NCG030579_ROS Request (Recevied by FRO)_20211213

RECEIVED
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DEC 13 2021
vision of Energy, Mineral & Land Resources
DE
Stormwater Program
Y wills Regional Office
µ National Pollutant Discharge Elimination System
Environmental REPRESENTATIVE OUTFALL STATUS (ROS)
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FOR AGENCY USE ONLY
Date Received
Year
Month
Day
REQUEST FORM
If a facility is required to sample multiple discharge locations with very similar stormwater discharges, the
permittee may petition the Director for Representative Outfall Status (ROS). DEQ may grant Representative
Outfall Status if stormwater discharges from a single outfall are representative of discharges from multiple
outfalls. Approved ROS will reduce the number of outfalls where analytical sampling requirements apply.
If Representative Outfall Status is granted, ALL outfalls are still subject to the qualitative monitoring
requirements of the facility's permit —unless otherwise allowed by the permit (such as NCG020000) and DEQ
approval. The approval letter from DEQ must be kept on site with the facility's Stormwater Pollution
Prevention Plan. The facility must notify DEQ in writing if any changes affect representative status.
For questions, please contact the DEQ Regional Office for your area (see page 3).
(Please print or type)
1) Enter the permit number to which this ROS request applies:
Individual Permit (or)
2) Facility Information:
Owner/Facility Name Schindler Elevator Corp.
Facility Contact
Street Address
City
County
Telephone No.
Duwayne Grimm
609 Industrial Dr.
Clinton
Sampson
910 590-5403
Certificate of Coverage
ti_,C. ;�0 3 0 0 0 0
11/C 6,O 3as"7i
State NC ZIP Code 28328
E-mail Address [e-mail]
Fax: [phone]
3) List the representative outfall(s) information (attach additional sheets if necessary):
Outfall(s)X C- is representative of Outfall(s)te 6
Outfalls' drainage areas have the same or similar activities? • Yes ❑ No
Outfalls' drainage areas contain the same or similar materials? a Yes ❑ No
Outfalls have similar monitoring results? ■ Yes ❑ No ❑ No data*
Outfall(s)z1,5_:� is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities? ■ Yes ❑ No
Outfalls' drainage areas contain the same or similar materials?
m Yes
❑ No
Outfalls have similar monitoring results?
■ Yes
❑ No ❑ No data*
Outfall(s) is representative of Outfall(s)
Outfalls' drainage areas have the same or similar activities?
❑ Yes
❑ No
Outfalls' drainage areas contain the same or similar materials?
❑ Yes
❑ No
Outfalls have similar monitoring results?
❑ Yes
❑ No ❑ No data*
*Non-compliance with analytical monitoring prior to this request may prevent ROS approval. Specific
circumstances will be considered by the Regional Office responsible for review.
Page 1 of 3
SWU-ROS-2009 Last revised 12/30/2009

Representative Outfall Status Request
4) Detailed explanation about why the outfalls above should be granted Representative Status:
(Or, attach a letter or narrative to discuss this information.) For example, describe how activities and/or
materials are similar.
Outfall B is sheet runoff from the roof and loading dock.Similiar, Outfall C is sheet run off from the parking lot with stored finished product.
Outfall D is sheet runoff from the roof. Similiar Outfall E is sheet runoff from the roof and parking lot.
5) Certification:
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record,
report, plan, or other document filed or required to be maintained under this Article or a rule implementing this
Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case
under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device
or method required to be operated or maintained under this Article or rules of the [Environmental Management]
Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed
ten thousand dollars ($10,000).
I hereby request Representative Outfall Status for my NPDES Permit. I understand that ALL outfalls are still
subject to the qualitative monitoring requirements of the permit, unless otherwise allowed by the permit
and regional office approval. I must notify DEQ in writing if any changes to the facility or its operations
take place after ROS is granted that may affect this status. If ROS no longer applies, I understand I must
resume monitoring of all outfalls as specified in my NPDES permit.
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: Duwayne A. Grimm
Title: EH&S Specialist
(Signature Applicant) r`
/-V o luau
(Date Signed)
Please note: This application for Representative Outfall Status is subject to
approval by the NCDEQ Regional Office. The Regional Office may inspect your
facility for compliance with the conditions of the permit prior to that approval.
Final Checklist for ROS Request
This application should include the following items:
❑ This completed form.
❑ Letter or narrative elaborating on the reasons why specified outfalls should be granted representative
status, unless all information can be included in Question 4.
❑ Two (2) copies of a site map of the facility with the location of all outfalls clearly marked, including the
drainage areas, industrial activities;.and raw materials/finished products within each drainage area.
❑ Summary of results from monitoring conducted at the outfalls listed in Question 3.
❑ Any other supporting documentation.
Page 2 of 3
SWU-ROS-2009 Last revised 12/30/2009

EscoAcAor Plc.nt RECEIVE®
DEC 13 2021
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