NCG050423_COMPLETE FILE - HISTORICAL_20140714

I TV I If 1.
4

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
Iv U&IDS W a 3
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑
YYYYM M DD

CDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. Mike Johnson
Palziv North America
7966 NC Hwy 56
Louisburg, NC 27549
Dear Mr. Johnson:
�j John E, Skvarla, III
5
July 14 2014 r "I
JUL 1 5 2014
NC DECOR Raleigh Regional Office
Subject: General Permit No. NCG050000
Palziv North America
COC No. NCG050423
Franklin County
In accordance with your application for a discharge permit received on June 23, 2014,
we are forwarding herewith the subject certificate of coverage (COC) to discharge under the
subject state — NPDES general permit. This permit is issued pursuant to the requirements of
North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the US Environmental Protection Agency dated October 15, 2007 (or as
subsequently amended).
Please take notice that this certificate of coverage is not transferable except upon
approval of the :Division of Energy, Mineral, and Land Resources. The Division of Energy,
Mineral, and Land Resources may require modification or revocation and reissuance of the
certificate of coverage.
This permit does not affect the legal requirements to obtain other permits. which may
required by the Division of Energy, Mineral, and Land Resources, the Coastal Area
Management Act, or any other federal or local government permit that may be required.
Per the requirements of the Tar -Pamlico Riparian Buffer Rule, all stormwater drainage
to stream buffers, from portions of this site that have been constructed after January 1, 2000,
must be discharged through a correctly designed level spreader or another device that meets
diffuse -flow requirements per 15A NCAC 2B .0259: Diffuse flow requirements are'described in
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http:l/Portal.ncdenr.orglweb/irl
An Equal Opportunity 1 Affirmative Action Employer —.50% Recycled 110% Post Consumer Paper

Chapter 8 of the North Carolina Stormwater BMP Manual, available at:
http: //portal. ncdenr. orp,/web/Iribmp-manual.
If you have any questions concerning this permit, please contact Julie Ventaloro at telephone
number [phone] or by email 'iilie.ventaloror&ncdenr.ov.
Sincerely,
ORIGiNk SWED Sg
KEN PICKLE
f©r 'Tracy E. Davis; P,E., OPM, Director
Division of Energy; Mineral and Land Resources
cc: Raleigh Regional Office, D. Parnell
Central Files
Stormwater Permitting Program Files

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG050000
CERTIFICATE OF COVERAGE No. NCG050423
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Palziv North America
is hereby authorized to discharge stormwater from a facility located at
Palziv North America
7966 NC Hwy 56
Louisburg
Franklin County
to receiving waters designated. as Wolfpen Branch, a class C;NSW water in the Tar -Pamlico
River Basin, in accordance with the effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III, and IV of General Permit No. NCG050000 as attached.
This certificate of coverage shall become effective July 14, 2014.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 14, 2014.
ORIGINAL SIGNED Sl
KEN PICKLE
for Tracy E. Davis, P.E., Director
Division of Energy, Mineral, and Land Resources
By the. Authority `of the Environmental Management Commission

M
MEW
NCG05,04423
N
w E.
S
Map . Scale 1:j4, 000.
-03 2
W',
p alziv North Arft&i6
pv,
NY
JO
)"M
FY/ ,- &I
A
Palziv North America
Palziv. North America
Latitude::366 04' 53".N
.Longitude: 78Q 20'09" W
County: Franklin
Reteiving Stream: WQlfpen Branch
.Index No: 28.'27
Stream Class: C;NSW,
Sub' basin: 03-03-0 1, (Tar -Pa rhliC6'Riv'&'Basi n)Ricility Location

Ventaloro, Julie
From:
Parnell, David
Sent:
Friday, June 06, 2014 9:57 AM
To:
Ventaloro, Julie
Subject:
RE: Palziv Group in Louisburg and rescission request
Follow Up Flag:
Follow up
Flag Status:
Flagged
Julie,
I wanted to follow up. So much going on this week.
Please rescind the permit for NCG180202 HNI Corporation.
Palziv does require a new stormwater permit, depending on their SIC code.
Thanks,
Dave
From: Ventaloro, Julie
Sent: Friday, May 30, 2014 4:10 PM
To: Parnell, David
Subject: FW: Palziv Group in Louisburg and rescission request
Dave,
I was just talking with Mike Johnson with Palziv Group. He said you had visited their site. Did you recommend a
particular general permit for them?
Thanks,
Julie
From: Ventaloro, Julie
Sent: Tuesday, May 20, 2014 11:55 AM
To: Parnell, David
Subject: Palziv Group in Louisburg and rescission request
Hi Dave,
Can you help me determine if the Palziv Group facility located in Louisburg needs to be covered under an industrial
stormwater permit?
It came up because I got a call from the HNI Corporation regarding their NCG180202 permit. They told me they are no
longer operating at that facility and that it was sold a while ago to a new company. I am sending them a rescission
request form. The representative with HNI wanted to know if they should transfer the permit to the new owner rather
than rescind their permit. I told him I'd check on. it, but I'm doubtful that the new owners of the facility, Palziv Group,
would qualify for an NCG18 since they manufacture polyethylene foams, not furniture.
Please let me know what you think as far as if the Palziv Group needs an industrial stormwater permit, and if so, which
one. You may also consider this a request for your recommendation on the rescission of NCG180202 HNI Corporation.
The facility address is 7966 NC Hwy 56, Louisburg. Main number of Palziv Group is 919-497-0010.

Thanks for your heIpI
julie Ventaloro
Stormwater Permitting Program
NC.Divisiori of ".11C.1,gy, Nfineitf, and [;and Resources
i612 Mail Service Center, Raleigh, NC ;-�699-i.612
Phone: [phone] Fax: (qte)) 8076491.
Wbbsite: hul/waUf sUppjMag6h dmc,goy
E-171Cil,-r)ri-e.s,1.5oiidei-ice to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third
parties.

r• Division of Water Quality / Water Quality Section
NCDENR National Pollutant Discharge Elimination System
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL REsouROE5
NCG050000
NOTICE OF INTENT
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate ofCovera e
NC
Check N
Ai unt
Pen it Assigned to
e— a 10 t-o
National Pollutant Discharge Elimination System application for coverage under General Permit
NCGO50000:
STORMWATER DISCHARGES associated with activities classified as:
SIC' 23
SIC' 265
SIC' 267
SIC' 27
SIC' 30
SIC' 31
SIC' 39
SIC* N/A
Apparel and Other Finished Products Made from Fabrics and Similar Materials
Paperboard Containers and Boxes
Converted Paper and Paperboard Products
Printing, Publishing and Allied Industries
Rubber and Miscellaneous Products (except as specified below)
Leather and Leather Products (except as specified below)
Miscellaneous Manufacturing Industries
Like activities deemed by DWQ to be similar in the process and/or the
materials, products, by-products, or waste materials
C kl?0�1ROW9 p
JUN 2 3 2014
D Nft - WATER QUALITY
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 TG.Iz:v 'Norlk Aa
Street Address
City
Telephone No.
E-mail Address
'79(.1, niC W-Iy 5'6
t,p.A,-s6a�g State Nc- ZIP Code 275�9
111C3 '19y- 5&27 Fax: 919 L496 - 2513
r�. j o (ny.in n fl p�12iy h0. , cow.
2) Location of facility producing discharge:
Facility Name —�c t2;v Nord- jAA_ctcc
Facility Contact
Contact E-mail AISV Ke- • cn w.
Street Address '79t: (; #Vc- Hwy SG
City l.o.t'A .rs State Nc ZIP Code 2,? s `/9
County Fe., k I
Telephone No. 919 '7 9 4 - 5621 Fax: q I q 41ii b - 2-52-3
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). f iAillo 1 N. �- -Tkn,. (eP+ eK+c
r4C .�6 Wjv - �Ia.,.+ it 1,�l w.:l c lc7�+ S;cle- a'r NC 56 hlwy
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required with this application)
Page 1 of 4
SWU-220-071408 Last Revised 7/14/2008

,a NCG050000 N.O.I.
4) Latitude 34 1 q Z 53• a 1ZY Longitude — 7 $ 2a 7. 293y (degrees, minutes, seconds)
5) This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility Date operation is to begin
;4 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: 3 0 8 Co
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: On—T" cross ^'oty ct�A le"t- `,oar
8) Discharge points:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property?
9) 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? i,Jcl-'Pa^ ��"^�� or'�k — -T.,k."r — Pay.l;co !Z .rcr — 5,J
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).
10) 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:
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
kr No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
12) Does this facility employ any best management practices for stormwater control?
9 No
❑ Yes
If yes, please briefly describe: .
13) Does this facility have a Stormwater Pollution Prevention Plan?
M No
❑ Yes
If yes, when was it implemented?
14) Are vehicle maintenance activities occurring at this facility?
DK No ❑ Yes
Page 2 of 4
SWU-220-071408 Last Revised 7/14/2008

No
4 NCG050000 N.O.I.
15) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
D4 No ❑ Yes
b) Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste generated per month) of
hazardous waste?
9 No ❑ Yes
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
l9 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:
16) 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: David W i Ike rso�
Title: r, Q c e r-
6 2 //
of Applicant) Date Si ned
(Signature pp ) ( 9 )
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to NCDENR.
Page 3 of 4
SWU-220-071408 Last Revised 7/14/2008

", • ' 4NCGO50000 N.O.I.
.4
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
1� Check for $100 made payable to NCDENR
This completed application and all supporting documents
�. Copy of county map or USGS quad sheet with location of facility clearly marked on map and nearby waters
Mail the entire package to:
Stormwater and General Permits 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 NPDES 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 ........
[phone]
Washington Office ...
[phone]
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........
[phone]
Page 4 of 4
SWU-220-071408 Last Revised 7/14/2008

Central Files: APS _ SWP _
7/11/2014
Permit Number NCG050423' Permit Tracking Slip
Program Category Status Project Type
NPDES SW In review New Project
Permit Type Version Permit Classification
Apparel/Printing/Paper/Leather/Rubber Stormwater Discharge COC COC
Primary Reviewer Permit Contact Affiliation
julie.ventaloro
LJ
Coastal SWRuIe
JUL 14 2014
Permitted Flow CENTRAL FILES
DWO/BOG
Facility
Facility Name
Major/Minor Region
Palziv North America
Minor Raleigh
Location Address
County
7966 NC Hwy 56
Franklin
Facility Contact Affiliation
Louisburg NC 27549 Mike Johnson
7966 NC 56 Hwy
Owner Louisburg NC 27549
Owner Flame Owner Type
Palziv North America Non-Govemment
Owner Affiliation
Mike Johnson
7966 NC 56 Hwy
Dates/Events Louisburg NC 27549
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
6/23/2014 �/ ��1Jj0 11 -7l Y 12,'1
Regulated Activities Requested /Received Events
Plastics & synthetics manufacturing RO staff report received 6/6/14
RO staff report requested 5/30/14
Outfal l 001
Waterbody Name Streamindex Number Current Class Subbasin
Wolfpen Branch 28-27 C;NSW 03-03-01
y

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. Mike Johnson
Palziv North America_
7966 NC Hwy 56 "
Louisburg, NC 27549
Dear Mr. Johnson:
John E. Skvarla, III
Secretary
July 14, 2014
Subject: General Permit No. NCG050000
Palziv North America
COC No. NCG050423
Franklin County
In accordance with your application for a discharge permit received on June 23, 2014,
we are forwarding herewith the subject certificate of coverage (COC) to discharge under the
subject state — NPDES general permit. This permit is issued pursuant to the requirements of
North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the US Environmental Protection Agency dated October 15, 2007 (or as
subsequently amended).
Please take notice that this certificate of coverage is not transferable except upon
approval of the Division of Energy, Mineral, and Land Resources. The Division of Energy,
Mineral, and Land Resources may require modification or revocation and reissuance of the
certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be
required by the Division of Energy, Mineral, and Land Resources, the Coastal Area
Management Act, or any other federal or local government permit that may be required.
Per the requirements of the Tar -Pamlico Riparian. Buffer Rule, all stormwater drainage
to stream buffers, from portions of this site that have been constructed after January 1, 2000,
must be discharged through a correctly designed level spreader or another device that meets
diffuse flow requirements per 15A'NCAC 2B .0259. Diffuse flow requirements are described in
Division of Energy,, Mineral, and Land: Resources..
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http://Portal.ncdenr.org/web/Ir/
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

Chapter 8 of the North Carolina Stormwater BMP Manual, available at:
http://yortal.ncdenr.or /web/Ir/bmp-manual.
If you have any questions concerning this permit, please contact Julie Ventalord at telephone
number [phone] or by email iulie.ventaloro(Cincdenr.gov.
Sincerely;
for Tracy E. Davis, P.B., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Raleigh Regional Office, D. Parnell
Central Files
St6rtnwater Permitting Program Piles

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG050000
CERTIFICATE OF COVERAGE No. NCG050423
STQRMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Palziv North America
is hereby authorized to discharge stormwater from a facility located at
Palziv North America
7966 NC Hwy 56
Louisburg
Franklin County
to receiving waters designated as Wolfpen Branch, a class C;NSW water in the Tar -Pamlico
River Basin, in accordance with the effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, I1,111, and IV of General Permit No. NCGO50000 as attached.
This certificate of coverage shall become effective July 14, 2014
This Certificate of Coverage shall remain. in effect for the duration of.the General Permit.
Signed this day July 14, 2014.
for Tracy E. Davis, P.E., Director.
Division.of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission

MapSca/e 1:24- 000
Palziv North America
Palziv North America
Latitude::360 041 53 N
Longitude: 780 20- 09" W '
County: Franklin
Receiving Stream: Wolfpen.Branch
Index No: 28-27,
Stream Class: C;NSW
Sub -basin: 03-03-01 (Tar -Pamlico River:Basin)
Facility -location.

f'
�v f
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
NOTICE OF INTENT
Division of Water Quality / Water Quality Section
National Pollutant Discharge Elimination System
NCG050000
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Cei,ificate of Covera ze
NICIGIOLV
Chcck N , An unt
Pcnnit Assi Lned to
x'v1 G O r0
National Pollutant Discharge Elimination System application for coverage under General Permit
NCGO50000:
STORMWATER DISCHARGES associated with activities classified as:
SIC 23
SIC 265
SIC 267
SIC' 27
SIC 30
SIC 31
SIC 39
SIC* N/A
Apparel and Other Finished Products Made from Fabrics and Similar Materials
Paperboard Containers and Boxes
Converted Paper and Paperboard Products
Printing, Publishing and Allied Industries
Rubber and Miscellaneous Products (except as specified below)
Leather and Leather Products (except as specified below)
Miscellaneous Manufacturing Industries
Like activities deemed by DWQ to be similar in the process and/or the
materials, products, by-products, or waste materials
C C�[� p
D
JUN 2 3 2014
D NR - VVA OUAI TY
The following activities are specifically excluded from coverage under this General Permit:
SICK 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 7o.l z �v N;,4r+1. A w.cr: cc_
Street Address -7 9 G G r4 c- w ­oy S G
City State N ZIP Code 21Sg9
Telephone No. 91cl 19 41 - SG 2- Fax: 919 LI96 - 25-2-3
E-mail Address ro, i o b.u&so . Pax il;V KrL . CoV% .
2) Location of facility producing discharge:
Facility Name
Facility Contact
Contact E-mail
Street Address
City
County
Telephone No.
1ti!6t','So _Q,a A&A2�.y P 0. . Co W�
79GG d��- Hw., SG
l.o..:rbu�s State NC- ZIP Code 2*7sqg
919 -79q - 562 1 Fax: cltq +iI6'2-52-9
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). Lo,.,.r +Js / US, qo l •- 7kn. lei'+ 0-Jo
f` c Slo H,,ay- `''i l-_+ ;r I.q o-&-s' c . t,_P+ s;�l� ,,.P Ne Sb- Ne N j:X
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required with this application)
Page 1 of 4
SWU-220-071408 Last Revised 7/14/2008

'NCGo50000 N.O.I.
4) Latitude are 53. c-?2V Longitude - 8 ZO9• 2-613y (degrees, minutes, seconds)
5) This NPDES Permit Application applies 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: 3 0 ig Co
7) Provide a brief narrative description of the types of industrial activities and products manufactured at
this facility: rn0.n Cross
V
8) Discharge points:
How many discharge points (ditches, pipes, channels, etc.) convey stormwater from the property?
9) 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? Ovi-rfe^ Or«k - 'Tar Q;.:cr - Pc..r.i;cc '-wer -
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).
10) 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:
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
Xf No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
-.. 12) Does this facility employ any best management practices for stormwater control?
X No
❑ Yes
It -'yes, please briefly describe: .
13) Does this facility have a Stormwater Pollution Prevention Plan?
DA No
❑ Yes
If yes, when was it implemented?
14) Are vehicle maintenance activities occurring at this facility?
IK No ❑ Yes
Page 2 of 4
SWU-220-071408 Last Revised 7/14/2008

lNCG050000 N.O.I.
15) Hazardous Waste:
a) Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
9 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
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste?
N 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:
16) 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; c)ompl`ete,, and accurate.
Printed Name of Person Signing: Dwv i d W i Ike rso�
Title: C_ I�ar)�c e r—
of Applicant) Date i ned
(Signature pP ) ( 9 )
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to NCDENR.
Page 3 of 4
SWU-220-071408 Last Revised 7/14/2008

R
NCG050000 N.O.I.
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
IS] Copy of county map or USGS quad sheet with location of facility clearly marked on map and nearby waters
Mail the entire package to:
Stormwater and General Permits 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 NPDES 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 ........
[phone]
Washington Office ...
[phone]
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........
[phone]
Page 4 of 4
SWU-220-071408 Last Revised 7/14/2008

r

Franklin County - Google Maps Page I of I
Olwal
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Chapel Hill
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