NCGNE0193_COMPLETE FILE - HISTORICAL_20100816

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
p ��G �J C
IV
DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ ��'� DS
YYYYMMDD

s�®
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
August 16, 2010
Mr. Randall Noftle
Media General Inc.
Subject:' No -Exposure Certification NCGNE0193
he McDowell News
IM'cDowell County
Dear Mr. Noftle:
Dee Freeman
Secretary
As a current holder of a No -Exposure Certification, please note the following important change to the Division's
implementation of this program. The No -Exposure Certifications no longer will have an expiration date. Previously your
no -exposure exclusion had to be re -certified with the Divisio:: every 5 years. This will no longer be required. Please
disregard the expiration date on your original certificatie•�. However, in order to assure that your facility stays in
compliance with all of the conditions in the no -exposure certification, you must self re -certify your facility at least
annually, Please see the attachment for information on self re -certification.
If you are waiting for a response from the Division for a renewal certification you already submitted, please consider this
letter the Division's approval for renewing your No -Exposure exclusion.
Please note that this does not change your obligation to�m;i i.: toin 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 storm"o.'ater discharge. Otherwise, the discharge becomes
subject to enforcement as an un-permitted discharge. State statute provides for fines of up to 125,000 per day for
un-permitted discharges.
Your conditional exclusion from permitting 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 your Regional Office, or Robert Patterson in the
Stormwater Permitting Unit at [phone], [e-mail].
Sincerely,
for Coleen H. Sullins
cc: Stormwater Permitting Unit No -Exposure Files
Attachments
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Ralegh, North Carolina 27604
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
temet: www,ncuvaterquaMy.org
:qual Opportunity 1 Affirmative Action Employer
One
NorthCarolina
Natura!!if

P!ed to clean up the list/make some adjustments to their permits. They have submitted for rescission on the
cable permits.
180062-Change facility address to 420 12t" Street NW Hickory, The property is contiguous to the previous facility
address and changes on site have made the 12`h street address the active address.
180063-ok
180064-o k
180065-rescind-no manufacturing/selling property
180066-Rescind—facility contiguous with 180064..covered under 180064
180068-rescind-no manufacturing
180198-rescind-no manufacturing
I saw only 4 active permits in BIMS so most of it may have already been done...This fell through the cracks of my desk O.
Forward as needed...
As always, thanks for your help.
Donna
Please note that my email address has changed to [e-mail]
Donna Hood - Donna. Hood @ncdenr,gov
North Carolina Dept. of Environment & Natural Resources
610 E. Center Ave.
Mooresville, NC 28115
Ph:704.663.1699 Fax:[phone]
------------------------------------------------------------------------
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
------------------------------------------------------------------------

Lowther, Brian
From: Georgoulias, Bethany
Sent: Tuesday, August 24, 2010 11:10 AM
To: Hood, Donna
Cc: Bennett, Bradley; Lowther, Brian
Subject: RE: SW permits for Cv Industries
Follow Up Flag: Follow up
Flag Status: . Flagged
Hi Donna,
Brian's been handl.ing rescissions, but we need a request in writing from the Permittee whenever possible. Is there any
way we can get that from Cv Industries for the permits that need rescission? We can save this email as confirmation
from the MRO that they should be done once we get those letters. (Or, like you said, several of them may have already
been rescinded... Brian, any records on those?).
As far as the change of address, we can change it in BIMS and it will appear correctly on the next renewal CDC. [BB -- I
just tried to do it myself in BIMS for that facility, but it wouldn't let me — the error said facility with owner/name already
exists? I may not have permission?]. Without an admin assistant, I'm not sure of the priority of fixing addresses on
COCs and sending out paper copies without a specific request from them, though. I'll check with Bradley.
-Bg
Bethany Georgoulias
Environmental Engineer
NCDENR [ DWQ I Stormwater Permitting Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
512 N. Salisbury St, Raleigh, NC 27604
Phone: [phone]
Fax: [phone]
NEW Website: httpalportal.ncdenr,org/web/wq/ws/su
E-mail correspondence to and from this address may be subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Hood, Donna [mailto:[e-mail]]
Sent: Tuesday, August 24, 2010 9:46 AM
To: Georgoulias, Bethany
Subject: SW permits for Cv Industries
Bethany,
I am sorry to send this to you, but with Sarah no longer there, I was not sure to whom I should send it .... So here goes ... I
visited Cv industries this year (3.29.2010) They have several NCG18 permits with us, they are as follows:
180062
180063
180064
1180065
180066
180068
180198

DENR Regional Office WAN Upgrade Costs
Site ID
Location Current
Upgrade Upgrade
Upgrade Service Provider One Time
Install Cost
123
Fayetteville T-1 FR
3M ATM 6M ATM
10M Metro E CenturyLink
$500
$806.00
$1,423.27 $2,393.54
$1,894.76
129
Asheville 3M ATM
6M ATM
10M Metro E AT&T (Bell South)
$500
$1,478.86
$2,331.32
$1,692.80
54
Raleigh T-1 FR
3M ATM 6M ATM
10M Metro E AT&T (Bell South)
$500
$840.00
$1,478.86 $2,331.32
$1,692.80
39
Wilmington 3M ATM
6M ATM
10M Metro E AT&T (Bell South)
$500
$1,478.86
$2,331.32
$1,692.80
145
Winston Salem T-1 FR
3M ATM 6M ATM
10M Metro E AT&T (Bell South)
$500
$840.00
$1,478.86 $2,331.32
$1,692.80
52
Washington 3M ATM
6M ATM
10M Metro E CenturyLink
$500
$1,423.27
$2,393.54
$1,942.70
56
Mooresville T-1 FR
3M ATM 6M ATM
10M Metro E
$500
$963.00
$2,109.00 $3,516.80
$1,932.50
AT&T AT&T
TWC
Note: Mooresville local service is
provided by Windstream. ITS doesn't
have an ATM contract with Winstream.
ATM service is provided by AT&T.
Metro E available from Time Warner Cable. Prices quoted for ATM are estimated.
Also Note: Metro E requires conduit
to the building and to the room where service will be installed.
Service Provider will survey the site after receiving an order. If they require any construction, they will advise before
installing the circuit.

Lowther, Brian
From:
Georgoulias, Bethany
Sent:
Tuesday, August 24, 2010 11:10 AM
To:
Hood, Donna
Cc:
Bennett, Bradley; Lowther, Brian
Subject:
RE: SW permits for Cv Industries
Follow Up Flag:
Follow up
Flag Status:
Flagged
Hi Donna,
Brian's been handling rescissions, but we need a request in writing from the Permittee whenever possible. Is there any
way we can get that from Cv Industries for the permits that need rescission? We can save this email as confirmation
from the MRO that they should be done once we get those letters. (Or, like you said, several of them may have already
been rescinded... Brian, any records on those?).
As far as the change of address, we can change it in BIMS and it will appear correctly on the next renewal COC. [BB — I
just tried to do it myself in BIMS for that facility, but it wouldn't let me — the error said facility with owner/name already
exists? I may not have permission?]. Without an admin assistant, I'm not sure of the priority of fixing addresses on
COCs and sending out paper copies without a specific request from them, though. I'll check with Bradley.
-Bg
Bethany Georgoulias
Environmental Engineer
NCDENR I DWQ I Stormwater Permitting Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
512 N. Salisbury St, Raleigh, NC 27604
Phone: [phone]
Fax: [phone]
NEW Website: http://portal,ncdenr.org/web/wq/ws/su
E-mail correspondence to and from this address may be subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Hood, Donna [mailto:[e-mail]]
Sent: Tuesday, August 24, 2010 9:46 AM
To: Georgoulias, Bethany
Subject: SW permits for Cv Industries
Bethany,
I am sorry to send this to you, but wit' Sarah no longer there, I was not sure to whom I should send it....So here goes ... I
visited Cv industries this year (3.29.2010) They have several NCG18 permits with us, they are as follows:
180062
180063
180064
180065
180066
180068
180198

CHPP 2009-2011 Implementation Plan - Division of Water Quality
DWQ ac#ions 05-09
Action_ r ; 1
IP_yr,
Target_yrj
Lead
Status x
Comment {
nt stormwater and buffer fessionals ro
workshops for p
09-
APNEP,
?
.11
JOngoing
.'
DWQ
[[[[Coastal
unds to local governments for educating citizens in
05-
DWQ
PC
Nonpoint Source Program awarded two educational grants
;dictions about DWQ's Neuse and Tar -Pamlico riparian
07
(Greenville and Pitt County, and Beaufort Soil & Water Conservation
les.
District) ) Grant to Soil & Water- educate in CREP areas, DWQ filling
position in central office re buffer education and other outreach
unds to local governments for educating citizens in
09-
DWQ
?
;dictions about DWQ's !Neuse and Tar -Pamlico riparian
11
les.
outreach to educate citizens in their jurisdictions
07-
Ongoing
DWQ
PC
DWQ created an educational brochure in spring 2007 that will be
VQ's Neuse and Tar -Pamlico riparian buffer rules.
09
updated in 2010. DWQ will schedule workshops in 2010 aimed at the
real estate community.
outreach to educate citizens in their jurisdictions
09-
Ongoing
DWQ,
1APNEP
? qJAPNEP
and DWQ developing information for display and distribution
VQ's Neuse and Tar -Pamlico riparian buffer rules.
it
about Riparian buffers and 401 Water Quality Certifications.
nformation to focus on students in K-12 understandingF
09-
Ongoing JAPNEP,
?
versity the lakes, streams and estuaries.
11
DWQ
Jnwide Planners review CAMA Land Use Plans
07-
Ongoing
DCM, DWQ
PC
Reviewed plans for Caswell Beach, Holden Beach, North Topsail Beach,
09
Ocean isle Beach, Swansboro, Tyrrell County/Columbia, and Sunset
Beach (9/15/2008). Reviewed plans for Craven County, Dare County,
Caswell Beach, Holden Beach, Ocean Isle Beach and Sunset Beach.
DWQ-Reviewed during 2008 and so far this year: Tyrrell County/Town of
Columbia 2007 Draft LUP, Town of Holden Beach 2007 Draft LUP, Town
of Caswell Beach 2008 Draft LUP, Town of Ocean Isle Beach 2007 Draft
LUP, City of Havelock 2030 Comprehensive Plan, Town of Windsor
CAMA Core Land Use Plan, Town of Southern Shores' CAMA Core Land
Use Plan Update, Town of Nags Head 2006 Draft LUP, 2008 Dare County
Land Use Plan Update, Town of Swansboro 2007 Draft, Onslow County
2007 Draft LUP, Holden Beach Draft LUP, Manteo Draft LUP.
inwide Planners review CAMA Land Use Plans ]09-
Ongoing
DWQ
?
- - -
11
]DCM,
— - -
---
- -
Page 1

I
They need to clean up the list/make some adjustments to their permits. They have submitted for rescission on the
applicable permits.
180062-Change facility address to 420 12`h Street NW Hickory. The property is contiguous to the previous facility
address and changes on site have made the 12`h street address the active address.
180063-ok
180064-ok
180065-rescind-no manufacturing/selling property
180066-Rescind—facility contiguous with 180064..covered under 180064
180068-rescind-no manufacturing
180198-rescind-no manufacturing
I saw only 4 active permits in SIMS so most of it may have already been done ... This fell through the cracks of my desk @.
Forward as needed...
As always, thanks for your help.
Donna
Please note that my email address has changed to [e-mail]
Donna Hood - [e-mail]
North Carolina Dept. of Environment & Natural Resources
610 E. Center Ave.
Mooresville, NC 28115
Ph:704.663.1699 Fax:[phone]
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
------------------------------------------------------------------------
tj

1y.,a xY-.+ ;ti ':�'"". "`',':.:,� 'q w._Ls'r'. -^c :—w r"Q'{:,.-.{...:.
All Waters,nnNC. are 1n Category 5 3p3[d) List for Merqury, to statewide fishLconsumption advice,farseveral#ishspecres,
'.,Y-r-� _
- _ue
�—
AU
Number, < AU Name AU•Description
LengthArea.AU_Units
Classification
„
I, .. ...,,✓.-W.. .t .... .. w..n.r. _ �. . .-_ _ -._ - . _-,_-• v.- y--•.u.a.. Fi
+Parameter Reason for Rating tUse Calegon
�._.,_.._L'_.-. .R-_aH',i,,... t . -
:Collection Year 303(d)vear
Q
11-55-(1.5) Gunpowder Creek
From a point 0.5 mile downstream of
13.4 FW Miles WS-IV
(Old Mill Pond)
Caldwell County SR 1127 to a point 0.8 mile
downstream of Billy Branch
5 EcologicaUbiological Integrity Renthos
Fair }3ioclassification Aquatic Lill;
2007 2010
Q
11-54-(0.5) Horseford Creek
From Frye Creek to a point 0.7 mile
0.4 FW Miles WS-IV
upstream of mouth
5 Ecological/biological Rile;;rs y Renthos
Poor Bioclassification Aquatic Lite
2002 2006
Q
11-54-(3) Horseford Creek
From a point 0.7 mile upstream of mouth
0.7 FW Miles WS-IV;CA
to Lake Hickory, Catawba River
5 EcologicaUbiological Integrity hzalhos
Poor 13ioclassitication Aquatic Life
2002
2006
Q
11-44-(3) M[Galliard Creek
From a point 0.6 mile upstream of mouth
3.9 FW Miles
WS-IV;CA
to Rhodhiss Lake, Catawba River
5 Ecological/biological Integrity FishCom
Poor Bioclassificalion Aquatic Life
2003
2006
Catawba
River Basin . `Lake Hickory-Catawba'Rive' Watershed '0305010109
Q
11-60 Falling Creek
From source to Lake Hickory, Catawba River
4.0 FW Miles
C
5 EcologicaUbiological It=tegrity Benthos
Fair 13ioclassification Aquatic Llle
2007
2010
,,Catawba River, Basin r^
Lookaat Shoals Lake -Catawba River Watershed." 0305010110; .
Q
11-69-(0.5) Lower Little River
From source to a point 0.5 mile upstream
14.0 FW Miles
C
of mouth of Stirewalt Creek
5 L.ow pli Standard Violation Aquatic Lile 2008 2010
Q 11-69-4 Muddy Folk From source to SR 1409 6.8 FW Miles C
5 EcnlogicaUbiological Integrity 4enthos Fair l3ioclassification Aquatic Lifc 2007 2010
=,Catawba River:Basin Upper Lake Norman Watershed., . 0305010111 f
Q 11-76-5-(0.7) McLin Creek From Catawba County SR 1734 to a point 6.8 FW Miles WS-IV
0.2 mile upstream of Catawba County SR
1722
5 F.cological1hiological Integrity Renthos Fair Sioclassification Aquatic Life 2007 2010
Catawba River Basin putchmans Creek Watershed 0305010113
Q 11-119-(0.5) Dutchmans Creek From source to a point 0.8 mile 7.4 FW Miles WS-IV
downstream of Taylors Creek
5 Turbidity Standard Violation Aquatic Life 2008 2010
Q 11-119-2-3 Forney Creek From source to Killian Creek 8.4 FW Miles C
5 Ecological/biological. Integrity FishCom Fair 13ioclassification Aquatic Life 2007 2010
Q 11-119-3-(2) Stanley Creek From a point 1.0 mile upstream of Gaston 4.7 FW Miles WS-IV
County SR 1918 to Dutchmans Creek
5 Low Dissolved Oxygen Standard Violation Aquatic I,ife .2008 2010
i Catawba'River;Basin Mountain island Lake Catawba.River Watershed ` •0305010114" x
NC 2010 Integrated Report Category 5-303(d) List EPA Submittal 20100329 Monday, March 29, 2010 Page 18 of 11S

O(r WATF Michael F. Easley, Governor
`O� RQG William Cr. Ross Jr., Secretary
4� North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleco H. Sullins, Deputy Director
Division of Water Quality
April 20, 2005
Randall Noftle, Director Human Re
Media General Inc.
301 Collett St
Morganton, NC 28655
Subject: No Exposure Certification NCGNE0193
The McDowell News - 26 N Logan St
McDowell 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 August 21, 2001. 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.
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,
b t_,J/ y
for Alan W. Klimek, P.E.
cc: Asheville Regional Office w Central Files — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1017 Mail Service Cenicr Ralcigh, North Carolina 27699-1617 (91.9) 733-7015
4�A
NCDENR
Customer SCrVICC
1-877-623-6749

o a a
NPDES
FORM
r —Form A �rov d
NO EXPOSURE CERTIFICATION for Exclusion from pp
QM & No. 2a40�Dc2
3510-11
,EPA NPDES Storm Water Permitting
r�
�1
i
C. Exposure Checklist
{ Q
o
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
"Yes'
C�
(Please check either or "No' in the appropriate box.) tf you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
�—
�x G v�
L_- -_Yes—
_No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spills/leaks
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during loading/unloading or transporting activities
6. Materials or products stored outdoors (except final products intended for outside use [e.g.. new carsf where
exposure 10 storm water does not result in the discharge of pollutants)
7, Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
51
S. Materials or products handled/stored on roads or raihvays owned or maintained by the discharger
❑
9. Waste material {except waste in covered, non -leaking containers [e.g., dumpstersj)C]
10. Application or disposal of process wastewater (unless otherwise permitted)
it. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(i.e., under an air quality controlpermit) and evident in the storm water outflow
D. Certification Statement
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES storm water permitting.
I certify under penalty of law that there are no discharges of storm water contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, it requested, to
the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I understand that I must
allow the NPDES permitting authority, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request. t understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water from the faaTrty.
Additionally. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
systam designed to assure that qualified personnel propeoy gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my
knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations. Print Name: D t A f Y I I I I, ib ISM 1 I415I f'n
11 I 1I I 1 I 1 I i I_ L_ t I l I i i I I
Print Title: Ll U41. I t:rf i
Signature:
Date. Ialero,if 101 I
_ -11 {10-99) EPA Form 351D Page 2 of 4

a
N 1r :r A ir, - fQi 1--, '
United States Environmental Protection Agency Form Approved
OMB No. 2040-0211
NPDES �
3510-11 EPA Washington, QC 20460
FORM �' NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities include the storage,
loading and unloading, transportatior, or conveyance of any raw material, intermediate product, final product or waste product. A storm resistant shelter is
not required for the following industrial materials and activities:
- drums, barrels, tanks, and similar containers that are tightly seated, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational taps or valves;
- adequately maintained vehicles used in material handfino; and
- finai products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting is
availab#e on a facility -wide basis only, not for individual outfalfs. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM_
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information
1, Name: I/ 14 QI I I I I LI -C&I 6-ILI AL 1 t ! 18'1 CJ I 1„_.L,.l_..I I I I I I I Ik 2. Phone: l�jjUf "/A I(' IC;
3. Mailing Address: a. Street: II jI 3 13 1 I IT I r 1FA 1/U kl C,y�_i kf _ I Si -(I I I I _ I I I , , I_I-_I I I I I I I
b. Cdy I/'I / I� I Iyj%rll f? IY I riI I I I I I I L_1_,l._l I I I I c. State: &�E d. Zip Code: I +'1 31 Z 1 f 191 - I I I I I
B. Facility/Site Location Information
1, Facility Name: ITfI/� I/`/lt'_LtlJs1_I�4li{I<<J� l VLtf4_jat SI t I I I I I t I I 1 I I
2. a. Street Address: IA(f- I ItU t L 101 GI lA 1 M 15 I r I I t I I I I I I I I I I I I I I 1 I I
b. City: li`itrtl �I / 1 M 1-1- -1 _1 I_ I I I I I I I I I I I I c. County: ICI 01 kV I LLf St LI G 1 I
d. State: e. Zip Code: 1;-] SI %1 S-1 A - I I I I 1
1 Is the facility located on Indian Lands? Yes ❑ No o
4. Is this a Federal facility? Yes ❑ No
5. a. Latitude: &L-(j o Lw J LDr [ 1 b. Longitude: I rx' I 10 101L lof
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No 21
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: 1.,171 / 1/ f Secondary(if applicable): I I 1 1
8. Total size of site associated with industrial activity: Z 0, acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes ❑ No L.C3
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to rive acres ❑ More than five acres ❑
EPA Form 3510-1 1 (10.99) Page 1 of 4