and all supporting documents
Copy of county map or USGS quad sheet with location of facility clearly marked on map
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
For questions, please contact the DEMLR Central Office or Regional Office for your area.
To visit our website, go to http✓/portal.ncdenr.org/web/lr/storm water
DEMLR Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office
... [phone]
Mooresville Office
... [phone]
Raleigh Office ........
[phone]
Washington Office
...[phone]
Wilmington Office
... [phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
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