NCGNE0940_COMPLETE FILE - HISTORICAL_20160824

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
(�
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DOC TYPE
El COMPLETE FILE -HISTORICAL
p
YYYYMMDD
DATE OF
RESCISSION

PAT MCCRORY
Governor
Energy, Min era I
and Land Resources
ENVIRONMENTAL OUAL[TY
August 24, 2016
Mr. Scott Doughty
Avery Dennison
1700 West Park Drive
Suite 400
Westborough, MA 01581
DONALD R. VAN DER VAART
Secrerary
TRACY DAVIS
Dimeror
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number qCGNE0940
& NCGNE0329
Guilford County
Dear Mr. Doughty:
On June 29, 2016, the Division of Energy, Mineral and Land Resources received your request to rescind
your coverage under Certificate of Coverage Number NCGNE0940 & NCGNE0329. In accordance with
your request, Certificate of Coverage Number NCGNE0940 & NCGNE0329 is rescinded effective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 the Stormwater Program at [phone], or the
Stormwater staff in our Winston-Salem Regional Office at [phone].
Sincerely,
)-�- �-
for Tracy E. Davis, PE, CPM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office
Stormwater Permitting Program
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Center i 512 North Salisbury Street I Raleigh, North Carolina 27699-1612
919 707 9220 T

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
eC( /t/e7 D yXD
DOC TYPE
0 COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
YYYYMMDD

Energy, Mineral
and Land Resources
ENVIRONMENTAL OUALITY
August 24, 2016
Mr. Scott Doughty
Avery Dennison
1700 West Park Drive
Suite 400
Westborough, MA 01581
PAT MCCRORY
Govemor
DONALD R. VAN DER VAART
Se LMUln'
TRACY DAV[S
Urrerrar
Subject: Rescission of NPDES Stormwatcr Permit
Certificate of Coverage Number NCGN E0940
`&.NGGN E0329:Z2
Guilford County
Dear Mr. Doughty:
On June 29, 2016, the Division of Energy, Mineral and Land Resources received your request to rescind
your coverage under Certificate of Coverage Number NCGNE0940 & NCGNE0329. In accordance with
your request, Certificate of Coverage Number NCGNE0940 & NCGNE0329 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 the Stormwater Program at [phone], or the
Stormwater staff in our Winston-Salem Regional Office at [phone].
Sincerely,
for Tracy E. Davis, PE, CPM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office
Stormwater Permitting Program
State oi' North Carolina I Environmental Quality j rnergy, Mineral and Land Resources
1612 Mail Sen'ice Center 1 512 North Salisbury Street I Raleigh, North Carolina 27699-1612
919 707 9220 'r

Alexander, Laura
From: White, Glen
Sent: Monday, August 22, 2016 10:22 AM
To: Alexander, Laura
Cc: Gantt, Matt
Subject: Rescission Request (NCGNE 0940 & NCGNE0329)
Laura
We're fine with rescinding NCGNE0940 & NCGNE0329. Both facilities are no longer in operation.
Glen White
Environmental Specialist
NCDENR Winston-Salem Regional Office
Division of Energy, Minerals & Land Resources
450 Hanes Mill Rd — Suite 300
Winston-Salem, NC 27105
glen. [e-mail]
[phone]

June 21, 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
Request for NPDES Permit Coverage Rescission
Avery Dennison
2025 t 6'h Street
Greensboro, Guilford County, North Carolina
Permit# NCGNE0940 & NCGNE0329
Dear Sir/Madam:
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 ask that you rescind the
facility's coverage under General Permit No. NCGNE0940 & NCGNE0329. 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 representative:
Scott Doughty
1700 West Park Drive, Suite 400
Westborough, MA 01581
[e-mail]
[phone]
Sincerely,
VV V l
Encl.

` • s Division of Energy, Mineral & Land Resources
f Land Quality Section/Stormwater Permitting Program
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NCDENRNational Pollutant Discharge Elimination System
C�,�a
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month11
Da
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
11 Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S I I I I N C G N F 0 9 4 0
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below &4'ol
Owner/Facility Name_Avery Dennison
Facility Contact Scott Doughty
Street Address 1700 West Park Drive, Suite 400
City Westborough State MA ZIP Code 01581
County E-mail Address scott.dou h ave dennison.com
Telephone No. 413 348-8620 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on June 2016 All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
on. 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 Date June 21, 2016
Scott Doughty Senior Director, Quality & EHS
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, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer

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FOR AGENCY USE ONLY
�`t • . Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Da
NCDENRNational Pollutant Discharge Elimination System
Nan+ Gnouw. p[P�+rM[IR a
EimrtowMei+r wo N,aun,ti RcfoVreces
RESCISSION REQUEST FORM
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 5 I I I I N C G N E Q 3 2 9
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/FacilityName_Avery Dennison
Facility Contact Scott Doughty
Street Address 1700 West Park Drive Suite 400
City Westborough State MA ZIP Code 01581
County E-mail Address Scott.doughtyi-averydennison.com
Telephone No. 413 348-8620 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on June 20i6 All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
on i 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�Zdc-
Date June 21, 2016
Scott Doughty Senior Director, Quality &t EHS
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, North Carolina 27699-1612
Phone: 91M07-63001 FAX: [phone]
An Equal Opportunity 1 Afftmative Action Employer

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Michael F. Easley, Governor
O 9QG
William G. Ross Jr„ Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
,r
Coleen H. Sullins, Deputy Director
Division of Water Quality
May 28, 2007
Ms. Karen L. Willingham
161h Street Group
1206 Colonial Avenue
Greensboro, NC 27216
Subject: No Exposure Certification NCGNE0329
Avery Dennison PFUHTL Printer Systems
2025 16th Street, Greensboro, NC
Guilford County
Dear Ms. Willingham:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on February 4, 2007. 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 (May 31, 2012). 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 Sarah Young at [phone], ext.
502, or at [e-mail].
cc: Winston-Salem Regional Office
Stormwater Permitting Unit Files
Sincerely,
for Alan W. Klimek, P.E.
Central:Files - w/attachments ,
N. C. Division of Water Quality 1617 Mail Service Center . Raleigh, North Carolina 27699-1617 [phone]
6*�
14CDENR
Customer Service
1-877-623-6748

WSR-0
United States Environmental Protection Agency Form Approved
OMB No. 2040 021 1
NPDES A Washington, DC 20460
FORM �Wt NO EXPOSURE CERTIFICATION for Exclusion from
3510-11 EPA
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, transportation, 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 sealed, 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 handling; and
- final 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
available on a facility -wide basis only, not for individual outialls. 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).
►L��I�17i].L►Jiff`ilr;L►1:1~�i:I�:Ii1►11raI��I�IIil:lt`��sliir
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: II I�ITI RI i'sTIRtI T� ihIMiUi r� I I I I AI I I f I I 1 1 2. Phone: l' )131L131� 131 1) I� I�
3. Mailing Address: a. Street: I hA) d 1 i i l 1� I (I f 10 In t I Cll f I I AV I EI I I I I I I I I I I I I I I
b. City: TIE I,E IN I S I $I I I I I I I I I I I I I I c. State: INS d, zip Code; 1XIl i 101- 11 1
B. Facility/Site Location Information
ff
1.FacilityName: I�IUltlr'1`I iultl�lu�51�1�,1 I�l�l�'I1117i�1�I�IrI{-fNlrlt�l Sy��
2. a. Street Address: Id41 dial 51 ! I I �i Ali{i _ls LTI�I EI CI r1 I I I I_1 I I I II I I I I I I
b.City: l�I�tIt1�51�IdIFZl01 1 1 1 1 1 1 1 1, 1 1 1 1 1 c.County: f;.11UITILIE1a1Pii
d. State: I Q q e. Zip Code: S -
3. Is the facility iorated on Indian Lands? Yes ❑ hlo W
4. Is this a Federal facility? Yes ❑ No ® O,
5. a. Latitude: 3J k I-.=-t_;t �� b. Longitude: 1 '7 9 * LJq u�
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No
b, If yes, enter NPDES permit number:
7. S1C/Activity Codes: Primary: 5I Secondary (if applicable): L��J
8. Total size of site associated with industrial activity: U/A 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 Ifi
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 qualily, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10.99) Page 1 of 4

NPDES �, NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM �-,EPA OMB No.2040-0211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" In the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
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 je.g., new cars] where
exposure to 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
El
41
8. Materials or products handledlstored on roads or railways owned or maintained by the discharger
Ilk
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
10. Application or disposal of process wastewater (unless otherwise permitted)
11. Particulate matter or visible deposits of residuals from root stacks and/or vents not otherwise regulated
(i.e., under an air quality control permit) 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 industrai
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 codification form once every five years to the NPDES permitting authority and, if 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. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water from the facility.
Additionally, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed 10 assure that qualified personnei properly 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: &A kil-'101 liLl
Print Title: IDiZZEICITIOI& IUIrI I()If IFlRl11l 1Tj.INI5I I I I i I_L 1 I I I I
Signature: [/� -
Date: Ill 1 I ! IZI 0I7I
EPA Form 3510-11 (10-99) Page 2 of 4

January 17, 2007
Stormwater Permitting Unit
1617 mail Service Center
Raleigh, NC 27699-1617
To Whom It May Concern:
ws�
AVERY
DENNISON
JAN 18 711n?
DENR - WAfKF—tC—Kj-A—Lff
WbWWWS & Soomiwater &anch
In accordance with NPDES federal and state requirements i am submitting a No
Exposure Certification Form for 2025 161h street in Greensboro, NC. It is a new facility
for Avery Dennison that we occupied recently. All information on the form is complete.
If there are any concerns or questions please respond at [phone] extension 3249,
Monday thru Friday 8:00am — 5:00pm.
Sincerely,
Mary Martin
EHS Coordinator
Avery Dennison — RIS
Greensboro, NC
Enclosures: No Exposure Certification for Exclusion

Re: ['lease respond to NCGNE0325 & NCGNE0329 again
Subject: Re: Please respond to NCGNE0325 & NCGNE0329 again
From: Corey Basinger <[e-mail]>
Date: Mon, 21 May 2007 09:15:44 -0400
To: Sarah Young <sarah.young@ncmai 1. net>
OK to issue 0329.
CI3
Corey Basinger
[e-mail]
NC DENR Division of Hater Quality
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
Fax [phone]
On 5/21/2007 9:15 AM, Sarah Young wrote:
16th Street Group -Facility Name: Avery Dennison PFL/HTL/Printer Systems
Corey Basinger wrote:
What is the name of the facility for 0329?
CB
Corey Basinger
Care .Basin ger a NCmail.net
NC DENR Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
[phone]
Fax [phone]
On 5/21/2007 9:12 AM, Sarah Young wrote:
thanks corey. just still need the one for ncgne0329. sorry about this. -sarah
Corey Basinger wrote:
I forwarded my original responses to this just a minute ago. Let me know if that's ok.
CB
1 of2 5/21/2007 9:17 AM