NCGNE0069_COMPLETE FILE - HISTORICAL_20110826

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
AlG � A16� � 6 (e
DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ d-6�i 68a�
YYYYMMDD

NC®ETR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
August 26, 2011
Mr. Kevin Tucker, Plant Manager
Brooks Food Group
2701 Simpson Street
Monroe, North Carolina 28112
Subject: General Permit No. NCG060000
Brooks Food Group
COC No. NCG060330
Union County
Dear Mr. Tucker:
Dee Freeman
Secretary
In accordance with your application for a discharge permit received on .tune 29, 2011, 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 bf the
certificate of coverage. This permitdoes 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.
The current No Exposure Certification, NCGNE0069, on this location, has been rescinded. If you have
any questions concerning this new permit, please contact Bill Diuguid at telephone number [phone].
Sincerely,
ORIGINAL SIGNED B)
KEN PICKLE
Coleen H. Sullins
cc: Mooresville Regional Office
Central Files
Stormwater Permitting Unit Files
Attachments
1617 Mail Service Center, Ral4h. North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 One
Phone: [phone] FAX: [phone] Customer Service: 1.877-623-6748 NorthCarolina
Internet: www.ncvraterquality.org Naturally
An EqualOpportunity 1 Affirmative Aclior Employer t

=M 5 4 u p( 40 /Ri 1 , f'tifc /J �-a 7I1 */ !
Horizon Engineering & Gonsuiting, Inc.
2510 Walker Road
MI. Pleasant, N.C. 28124-8567
704-788-4455
Fax: [phone]
May 25, 2011
Stormwater Permitting Unit
Division of Water Quality
NPDES Unit
1617 Mail Service Center _
Raleigh, N.C. 27699 - 1617
@�� ti/ L5
Subject: Stormwater NPDES Permit Notice of Intent
Brooks Food Group JUN 2 9 2011
Monroe, NC
Union County yy 'N� .-,T R
Gentlemen:
Attached are three (3) copies of the NOI and supporting documents, which are our request for
coverage under General NPDES permit NCG060000. We have enclosed and a check for $ 100
(application fee.)
This is an existing facility that has held a stormwater No Exposure Certificatio4i�errn
GNE0069.)
In the course of reviewing the facilities as part of the annual recertification, it watn
that there are exposed materials and operations that necessitate our application for coverage
under the general discharge permit for our industry.
We appreciate your consideration of our application. If you have any questions or if there is
anything we need to discuss, please call me (704-788-4455) or the facility contact, Mr. Mike
McRorie, Maintenance Coordinator (704-289-8300.)
sin
y,
. Thi nnan Horne. P. la_
C: Mike McRorie

1N A ]'E Michael F. Easley, Governor
`O�O 9QG William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimck, 11. E. Director
Division of Water Quality
Q Coleen IL Sullins, Deputy Director
Division of Water Quality
April 20, 2005
David G Hill
Gold Signature Foods LLC
2701 Simpson St
Monroe, NC 28112
Subject: No Exposure Certification NCGNE0069
Gold Signature Foods LLC - 2701 Simpson St
Union County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on June 17, 2002. We apologize for the extended period it
has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. Based on your submittal and signed certification of no exposure at the above referenced facility
the Division is granting your certification as provided for under 40 CFR 126.22(g) which is incorporated by
reference in North Carolina regulations. In addition, your coverage under general permit NCG060183 is also
hereby rescinded. This rescission is based upon your certification of no exposure conditions at this facility.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (April 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Mooresville Regional Office Central Files — wlattachments
Stormwater Permitting Unit Files Fran McPherson - DWO Budget
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
NCDEhft
Customer Service
I-977-ti23-0748

v
L r
Gold Signature Fooc
2701 SIMPSON STREET • MONROE, NC 28112
[phone]
June 13, 2002
T17
ek
, Stormwater and General Permits Unit
Service Center
Raleigh, NC 27699-1617
Dear Mr. Klimek:
C JUN 7 2002 f"J
.2 0111'ff%b�
,all
JUN 1 4 2002
DIV. OF WATER QUALITY
DIRECTOR'S OFFICE
Per your request, I have enclosed our completed No Exposure Certification for Exclusion
from NPDES Storm Water Pennitting and our Rescission Request Forms.
Please not that we are no longer Cuddy Farms but are under new ownership and are now
Gold Signature Foods, LLC. Also, David G. Hill is no longer employed here. Please
send any further correspondence to Wade Aldridge, Maintenance Manager.
If you have any questions you can contact either Wade Aldridge at 704-291-3415, or
Richard Creighton, General Manager, at 704-291-3483.
Sincerely,
� 2 417f
,1 anet Hudson
Human Relations Manager
`� QUALITY

HCDENR-DIdQ Fax;919-733-13719 Jun 12 '02 14:22 P.02/05
Form Approved
United States Env,rnnmental Protection Agency OMB No.2040-0211
NF DES Washington, DC 20,180
FORM asiaf t V�� NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
$uktm sour. of this No Eapoaure Certi6callon constitutes notice thal the entity identified in Section A Ices not requlra permit authorization for its storm wafer
discharges associatea with industrial activity In the State Identified in Section 6 under EPA'% Storm Victor Mgfli-$ey-For General Permit due to the existence
of a --ondition of no exposure.
A condition of no exposure exista Ai an industrial facility when all industrlai materials and activities are protected by a storm resistant snrltnr to prevont
exposure to rain, snow, snowmelt, andlor runoff, Irdustrial materials or act,Mtieb irreuda, bit are not limitad to, natarial .handling equipment at aetivititi
industrial rraohlrery, raw materials, httermedlate prorluots, by-products, flnai products, or waste product&. Material handling aetivif-ea include the aroregn,
leading ono unloading, transponatiori, or corrreyence of any raw material. htlermediate product, final product or waste produce. A svrm reaiutant shelter is
notirequhed for the following industrial materials and activities:
dr;,ma, barrels, tanks, and similar containers that are tightly sealed, provides those containers are not dets!iwatk and ao no: +aak. "Soaloc"
means tiAnded or otherwise secured and without ooerational taps or valves;
adequately maintairad vahiclgi used in material handling; and
final products, other than products that would be mobilized in storm water d.schargrs (e.g., rock salt).
A ftio Exposure Certiticeticn must belprovided for each faclllry qualityliig for tho no exposure exclusion. in addition, the exclusion from NPDES parnnhdng Is
available on a taoility-wide basis only, not for Individual oatfalla, If any Industrial activities or materials ate or will be exposed ;o precipitation, the facility is
not,eligiWe for the no exposure exclusion.
P
By iiignirg and ovb�ttinq thiv No Exposure Cartlfication form, the entity in Section A is csrI;V. ny that a r-oWlt!on of no exposure extws at Its fadlay or sate,
and is olbligatea to comply with the terms and conditions of 40 CM 122.251 Q).
r
ALL INFORNIATIGN MUST BE Fri IC EO ON THIS FORM. �
Detailed Instructions for completing this form and obtaining the norrxpveure exclusion vr�pvid d 06$ and 4.
n t� �_a�r
F � t
A. ,facility Operator Inbormstion JJJ}}}
i1. Nome: ICIJCJEo 12Z6fiDj 2. Phone: I
r
3. Mailing Address: a. Stleet: '21 7 0 % : r .~
f b. Citir 0 . 1 f r I c. State_ Lk -C d. zip code: Io7� J�'I l / !.Z - I I l I I
9, FaciiitylStte LocationnI/Intorm/yaticn
�. faclf'lry Name: 6�1�1�''f � L•�! 1`?f�i�i �� �f/`Tl �- i � a ��_L„t [r!. >Ll�i 1 i t ?,._�
�, a. Street Address; 271Alt Is r S 4
r
i b. City: I G. Caunty, &A j2l Al I I L
d. 5tat'3 e, Zip; Code:
3. is +he tai bested on Indian Yes Yes ❑ No
.4. Is this a Fedora! facility? Yet ❑ No 9
I a. L fitud1....
e. LJ � l__LJ L-j -1 b. Longitude; L—L_
�. It. 'Nea the facility or slip previousiy covered under an NPDES storm water permit? Yes +� No ❑
h N yes, enter NPDES permit rxrmber: NcG o1,0 183
j. SIC/Activity Codes; Primary: 12111 Secondary (if applicable): I I
!i. Total size of Sits ea":,Iated with industrial activity: �L -5- _ acres
�. 0. Have, you paved 6f ro0tr0 over a formerly exposec, pervious area In odor t0 cuatlty for the no expcsure axcluulon? Vas No
.t D. if yes, plan" indicate apvro:amatety how much area was pawn or rooked over. Complettrig this question does not disqual',ry you to: the no axpaar:re
excluslon. HgAever, your pie mn inp authority may use this inirmation in considering whether storm water diteMarges Trom you! site are lfkgty to ttave
on adverse impact on watergLl ity, in which case, you could be rsquiroa 10 obtain parmlt :overage.
Less than Ono acre [] One to five acres ❑ More 'hen five acres ❑
trH Norm Sy7U•71 pu-94) Yaffe , GS 4

t1C3_NR-Dj1Q Fax :[phone] Jun 12 '02 14 :23 F. 03f 05
r
mopes EPA Form Approved
f UFiM NO CERTIFICATION for Exclusion from OMB No. 2540•C211
3statt NPDES Storm Water Permitting
C.Exposure Checl iet
i Are any of the li materials or activities exposed to procii nation, now or in 1ho foreseeable future
i (Please thank either "Yea" or "Nii' In the appropriate box.) If you answer "Yes" to any of these questions
(1) through (t 11, you are not eligible for the no exposure exclusion.
'>'as Nu
1, Using, storing or evaning industrial machirery or equlpmsnl, and areas where residuals frorr, u4ng, staring j
or deaning lnouetrial machinery or eeuipmeni remain and are exposed 10 storm water
2. Materials or residualt, on the ground or in storm water inlets from spina/leaks [�
3 lylaferi418 or products fmm pest industriai activity
4. Material handlini; equipment (except adequately maintained vehiciee)
S. Materials or products curingkmdingVurdoaoing ar irencporting eofiviiies
6. Matattels or products storedi!ouldoora (except final products Intended for outside use (e.g., new cars) where Q
v4posure to storm water dots not reeuit in the discharge of poilulii
7. Materials contained in opan'deteriorated or leaking storage drums, barrels, tonlre, and similar oontalnareEl
e. Materials or products hand'aWmored on roads or railways owned or maintained try the dist;narger ❑ �.
9. Waste malwiai (except wast in covered, non -leaking contalpers (e.g., eumpstars)) [j
r10, APPh4 ti0ri or disppeal of process wastewater (unless otnerwtae permitted)
r11. Particulate matter or visibie dopouta of neiduais from roof stacks anti vents not o:herw'se regu'ated u
(i.e., uncer an air quality control permit) and evident In the storm weer outllew
D. Icerliticatlon statement
I certify under penalty of law that I have read and understand the eligibiitty, requirements for claiming a condition of 'no exposure" and obtaining an
;exclusion 'rom NOES storm water permittili
t certify urWGr penalty pf law thatrthere are no Clscharges of storm ureter contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in tr11s document (except as allowed under 40 CFR t 22.26(ti
t understand that I am obligated to aubmil a no exposure cartilicat.'on form once ovary rive Veers to the NPOES permitting aulnority and, it requested, to
,the operator of the local fruniclpil-sepaarate storm sewer system (MS4) into which -the facility discharget< (where applicable). I understand that I must
allow the NPDES permitting authority, or MS4 operator where the discharge is irno the k=1 MS4, to pox orrh inspections to oonrirm the condition of nu
ax6oaure and to Take such Incpjetion repo;t3 publidy available upon request. I undervand that I must obtain, cmorage under an NPDFS permit prior
io any point source discharge of storm water from the facility,
.44aitionally, I certify under penalty' of law that this document and all attachments were Prepared under my cilrocii or supervis on in accorcance with a
6yswom designed to assure that <iuslif+ad personnel properly gathered and evaluated the Information submitted. Based on my inquiry of the person or
Wsoos wrla manage the system, or those parsons directly rosponsible for gathering the Information, thn information eubmined is to the babt of my
:,nowlecge and belief true, aoovrste and VIDM iete. I am aware toe; there are slgndicant penaltiee for subm;ning taise Information, including ;he possibility
;,?t tint and imprisonment fur knowing vloiaCorm.
print Namw ((r.l 1 1 Ej 2 /X A-�
Print Title:
aigna[ure:
i
bate: L[_L.�
EPA F,arrri 3510-11 (10-99)
Pill

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NCDENR-DWQ Fax ; 919- 733-0719 Jun 12 ' 02 14 � 2? F. 04.'US
NPOES �, r�q Instructions for the NO EXPOSURE CERTIFICATION for Form Appronad
FORM rl�yP�rM ores No. 2040-0..t t
asro-11 \ ` Exclusion from NPDES Storm Water Permitting
who May File a No Exposure Certlfleation
F.,daral law at 40 CFR Part 122,28 prohibits point source discharges of
storm venter associated with Iriduatrlar actiVry to wavers of the U.S. without
a ;rational loo(lutant Diachatye Eliminitlon System (NPpES) permit. However,
NI,°pF5 permit coverage is rot required for discharger of storm water
a0oaleted with industrial. activities; identified at 40 CPR 122.26(b)(td)(Ij-
lix) anc lxl) it the dischiarger can c4 lfy that a ocnaition of 'i exposure"
exsts at the industrial facility m site:
Stbrm water olacharges hom consi.ruil for activities identified fn 40 CFR
1212.26(b)(14)(x) and (0)(15; are noieilgfbla for the no exposure exclusion.
otoWnlng, and Maintaining the No Exposure €ttelusiom
f
Till form is need to certify that a Cenditcn of no exposure exists at the
industrial facility or site descrioed herein. This ceftlfirason is only applicable
in jurisdictions where EPA is the N--.l Permitting authorlty and must be
re-suhml;ted at least once every five years.
Thg industrial !acility operator must maintain a condition of no expouura at
its facility cr site In 3rcer for the no exposure exclusion to remain tpplicatre.
11 conditions charge resulting In the'artpotwre of materials and activities to
stare water, the facility operator must obtain coverage under an NPM
storm water permit hirmedlatety. {
Where to Ftlsthe No Expovun Certlflclll Form
Mrill the completed no exposure cerffficatlon form to:
.itorrn Water No Exill Certification (4203)
6,5 E PA
401 M Street, SW !
sNashington, D.C. 20460
Campleting the Form
i
you must type or print, using uppsresea testers, in appropriate areas only.
Ertler only ono, character per space fl.e., botwaon the marks). Abbreviate
if necessary to stay within the number of characters allowed for each item.
Uaii one apace for breaks wetween words. One form must be completed
for each facility or site for wnich you ire eeekiry to certify a condition of no
exposure. Additional guidal on completing this form can be accessed
thni ugh EPA's Met site at www.epa.gov,owmistn'. Pteasa make sure you
have addresaed all applicable quastlor,s and have made a photocopy for
your records before sending the completed form to the above address.
Stroll A. Facility Operator Information
1. Provide the legal rams of the person, firm, public organization, or any
other entity that operates the fpelll.ty or airs described in this coNficatio,.
'IThe name of the operator may or;.rrtay not bs the earns as li Warne of
'.he facility. The operator is the legal entity that controls the fai
Operal'on, rather than the plantorsile'manager,
2, Provide the tetephons number 7,`i" Ill operator.
3, �rovlde the mailing address of the operator (P.O. Box numbers may be
iisad). Include the city, state. arxr xio code. All correspondence will
be ,cnt to this address.
EPA RI)rri1 (11
Section B. Facinty,'Site Locatlon Information
I. Enter the official or loyal name of the facliir/ or Bite.
2. Enter the complete street address (If no rivet address oxlsl5, provide
a geographic desonpticn [e.g., lnmrsection of Routes 9 and 55]), city,
county, state. and up code. 0e not use a P.O. Box number.
3. Indicate whether the facility iy located on Indian Lands.
4. indicate whether the industriai facility Is operated oy a department of
agency of the Federal Govornment {see also Section 313 of the Clean
Water Act),
S. Enter the latitude We longitude of the approximate center of the facility
or site in degrees/rninutesisl Laiitudrr and longitude can
be obtained from United States Geological Survey (USGS) quadrangle
or topographic-i-Aps, by calling 1 •($86) ASK•USGS, or by accessing
EPA's Net: site at hit :Nvrww.e ov/orvrtilsw!!nduS�/indox,htm and
salowing LAtitud�+ amj Lcngitu a fndero under the PesoufcoetPormit
section.
Ladludo and longitude for a facility In decimal form must be converted
to degrees (v!, minutes ('), ane seconds (') for proper entry of;
ire certification form. To convert cecimal latrtude or longitude to
dagre S'rr1irwtesraeconds, follow the steps in the loilcwing example.
Example: Convert decimal latitude 45,1234557 to degrees t'l, minutes
i and seconds (' ).
a) The numbers to the tvh of tfita decimal point are the degrees: 45
b) To obtain minutes, multiply the f1ml tour nurrtbets to the r',ght oil the
oWmal point by 0,006: 1234 x 0.D05 : 7.404.
c) The numbers to the left of the decimal point in the result obtalr,s-
in (b) ere the rtrin,ttest 7'.
d) To obtain seconds, muhlply the (ern■ininq three numbers to the
right o1 the decimal trom Me result obtained )n 1) by 0.06:
404'x 0.06 a 24 24. Since the numl to the right of the decimal
point ate not used, the result is 24".
a) The oonvaraion lcr 45.1234567 - 451 7' 24'%
8. Indicate whether the facility was previously covered under an Nl'
atorm water p,rmlt. 9 so, iodude the permit number.
7. Enter the 4•0il SIC snide which identifies the fadglj'S primary activity,
and second 4-digit SIC code Identifying tho facility's vecondary noivir;,
If WIlicabla. SIC oedev can be DD'er ed from the Standard Inoue trial
Glasa,5cation Manual, 1987.
8. Enter the total size of the site associated with industrial =1viy In acres.
Acreage may be determined by dWding .squaro footage by 43,560, as
demonstrated in the following example.
Exam le: Convert 54 A50 1`12 to acres
Divide 54,450 1t2 by 4,`,560 sguaro toot par acre:
54, 450 ft2 . 43, 660 ft2'acre = T,25 awes.
5. Ghcck "Ycs' or "rVo" as &pproprlate to Indlcele WneD-we you i paved
or roofoc over a ti exposed, perviout Area ii.e., lawn, meadow,
dirt or gavel road/oarking lot) In order to euatiFy for no expoauro. It vea,
also Indlcare apprgximatery hour much area was paved or rooted over
and is ri mpery out area.
Page 3 ct 4

NCD NR-DWQ Fax:[phone] Ain 12 '02 14:24 P.05/05
rRORM
Nr3ES Form Approved
PIEgi p/► Instructions for the NO EXPOSURE CERTIFICATION for r��trj No. zoaaczt t
fa tt �K Exciusion from NPDES Storm Water Permitting
Si: rctlon C. Expoeurtt Checklist .l
Crieck "Yea" or "No" ae upproprlate io describe the exposure Donditions at
yovr lae;My If you answer "Yes" to'ANY of th6 questions (I) through (11)
In 11n's section, a potential for axpos_ufe wJ its at your site and you cannot
certify to a condition of no exposure. You must obtain (or already have)
Coverage under an ,NFOE$ rrtormwater permit. After obtaining permit
coverage, you can Insilwle modifications to ellminate the potential for a
di$charge ut Storm water expesed,to industrial activity, and then cenlfy to
a tvndWon of no erpoavre.
StTlion 0_ Certification Stabwner t
Feideral etatutee provide for severe penalties for %bmittlnp false information
or this application form, Federal raguladons require this appllcaron M be
si(tned as tollowc
For a corporation: by a responsiNe corporate officer, which means:
(i) president.secretary,treaiurer.orvice-pros!dentottheoorporallon
in charge of a principal business function, or any other petsur.
who per'orms slmliar po!toy or decision making tuncllons for the
corporation, or
(ii) the manager o1 one or,more manufacturing, production, or
operating faci!itia5, provltlad the manager !s authorized to make
meragement decieionj which govern the operation of the
regulated facility (ncllxiing having the exp9ch or implicit duty of
making majorcapltal invpatrid'nI recommendations, and initiating
and dirocting other ooniprehen6lve measures to assure lorg
term anv!ronmontal compliance with environmental laws and
regulations; the managei'oen ensure that the necessary sysleme
are eatailiahed or aotiona taken to gather oomplele and avourate
information for parmlt ipplicalion requirements; and whore
EPA I,`orrr 351t>w11 (10-991
authority to sign documents hae been assigned or delegated to
the manager in accordance with corporate procedures;
For a partnershlp or sole proprietorship: by it general partner or the
proprietor; or
For a mun cipai, State. Federal, or other public facility: by either a
principal executive or iariking elected official.
Paperwork Reductlon Act Notice
Public rvpor:irrg burten for Via certification is ea:imatW to aver age 1.0 hour
per Cann lcallon, including brae for reviewing instructions, searching exist rig
data souroea, gathering and maintetnind the data needed, and ; omglwirg
and reviewinQ the collection of !ntormalion. ©wden means the Iota! time,
effort, or financial reeourcve expended by persona to generate, maintain,
retain, or disclose to provide !nformatlon to cl far a Faders! agency. This
includes the time needed to review initruccorta; develop, aoquire, inatall,
and uVize reohnobg;r enc systems lbr the purposes of toVeoting, validating,
and verifying Information, processing and nlalntalring Ilttonnatlon, and
diso'esing and provicing intorrnation; adjust the existing ways to wmply ',wth
any provlouWy eppl+cable Instructions and ruqulrarnoats; trrtin porsom* to
5e able to respond to z colectlon of information; search data source.;
complete and review the oolleotion of information; and trnnsmil or otherwiee
disclose fits informaton. Art aQoncy may not cunduct er saonsor, and a
parson is not required to respond te, a collection of Infot matlon unless it
d!aPlaya a currently valid OM& control number. Sanu comments regarding
the burden estimate, any other aspect of the collection of intormation, or
sugpeat;rns for 'mptoving this form, including any auggestionf> wh4h may
Ircrease or reduce this burden to: Director, OPPE Hejulatory Information
Division (2137), USEPA, 401 M 5treet, SW, Waehinator„ D,C. 204130.
Include the OMO control number of this torn on any correapondarres. Do
n-r, aend the cornplated No Expcsure Certflicatlon form to this dddreos.
Parja 4 of 4

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UNITED STATES
DEPARTMENT OF THE INTERIOR
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0F WArFRpG PERMIT COVERAGE
RESCISSION REQUEST FORM
National Pollutant Discharge Elimination System
Stormwater General Permit NCG060000
GOLD SIGNATURE FOODS LLC
COC Number NCG060183
Union County
FACILITY INFORMATION
The following is the information currently in our database for your facility. Please review this information
carefully and make all corrections as necessary in the space provided to the right of the current
information.
Facility Name: GOLD SIGNATURE FOODS LLC
Mailing Address*: 2701 SIMPSON ST
MONROE, NC 28112
Location Address: 2701 SIMPSON ST
MONROE, NC 28112
.s7�^z �!'
Facility Contact: DAVIDG HILL
Phone [dumber: 7042913415 d
Fax Number: No number on file 7a 41 A k, ia.2 .3
E—mail address: No address on file /^Gh'eQ�
" CO/JJ
* This is the address to which all permit correspondence will be mailed
11
}
Reason for rescission request:
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REQUEST AND CERTIFICATION
1, as an authorized representative, hereby request rescission of coverage under NPDES Stormwater General
Permit NCG060000 for the subject facility. 1 am familiar with the information contained in this request and that
to the best of my knowledge and belief such information is true, complete and accurate.
Signature - Date //C
Print or type name of person signing above 'Title
Please return this completed rescission request and any relevant documentation to:
General Permit Coverage Rescission
Attn: Valery Stephens
Stormwater and General Permits Unit For Office Use Only
1617 Mail Service Center LRqursJ"J),1C
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Raleigh, North Carolina 27699-1617 ❑