NCG050141_COMPLETE FILE - HISTORICAL_20121214

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ aolJ
YYYYMMDD

�F WA7,4
Permit Coverage N v �� i �4
Renewal Application Form
National Pollutant Discharge Elimination System Certificate of Coverage Number
Stormwater General Permit NCGO50000 NCG050000
Please complete the information in the space provided and return the completed renewal form to the address indicated
below.
Owner Information
* Address to which permit correspondence will be mailed
Owner / Organization Name: Exopack,LLC
Owner Contact:
Jerry Quesinberry
Mailing Address:
1308 Blair Street
Thomasville, NC 27360
Phone Number:
[phone]
Fax Number:
[phone] _
E-mail address:
[e-mail]
Facilitv Informatio
Facility Name:
Exopack,LLC
Facility Physical Address:
1308 Blair Street
Thomasville, NC 27360
Facility Contact:
Jerry Quesinbeny
Mailing Address:
1308 Blair Street
Thomasville, NC 27360
Phone Number:
[phone]
Fax Number:
[phone]
E-mail address:
[e-mail]
Permit Information
Permit Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
legy Quesinbegy
1308 Blair Street �� ���
Thomasville NC 27360 I) n
Discharge Information
Receiving Stream: Unnamed stream tributary of Yadkin river.
Stream Class: Branch
Basin: Yadkin -Pee Dee
Sub -Basin: Yadkin River
Number of Outfalls: 2
DEC x 4 2012
MNR - WATER {aUALITY
Facility/Activity Chanaes Please describe below any changes to your facility or activities since issuance of your permit. Attached a
separate sheet if necessary.
No changes to date.
CERTIFICATION
I certify that I am familiar with the information contained in the application and that to the best of my knowledge and belief
such information is true, complete and accurate.
Signature
1 i vi ki otrr^
Print or typ name of person signing a
Date
Eno irorlm en ct.l__%��tnQger
Title LJ
Please return this completed application form to: SW General Permit Coverage RenewalStormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617