NCG170420_COMPLETE FILE - HISTORICAL_20161003

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
/ v G 6 / %0 9 210
DOC TYPE
❑ COMPLETE FILE - HISTORICAL
DATE OF
RESCISSION
❑�
YYYYMMDD

Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
October 3, 2016
Mr, Bruce Martin
Avery Dennison
130 Walnut Strcet
Douglas, MA 01516
PAT MCCRORY
c hmr•,,,r„
DONALD R. VAN DER VAART
"Wre+urr
TRACY DAVIS
U'rrruu
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCG 170420
Caldwell County
Dear Mr. Martin:
On .tune 20, 2016, the Division of Energy, Mineral and Land Resources received your request to rescind
your coverage under Certificate of Coverage Number NCG 170420. In accordance with your request,
Certificate of Coverage Number NCG 170420 is rescinded effective immediately.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 us at 919-707-9200, or the Stormwater staff in our
Asheville Regional Office [phone].
Sincerely,
ORIGINAL SIGNED BY
BETHANY GEORGOULIAS
forTracy E. Davis, PE, CPM, Director
Division of Energy, Mineral and band Resources
cc: Asheville Regional Office
CStormwater Permitting.P_rogram
f Central I Files - w/attachments
State of North Carolina I F.nvirotnuental Quality' Energy, Mineral and Land Resources
1612 Mail Ser0ce Center 1 512 North Salisbury Street I Raleigh, North Carolina 27699-1612
919 707 9220 T

IVA
M;
Division of Energy, Mineral & Land Resources
_
iii
Land Quality Section/Stormwater Permitting Program
E&
NC® "NR
National Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year IMonth I Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N; =C rG 17 j 0 j 4 1 2 0
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Avery Dennison
Facility Contact _Bruce Martin
Street Address _ 130 Walnut Street
City _Douglas State _MA _ ZIP Code 01516 _
County _Worcester E-mail Address Bruce. Mart in@Averydenni son. corn
Telephone No. _ 508 476-5041 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Q Facility closed or is closing on e72016 All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to F7 ::.:.7' _. _ on s, .- . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature ate
Print Print or type name of person signing above Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, Noah Carolina 27699-1612
Phone: 91M07-63001 FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer
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June 13, 2016
Stormwater Permitting Program
North Carolina Department of Environmental Quality
Division of Energy, Mineral and Land Resources
1612 Mail Service Center
Raleigh, NC 27699-1612
Re: Change of Facility Operations & Facility Contact Information/
Request for NPDES Permit Coverage Rescission
Avery Dennison
950 German Street
Lenoir, Caldwell County, North Carolina
Certificate of Coverage No. 170420
Dear Sir/Madam:
AVERY
DENNISON
Avery Dennison Corporation
Environmental, Health & Safety
130 Walnut Street
Douglas, MA 01516 USA
Office: 508/ 476 5041
Fax: [phone]
CEI
JUN 2 0 2016
This correspondence is to notify the North Carolina Department of Environmental Quality (NCDEQ),
Division of Energy, Mineral and Land Resources (DEMLR) that active manufacturing operations at the
above -referenced facility have ceased. Given this changed condition, we intend to rescind the facility's
coverage under General Permit No. NCG 170000. As an initial step in this process, we are submitting
the enclosed "Rescission Request Form." We understand that the DEMLR will then contact Avery
Dennison to schedule a confirmatory site visit.
As noted on the attached form, we request that future correspondence regarding this facility be directed
to the following Avery Dennison corporate representative:
Bruce Martin, Corp. Manager, Env.
Avery Dennison Corporation
130 Walnut Street
Douglas, MA 01516
[phone]
[e-mail]
Averydennison.com
Remediation Services
Please do not hesitate to contact me at [phone] if you have any questions or require additional
information.
Sincerely,
Bruce Martin
Corporate Manager, Environmental Remediation Services
Encl.

Alexander, Laura
From: Conway, Jean '
Sent: Monday, September 26, 2016 9:24 AM
To: Alexander, Laura
Subject: RE: Rescission Request for NCG170420 - Caldwell County Facility
Attachments: NCG170420 Avery Dennison Recission Regst.pdf; IMG_0051.JPG; IMG_0055JPG; IMG_
0063.JPG; IMG d070jpg; IMG_0071.JPG
Follow Up Flag:
Flag Status:
Follow up
Flagged
La u ra,
According to DWM, it appears there may be a Brownsfield Agreement (or a request possibly in June 2016) for this
facility.
I have attached the inspection report and photos but have NOT SENT the report to the facility owner.
Feel free to contact me if you need further info.
Jean
From: Alexander, Laura
Sent: Thursday, August 11, 2016 4:45 PM
To: Conway, Jean <[e-mail]>; Riddle, Shawna <[e-mail]>
Subject: Rescission Request for NCG170420 - Caldwell County Facility
Good Afternoon,
Please see the attached rescission request.
Thank you,
Laura Alexander
Administrative Assistant
Stormwater Permitting Program
North Carolina Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
919 807 6368 Office
919 807 6494 Fax
laura.alexanderCa)ncdenr,9ov
512 North Salisbury Street
1612 Mail Service Center
Raleigh, North Carolina 27699
-5:> Nothtng Compares...

Compliance Inspection_ Report
Permit: NCG170420
SOC:
County: Caldwell
Region: Asheville
Contact Person: Birin Patel
Effective: 10/02/14 Expiration: 07/31/19 Owner: Avery Dennison
Effective: Expiration: Facility: Avery Dennison - RBIS
950 German St
Title: EHS Manager
Lenoir NC 28645
Phone: [phone]
Directions to Facility:
Travel on creekway dr heading north turn right onto meadowlane dr travel 300 ft and take a slight left onto german st the facility will
be located .2 mi on the right
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 09/22/2016 EntryTime: 10:OOAM Exit Time: 11:00AM
Primary Inspector: Jean Conway Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Textile Mill Products Stormwater Discharge COC
Facility Status: Compliant [1 Not Compliant
Question Areas:
■ Storm Water
(See attachment summary)
Page: 1

Permit: NCG170420 Owner- Facility: Avery Dennison
Inspection Date: 09/2212016 Inspection Type : Compliance Evaluation
Reason for Visit: Routine
Inspection Summary:
This inspection was conducted to determine whether the permit is eligible for rescission.
Met with Terry Grant.
No industrial activity is presently taking place. The site is being tested for groundwater contamination.
The only materials observed that were exposed to stormwater were three large roll off trash containers, 2 covered and one
alongside the building that was being used for empting out the contents of the building at time of inspection.
Three empty metal 55 gallon drums were observed in the parking lot awaiting water samples for the groundwater sampling
operation.
An covered aboveground storage tank on the side of the building was observed with no signs of leaking. Mr. Grant stated
the tank was empty.
Several white PVC pipes along the rear of the building day lighted to the creek and Mr. Grant assumed that they were
connected to the roof downspouts as they seemed to be aligned with them but this was not confirmed.
Page: 2

a
permit. NCG170420 Owner- Facility: Avery Dennison
Inspection Date: 09122/2016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Permit and Outfalls Yes No NA NE
# Is a copy of the Permit and the Certificate of Coverage available at the site? ❑ ❑ ❑ 0
# Were all outfalls observed during the inspection? 0 ❑ ❑ ❑
# If the facility has representative outfall status, is it properly documented by the Division? ❑ ❑ ❑ 0
# Has the facility evaluated all illicit (non stormwater) discharges? ❑ ❑ ❑ 0
Comment:
Stormwater Pollution Prevention Plan
Yes
NQNA NE
Does the site have a Stormwater Pollution Prevention Plan?
❑
❑ ❑
# Does the Plan include a General Location (USGS) map?
❑
❑ ❑ 0
# Does the Plan include a "Narrative Description of Practices"?
❑
❑ ❑ 0
# Does the Plan include a detailed site map including outfall locations and drainage areas?
❑
❑ ❑ 0
# Does the Plan include a list of significant spills occurring during the past 3 years?
❑
❑ ❑ 0
# Has the facility evaluated feasible alternatives to current practices?
❑
❑ ❑ 0
# Does the facility provide all necessary secondary containment?
❑
❑ ❑ 0
# Does the Plan include a BMP summary?
❑
❑ ❑ 0
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
❑
❑ ❑ 0
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
[]
❑ ❑
# Does the facility provide and document Employee Training?
❑
❑ ❑ 0
# Does the Plan include a list of Responsible Party(s)?
❑
❑ ❑ 0
# Is the Plan reviewed and updated annually?
❑
❑ ❑ 0
# Does the Plan include a Stormwater Facility Inspection Program?
❑
❑ ❑ 0
Has the Stormwater Pollution Prevention Plan been implemented?
❑
❑ ❑ 0
Comment:
Page: 3

P-11516 YA__
L7�
ia
RCDENK
ENVlftp Mn N AND NijnU ResouRCE9
Division of Energy, Mineral and Land Resources
Land Quality Section 1 Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USG ONLY
Date Received
Ycar Month
I)ay
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the owner of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean? '
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprieto`r'ship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(vr} Certificate of Coverage
N I C I G I I 1 -1 Q D
I-Men't-,n S�»
Address
n (21 Pia 4-"5�
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.org/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: 4_Th" k , I—,,_rr+crr
First M I Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: 19�(I,11A ► e. 3. I:ht'
First M I Last
Pagel of 2
SW U-OW NERAFFIL-25July2014

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
r_ %SIB i /iilcr� czGC.r
/� Title
"/50 Crlrm�n
Mailing Address
City State 'Lip
f 115I-343a
Telephone E-mail Address
( 9-4) 7-�-,q- a o s 9
Fax Number
5) Reason for this change:
Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
ff other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
'(u.�--� .( �attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
'Z'��jj Ck�-� 4-L" �' Lo
Signature Oate
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call 919-707-9220 or visit the website at:
http:l/portal.ncdenr.org/web/Ir/stormwater
Page 2 of 2
SW U-OW NERAFFIL-25July2014

. 4 a r2h
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Pat McCrory Charles Wakild, P.E.
Governor Director
February 22, 2013
Mr. Jeffrey B. Suttles, Plant Manager
Avery Dennison
950 German Street
Lenoir, North Carolina 28645
Subject: General Permit No. NCG170000
Avery Dennison
COC No. NCG1170420
Caldwell County
Dear Mr. Suttles:
John E. Skvarla, III
Secretary
In accordance with your application for a discharge permit received on November 19, 2012, 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).
If any parts, measurement frequencies, or sampling requirements contained in this permit are unacceptable to
you, you have the right to request an individual permit by submitting an individual permit application. Unless such
demand is made, this certificate of coverage shall be final and binding.
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 Bill Diuguid, Stormwater Staff Planner at
telephone number [phone].
Sincerely,
ORIGINAL SIGNED Bl
KEN PICKLE
Charles Wakild, P.E.
cc: Asheville Regional Office
Central Files
Stormwater Permitting Unit Files
Attachments
Wetlands and Stormwaler Branch
1617 Mail Service Center, Raleigh, North Carolina 27699.1617
location: 512 N. Salisbury SL Raleigh, North Carolina 27604
Phon :: 919-807-6300 4 FAX: [phone]
Inter 1: www.ncwalerquality,org
NorthCarofina
Naturally
An Lq�al Opportunity 1 Alhrmative Action Employer

STATE OF NORTH CAROLINA
DEPARTMENTOF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG170000
CERTIFICATE OF COVERAGE No. NCG170420
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,
Avery Dennison
is hereby authorized to discharge stormwater from a facility located at
Avery Dennison
735 Monroe Street
Lenoir
Caldwell County
to receiving waters designated as an unnamed tributary to Spainhour Creek, a Class C waterbody, Catawba River
Basin; in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I,
11, 111, IV, V and VI of General Permit No. NCG 170000, as attached.
This Certificate of Coverage shall become effective February 22, 2013.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day February 22, 2013.
ORIGINAL SIGNED W
KEN PICKLE
Charles Wakild, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

.a U,,r,•^� �r .ice �Y j
r� �'f.��•'��'1��✓r� �1 :1� f ,ate '1 �� �� •' L.
CM
ii krvrrC`\�; tr +wra�r cc
- •.• r.� ,.1 •.
I Site Location K
'1 u•a;'*,l_•�t` : ii'fua\Ss, �firY�t
Spainhour Creek,
Tributary of Lower Creek
U
within a TMDL watershed
for Turbidity
0 1,000 2,000 4,000 6,000
8,000
Feet
1 inch = 2,000 feet
N
Figure 1
��
Site Location'
Ave Dennison
Environmental
Creating th e
950 German Street
Offices in CT
Lenoir, North Carolina
1327 Miller
USGS Quadrangle Information
QuadlD: 35081-H5 HRP # AVE2005.WM
Greenville,
Name: Lenoir, North Carolina Scale 1" 2 000'
Date Pub: 1958
Ph:(864)2$�
www.hrpas,

HRP ?*vc,.
Creating the Right Solutions Together
CONNECTICUT
November 2, 2012 Corporate Headquarters
197 Scott Swamp Road
Farmington, CT 06032
Stormwater and General Permit Unit 8860-0-674-974-957070
Division of Water Quality FAX [phone]
1617 Mail Service Center 999 Oronoque Lane
Raleigh, North Carolina 27699-1617/ Second Floor
Stratford, CT 06614
203-380-1395
RE: Notice of Intent for Avery Dennison, Lenoir, NC, FAX [phone]
To Whom it May Concern: FLORIDA
2435 U.S. Highway 19
In accordance with the General Permit No NCG170000 to discharge stormwater under Suite 550
Holiday, FL 34691
the NPDES, please find the following enclosed on behalf of Avery Dennison located in 727-942-2115
Lenoir, NC: FAX [phone]
• NOI form for NCG170000: Stormwater Discharges associated with SIC MASSACHUSETTS
22:Textile Mill Products; 241 Boston Post Rd West
First Floor
• Check for $100 made payable to NCDENR; and Marlborough, MA 01752
0300
• USGS quad Ma with location of Ave Dennison clearly marked on map FAX 508-786-
q P Avery y FAX [phone]
If you have any questions regarding this submittal, please do not hesitate to contact NEW YORK
me at 800-752-3922 or Ms. Beth Covey of Avery Dennison at [phone]. 1 Fairchild Square
Suite 110
Sincerely, Clifton Park, NY 12065
888-823-6427
518-877-7101
HRP Associates, Inc. FAX [phone]
SOUTH CAROLINA
1327
Jackie Baxley Suite Diller Road
Project Manager D C►/Jj;a Greenville, SC 29607
VV 11�� 800-752-3922
864-289-0311
Nn z 9 zorz FAX [phone]
DENR ` _ TEXAS
OUptin, 5601 Bridge Street
ate &s►lch Suite 300
Fort Worth, TX 76112
817-492-7092
FAX [phone]
it
-35
www.hrpassociates.com

+
V
AVERY DENNISON
8080 NORTON PKWY
BLDG 22-D
MENTOR OH 44060
2100043 01 SD T 3220 MTR-P00043 '
NCDENR- ❑IV OF AIR QUALTIY
I 1617 MAIL SERVICE CENTER
STORMWATER AND GENERAL PERMITS UNIT
DIVISION OF WATER QUALITY
RALEIGH INC 27699-161
1 1
5
AVERY
DENNISON
PAGE 1 OF 1
CHEQUE DATE: 11/12/2012
VENDOR NO: 928
`CHEQUE NO.: 0000650541
INVOICE DATE
INVOICE NOJ
INVOICE AMOUNT
DISCOUNT
NET AMOUNT
VOUCHER
MO, DAY YR
CREDIT MEMO
00000000
10000110212
100.00
0.00
100.00
TOTALS
$100.00
$0.00
$100.GO
DETACH AND RETAIN THIS STUB FOR YOUR RECORDS.
AVERY DENNISON
AVERY 8080 NORTON PKWY
ADENNISON BLDG 22D --7 62-20
MENTOR OH 44060 n C C/ Q v 311
One Hundred and 00/100 Dollars
PAY TO THE NCDENR- DIV OF AIR QUALTIY
ORDER OF: 1617 MAIL SERVICE CENTER
STORMWATER AND GEN7-RAL PERMITS UNIT
DIVISION OF WATER QUALITY
RALEIGH INC 27699-161
CITIBANKI N.A.
ONE PENN'S WAY, NEW CASTLE, DE 19720

1

Diuguid, Bill
From: Wilson, Susan A
Sent: Tuesday, February 05, 2013 12:01 PM
To: Diuguid, Bill
Cc: Stepp, Jonathan
Subject: Avery Dennison NCG170420
Hey Bill —feel free to issue this one (we got the application in). Don't know of any outstanding issues with this and we'll
get out to inspect after you issue it.
Thanks!
Susan
Susan A. Wilson - [e-mail]
North Carolina Dept. of Environment and Natural Resources
Asheville Regional Office
Division of Water Quality - Surface Water Protection
2090 U.S. 70 Highway
Swannanoa, NC 28778
Tel: [phone]
Fax: [phone]
Notice: E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and
therefore may be disclosed to third parties.