NCG060285_COMPLETE FILE - HISTORICAL_20130724

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
AIC6 O &6
OOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ C730136
YYYYMMDD

��A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Thomas Reeder
Governor Acting Director
July 24, 2013
Shawn Keiser
Interstate Brands Corporation - Merita Bakery
2551 N Church St
Rocky Mount, NC 27804
Dear Mr. Keiser:
John Skvarla, III
Secretary
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCG060285
Interstate Brands Corporation - Merita Bakery
Nash County
On 4/23/2013, the Division of Water Quality received your request to rescind your coverage under
Certificate of Coverage Number NCG060285. In accordance with your request, Certificate of Coverage
Number NCG060285 is rescinded effective immediately.
Operating a treatment facility, discharging wastewater or discharging specific types of stormwater to
waters of the State without valid coverage under an NPDES permit is against federal and state laws and
could result in fines. If something changes and your facility would again require stormwater or
wastewater discharge permit coverage, you should notify this office immediately. We will be happy to
assist you in assuring the proper permit coverage.
If the facility is in the process of being sold, you will be performing a public service if you would inform
the new or prospective owners of their potential need for NPDES permit coverage.
If you have questions about this matter, please contact Boyd DeVane at 919 807-6373, or the Water
Quality staff in our Raleigh Regional Office at 919-791-4200.
Sincerely,
or Tlt6mas A. Reeder Actin Director
.� g
cc. Raleigh Regional Office
Stormwater Permitting Unit
DWQ Central Files - w/attachments
Fran McPherson, DWQ Budget Office - please waive applicable fees
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 NorthCarohna
Location: 512 N. Salisbury St. Rategh, North Carolina 27604
Phone: [phone] FAX: 91 M07-6494 Naturally
aturally
Internet: www.ncwaterquality.org �J
An Equal Opportunity 4 Affirmative Action Employer

1";61
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Shawn Keiser
Interstate Brands Corporation
2551 N Church St
Rocky Mount, NC 27804
Dear Permittee:
Division of Water Quality
Charles Wakild, P. E.
Director
December 4, 2012
Dee Freeman
Secretary
Subject: NPDES Stormwater Permit Coverage Renewal
Merita Bakery
COC Number NCG060285
Nash County
In response to your renewal application for continued coverage under stormwater General Permit NCGO60000
the Division of Water Quality (DWQ) is forwarding herewith the reissued General Permit. This permit is
reissued pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of
Agreement between the state of North Carolina and the U.S. Environmental Protection Agency, dated October
15, 2007 (or as subsequently amended).
The following information is included with your permit package:
• A new Certificate of Coverage (COC)
• A copy of General Permit NCG060000
• A copy of the Technical Bulletin for the General Permit
• Two copies of the Discharge Monitoring Report (DMR) Form
• Two copies of the Qualitative Monitoring Report Form
The General Permit authorizes discharges of stormwater, and it specifies your obligations for discharge
controls, management, monitoring, and record keeping. Please review the new permit to familiarize yourself
with all the changes in the reissued permit. Your facility has six (6) months from the time of receipt of the
permit to update your current SPPP to reflect all new permit requirements.
The first sample period of your permit begins January 1, 2013. Your facility must sample a "measureable
storm event" beginning during the periods beginning January 1 and July 1 of every year (or, if applicable,
report "No Flow," as outlined in Part III, Section E). Also, please note that Tier 3 Actions in Part II of your
permit are triggered by benchmark exceedances on four occasions beginning on the effective date of this
permit and do not count prior exceedances.
The more significant changes in the General Permit since your last COC was issued are noted either in the
Draft Permit Fact Sheet that accompanied the public notice (http://portal.ncdenr.org/web/wq/ws/su/current-
notices), or in the Response to Comments / Summary of Changes and Technical Bulletin documents that are
posted on the Stormwater Permitting Unit's website with the new General Permit. Please visit
http://Portal.ncdenr.org/web/wq/ws/su/npdessw (click on 'General Permits' tab) to review that information
for your specific General Permit carefully.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Ralegh, North Carolina 27604
Phone: [phone]e FAX:[phone]
Internet: www.ncwa!r-rqual4y.or
An Equal Qpponunityl V mm.aive Adon Employer
One
NexthiCaroliii
� J amrally

q�
Shawn Keiser
December 4, 2012
Page 2 of 2
Some of the changes include:
Part II:
• Section A: The Stormwater Pollution Prevention Plan (SPPP) section, if applicable, has been updated
to the most current language of our permits. Additional conditions for specific industry sectors have
been added to the SPPP requirements in some cases.
• Sections B, C: Failure to perform analytical stormwater monitoring may result in the Division requiring
that the permittee begin a monthly sampling scheme.
• Sections B, C: A lower TSS benchmark of 50 mg/I for HQW, ORW, PNA and Tr Waters applies to these
more sensitive waters.
• Sections B, C: The monitoring parameter Oil & Grease (0&G) has been replaced by the parameter
Total Petroleum Hydrocarbons (TPH) for vehicle maintenance areas, and in some cases, other
analytical monitoring requirements.
• Sections B, C, D: Inability to sample due to adverse weather must be recorded in the SPPP, or in
separate on -site records if your General Permit does not require an SPPP. Adverse weather is defined
in the "Definitions" section of the permit.
• Sections B, C: The term "Representative Storm Event" has been replaced by "Measurable Storm
Event." A measurable storm event is defined in the permit.
• Section D: If the permittee fails to respond effectively to problems identified by qualitative
monitoring, DWQ may require the permittee to perform corrective action.
Please review Parts III and IV to understand the Standard Conditions of your new NPDES General Permit,
including Compliance and Liability, Reporting, Monitoring and Records requirements; Operation and
Maintenance obligations; and Definitions. Please note that all samples analyzed in accordance with the terms
of this permit must be submitted to the Division on Discharge Monitoring Report (DMR) forms available on
the Stormwater Permitting Unit's website above. DMR forms must be delivered to the Division no later than
30 days from the date the facility receives the sampling results from the laboratory. Also note that existing
permittees do not need to submit a renewal request prior to expiration unless directed by the Division.
Your coverage under the General Permit is transferable only through the specific action of DWQ. This permit
does not affect the legal requirements to obtain other permits which may be required by DENR, nor does it
relieve the permittee from responsibility for compliance with any other applicable federal, state, or local law,
rule, standard, ordinance, order, judgment, or decree. If you have any questions regarding this permit
package, please contact the Division's Stormwater Permitting Unit at [phone].
Sincerely,
ts
for Charles Wakild, P.E.
cc: DWQ Central Files
Stormwater Permitting Unit Files
Raleigh Regional Office

'VF'
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG060000
CERTIFICATE OF COVERAGE No. NCG060285
STORMWATER
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,
Interstate Brands Corporation
is hereby authorized to discharge stormwater from a facility located at:
Merita Bakery
2551 North Church St
Rocky Mount
Nash County
to receiving waters designated as Horn Beam Swamp, a class QNSW waterbody in the Tar -
Pamlico River Basin in accordance with the effluent limitations, monitoring requirements, and
other conditions set forth in Parts I, 11, 111, and 1V of General Permit No. NCG060000 as attached.
This certificate of coverage shall become effective December 4, 2012.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this 0 day of December, 2012.
for Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

•
712
WONDER
R
Interstate Brands Corporation
P. O, Box 591
Rocky Moult, North Carolina 27802
Phone [phone]
.July 22, 2008
Mr. Ken Pickle
Storm Water Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699- l 617
Dear Mr. Pickle,
I am writing on the behalf of the Interstate Brands Corporation's Merita bakery located in
Rocky Mount, NC. The bakery's new Storm Water Permit (COC NCG060285) requires semi-
annual storm water sampling at.the site's two outfalls. Due to the combination of erratic rain
events and insufficient employee oversight, the first semi-annual analytical and qualitative
sampling did not occur for CY2008.
As a result of our recent conversation, the IBC Merita bakery insures that the following
activities will take place:
• 'Two storm water samples, taken at least 30 days from each other, will be taken during
the period of July — December 20008. The appropriate Discharge Monitoring Reports
• will be submitted as well
A rain gauge will be purchased and kept on -site to be used for the determination of
significant rain events
• IBC employees will take the required samples as there is employee coverage on all
three shifts all week long
• Field pH measurements will be taken by IBC personnel familiar with the EPA
Standard Methods test for pH
I f'there are any additional recommendations, please let me know. I can be contacted at 508-
954-6271.
Sincerely,
Bart Petracca
Area Environmental Manager

ll3C Storm Watcr Sampling
.+l
Subject: 113C Storm Water Sampling
From: "Petracca, Bart" <[e-mail]>
Date: TLle, 22 Jul 2008 16:53:48 -0500
To: <[e-mail]>
CC: "Stoga, Marion" <Stoga_Marion a interstatebrands.com>, "Ray, Robert"
<Ray_Robert a interstatebrands.coiii>, "Davis, Dan" <Davis_Dan cr interstatebrands.com>
Mr. Pickle,
Thank you for our conversation today. Attached, please find the requested letter pertaining to additional storm
water sampling for the next six months.
Bart Petracca
Eastern Area Environmental Manager
508-954-6271
Content -Description: Storm Water Letter 072208.doc
Storm Water Letter 072208.doc Content -Type: application/msword
Content -Encoding: base64
1 ol' l 8/28/2008 9:08 AM

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT
AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
FAX [phone]
Facsimile, transmittal
To: Dan Davis, Interstate Brands Fax: [phone]
From: Ken Pickle, Stormwater Permitting Unit, Date: November 26, 2007
Division of Water Quality
Phone: [phone] ext. 584 Pages: 3
E-mail: Ken. [e-mail]
Urgent For review Please comment Per your request FYI, no action Please recycle
Subject: Duplicate COC, NCG060285, Merita Bread, Rocky Mount, NC
Hi Dan,
Please contact me with any questions.
Ken

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural RCSUnrCUS
Alan W. Klimek, P.E. Director
Division of Water Quality
May G, 2005
Mr. Rory Whittle
Interstate Brands Corporation
2551 North Church Street
Rocky Mount, NC 27804
Subject: General Permit No. NCG060000
Interstate Brands Corp.—Merita Bread
COC No. NCG060285
Nash County
Dear Mr. Whittle-.
In accordance with your application for a discharge permit received on March 24, 2005,
we are forwarding herewith the subject certificate of coverage to discharge under the subject
state — NPDES general permit. This permit is issued pursuant to the requirements of North
Carolina General Statute 143-215. I and the Memorandum of Agreement between North Carolina
and the US Environmental Protection Agency dated May 9, 1994 (or as subsequently amended).
Please take notice that this certificate of coverage is not transferable except after notice to
the Division of Water Quality. The Division of Water Quality 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 Water Quality or permits required by the Division of Land
Resources, Coastal Area Management Act or any other federal or local governmental permit that
may be required.
If you have any questions concerning this permit, please contact Bethany Georgoul6s. at
telephone number [phone] ext. 529.
Sincerely,
ORIGINAL SIGNED BY
BRADLEY BENNETT
Alan W. Klimek, P.E."
cc: Raleigh Regional Office
Central Files
Stormwater Permitting Unit Files
NorthCarolina
JValrrrally
North Carolina Division of Water Quality 1617 Mail Service Center Raicigh, NC 27699-1617 Phone (')1')) 733-7015 Customer Service
Internet: h2o.enr.state.nc.us 512 N. Salishury St. Raleigh, NC 27004 FAX [phone]
An Equal OpportunitylAHirmative Action Employer — 50% Recycled/10% Post Consumer Paper

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT' NO. NCG060000
CERTIFICATE OF COVERAGE No. NCG060285
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision o1' 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,
Interstate Brands Corporation
is hereby authorized to discharge stormwater from a facility located at
Merita Bread
2551 North Church Street
Rocky Mount, NC
Nash County
to receiving waters designated as an unnamed tributary (UT) to 1-lorn Beam Swamp, 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 1, II, III, IV, V, and VI of
General Permit -No. NCG060000 as attached.
This certificate of coverage shall become effective May 6, 2005.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day May 6, 2005.
ORIGINAL SIGNED BY
BRADLEY BENNEIT ►
for Alan W. Klimek, P.E., Director
Division of Water Quality
By the Authority of the Environmental Management Commission

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Latitude: 35'58'44"
NCG060285 Facility
Longitude: 77"47'1"
Interstate Brands Corp.
County: Nash, NC Location
Stream Class. C-NSW Merita Bread
Receiving Stream: UT to Horn Beam Swamp
Subbasin: 03-03-02 (1`,tr-P,,irn11co River Basin) rX0 t L DALE 1:24,000

NCG060285
Interstate Brands Corp.—Merita Bread
rev. 4/25/05
April 22, 2005
B. Georgoulias
Summary
This facility submitted a Notice of Intent to be covered under General Permit NCG060000
(Food and Kindred Products). This facility manufactures bread and baked products for
wholesale. The stormwater discharge drains to a UT to Horn Beam Swamp (from BIMS—
assume this is downstream of `Hornbeam Branch' on the map), a Class C-NSW water in the
Tar -Pamlico River Basin. This facility is located in Nash County, handled by the Raleigh
Regional Office.
Application review
a) The permit application has been signed and sufficiently completed. Yes.
b) The SIC code accurately describes this facility's activities and is covered by this
general permit. Yes. SIC: 2051 (Bread and Other Bakery Products)
c) Does this facility have other permits? Yes. Says #3000 (wastewater?) on
application; BIMS only shows WQ0012589 (gravity sewer extension).
d) Hazardous Waste Activities? No.
e) Regional Office input requested: 4/25/2005 (via e-mail to RRO DWQ.)
RO Approval received: 4/25/2005 (via e-mail from Barry Herzberg)
g) Application. approved? Yes.

J�
1 c: 10. NOI for Merita Bread, Nash CauntyI
Subject: Re: [Fwd: NOI for Merita Bread, Nash County)
From: Barry Herzberg <[e-mail]>
Date: Tue, 26 Apr 2005 06:20:32 -0400
'Co: Bethany Georgoulias <bethany.georgoulias@ncmaiLnet>
Bethany:
Why the permit was rescinded is a mystery. We think it was due to some confusion
between flood control plans and stormwater permits. Rumor has it that Merita thought
a stormwater permit was not required because they had a flood control plan.
Apparently, someone at DWQ agreed, and the permit was rescinded.
Barry
Bethany Georgoulias wrote:
Barry,
Thanks for the comments. Do you know why the permit was rescinded? It appears
they should be covered, so I will go ahead with the COC.
Bethany Georgoulias
Environmental Engineer
NC DENR DWQ
Stormwater Permitting Unit
[phone], ext. 529
[e-mail]
Barry Herzberg wrote:
Bethany:
As Ken said, we toured this facility some time ago. They have bulk unloading
stations for sugar, syrup, honey, etc., and a rail bulk unloading station for
flour. Everything looked okay and operational to us during our visit. As far
as other permits, they should have an air quality permit for the baghouse
collection system atop the dual flour storage silos. The WQ0012589 permit is
for the gravity sewer connection to the Rocky Mount collection system.
For history purposes, the facility was at one time covered by permit
NCG050038. They were told in September of 1998 they didn't need a stormwater
permit and it was rescinded on May 3, 2002.
Please advise if you need any additional info.
Barry
Ken Schuster wrote:
Bethany, Barry and I had been out to this location several months ago.
Barry will be forwarding comments to you.
-------- Original Message --------
Subject: NOI for Merita Bread, Nash County
Date: Mon, 25 Apr 2005 08:11:39 -0400
From: Bethany Georgoulias<[e-mail]>
To: Ken Schuster <[e-mail]>
Hi Ken,
1 42 4/26/2005 7:40 AM

Re: ]Fwd: NOI for Merita Bread, Nash County]
'r . , *.
I'm reviewing an NOT application from Interstate Brands Corporation for
Merita Bread in Rocky Mount for coverage under the General Stormwater Permit
for Food & Kindred Products (NCG060000) and wanted to get input from the
Raleigh Regional office. I'm not sure who the stormwater contact is since
Joe Albiston left, so I'm sending the request through you. Here's the info.
on this facility:
NOT for COC #N00060285
Merita Bread (Nash Co.)
2551 North Church Street
Rocky Mount, NC 27804
(Hwy 64 to N. Church Street exit, left, about 3 miles down)
contacts: J.C. Goins, Jr. or Rory Whittle
tel. [phone]
Main activity: Wholesale manufacturer of bread and baked products. Bread is
distributed via tractor trailers.
Discharge is to: UT to Horn Beam Swamp (Class C-NSW) in the Tar -Pamlico
Basin
Other permits: Application says #3000 (wastewater) (?), but BIMS shows
WQ0012589 (gravity sewer).
This facility is not a hazardous waste generator, but there vehicle
maintenance activities are performed on site.
Does the Regional Office have any concerns with issuing a COC for this
facility?
Also, have you designated another stormwater contact in the RRO? Thanks for
your help,
BG
Bethany Georgoulias
Environmental Engineer
NC DENR DWQ
stormwater Permitting Unit
[phone], ext. 529
[e-mail]
2 of 2 4/26/2005 7:40 AM

Division of Water Q,'.��ddy I Water Quahty Section
r li�N1Cl�1� i Tiasioza�l Pollutant
NCC.00M
n�L� L,0.1Mr"oh�V.4 97
�S
NOTICE OF INTENT 0
Nadal Pollutant Dirge Elimination System application for caimrage under Coral "JR 2 4 I! l
NCG:
QENR- WATER QUA!_ITy
STOltl MATM 1131SCHARGIM meted w[O activities ciassillied as- WETLANDS AND STORMWATER BRANCH
SIC 20 Food and IGndred Products
SIC 21 Tobacco Products
SIC" 283 Drugs Public
SIC 284 Soaps, Detergents, & Cleaning Preparations; Perfumes, Cosmetics, It Other Toilet Preparations
SIC 422 Warehousing and Storage (except 4226)
St3ndard bHhtSb td CLE04ficafim code
(Please print or type)
1) Mailing address of
Name
Strom Address
City
_ Telephone No.
' Addr ws to whiCh a f pemdt carsesPorKdenoe will Ge mailed
2) Location ity
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
3) Physical Location Information:
Please provide a narrative description of have to get tofacility (use street najnes, state dJ� and
distance d dire from a yalway int rise-tion). `'
(A copy of a oawrty nW or USES quad shad,fh amity d®Wy boated an toe UW es regimed b be WAMMed with the app5ratim) Ci/o /*
4) This NPDES Permit Application applies to which of the following : J
Za Proposed Facility Date oaemtion is to begin
stingfla
5) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: Z O o -
7 7
Page 1 of 3
-T ,
SWt;-221-1097Q1 i.l•n,J 11 7��'�^ ('k-ti :/:';1 r'_.CI..-
py
$IMSt1��'� '��21'�T �wri-,u� I✓.-NSI

?) pofift I Receiving craters:
M How many discharW points (ditches, pipes. charmels, etc.) amvey stormwater from the prof#"ly
What is the name of fie body or bodes of water (week, stream, river, lake, etc.) that the faci4ly Rtorr waisr
des end up in?
If the site sknnwater drsdrarges to a separate storm sewer system. name the operator of the Wmarate storm
sewer systat (e-J- City of Raleigh rmxridpal storm sew+er)-
8) Does this f*A ty have any other NPDES permits?
0 No
If yes, fist fire permit numbers for all amend NPDES permits for this facility. 7-1---3C Q.C1G..,r7SAXr--
9) Does Oft facility have any Nor} D-rschange permits (ex: recycle permits)?
❑ Yes
If yes, list the permit numbers for a9 current Non4)isdsarge permits for this faaliby:
10) Does this facility employ any hest management practices for stormwater control?
❑..,, Now�
t�J*eS
If yes. please brk* desgbe:
11) Does tMs TaKTty have a S'tommadw
❑ Yes
If yes, when was it implemented?
Prevention Plan?
12) Are vehicle maintenance activities occurring at this fadlity?
❑ No Ifs Yes
13) Hazardous Waste:
a) Is this lity a Hazardous Waste Treatment, Storage, or Disposal Facility?
❑ Yes
r�
b) Is this facility a Small Quantity Generator (less than 1000 kg. of harandous waste germerkwd per month) of
as waste?
7❑ Yes
c) Is this faaTity a Large Quantify C ater (1000 k9. or more of hazardous waste generO#.t Per nvx th) of
hazardous waste?
1� No ❑ Yes
d) If you answered yes to questions b_ or c., please provide the fohowing information:
Type(s) of waste: ., .
Page 2o€3
swt-221-101-M
/'

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.,a.,�,�.,�. ;to;r_�1"`'u'�i�i.Y�i�iCt'.11 .��zr?s�. •' �k �}�1' �W..;�.:"��....1'�' Sro •4+"�
LS .lYAQu: � •.
iA". .tJ.�`�i.�i3%'1f '+ "�'• i ""S �' °"� T• lY!" `� +w�i..-y - .. •ar.,_
Y' i •+;: c+•, f-G ?iy...�'' '� '�� Wes, i'�` v�f.�`�:'1;..YL, °., �,, ,.`
Where s5 maltBrted �:_.• .��-�'x��' x_».�v. �?<�.., i'��.:.{3....+�L�4.^��" � ..�. �.., _ �,
Name of transport / disposal vendor:
Vendor address`„'z�`'w }"
•14) Cedification:
North Canafim General Statute Ia415.6 b (Q provides that
Arr/ pgan wt o lamxn* metres any Ulm stamei� regiremitam ar cer ificaticm in arty apokoban, record. report
plan or ador doanneft fled or to be rrtai Id under Article 21 or regimes of the Emkorn mmW
I�rnagerne�rt Qanar enrr irplexreerr�rg heat Artit� at afro fall tarenpers ree'ttr ar knowingly rerdea kvianrate any
reaor - Orwirotmilg device ar I. to be aped a makitaiaed under Article 21 ar or the
Bwwa tner t Mwagemad Catmasew o #emmnUng But Article, shall be q ty d a modememw purmhahle by a
bw not to e=eed $1OAM. ar try crrp im.. N not m emeed sir mord ar by bdrL (18 US.C. Se chm 1001 pnxide_s
a pti idreiert by a fine at not rnae limn SlAOM or brwffi! t nat -,wA than 5 yeah c r both, fora shrviar dievse.j
I hereby request coverage under the relerenced Gerieral Permit 1 under land that coverage under this permit
will constitute time permit rNuirernents far the discharge(s) and is enforceable in the same manner as an
individual pear&
I certify itiat I am farniliar with the irdorma tim contained in this application and that to the best of my knowledge
and belief such in{iorriv inn is true, complete. and aommie.
Nye of hdxw t moist be at owVanied by a dKc k or money wder for SSo t10 made pay* a to:
NCDENR
Final Checklist
This application will be retumned as incomplete unless all of the foUowing items have been included:
l� Check for $80 made payable to NCDENR
C� jThis completed application and all supporting documents
0' Copy of county nrap or USGs quad stied with bcabon of facility dearly marked on map
Mail the entire package to:
StonTrwater and General Permits Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 276941617
Hobe
The submission of tines document does not guarantee the issuance of an NPDES permit.
Page 3 of 3
SWU-2214M7M

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