NCG110167_Application_20251021

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FOR AGEN Y USE ONLY
NCG1' rtj
Assigned to: S. COOV\
ARO FRO MRO RRO WARD WIRO W'SRO Q
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Division of Energy, Mineral, and Land Resources Land Quality Section r' EE
National Pollutant Discharge Elimination System
NCG310000 Notice of Intent U N W
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This General Permit covers STORMWATER DISCHARGES associated with activities classified as:Treatmekworks
treating domestic sewage or any other sewage sludge of wastewater treatment device or system, used ilWe
storage, treatment recycling,and reclamation of municipal or domestic sewage, with a design flow of 1.0 million o
gallons per day or more, or required to have an approved pretreatment program under Title 40 Code of federal
Regulations(CFR)Part 403, including lands dedicated to the disposal of sewage sludge that is located within the
confines of the facility;and like activities deemed by DEMLR to be similar in the process and/or the exposure of
raw materials,products, by-products, or waste materials. You can find information on the DEMLR Stormwater
Program at deq.nc.gov/SW.
Directions: Print or type all entries on this application. Send the original,signed application with all required
items listed in Item (6) below to: NCDEMLR Stormwater Program, 1612 MSC, Raleigh,INC 27699-1612. The
submission of this application does not guarantee coverage under the General Permit. Prior to coverage under
this General Permit a site inspection will be conducted.
1. Owner/Operator(to whom all permit correspondence will be mailed):
Name of legal organizational entity: Legally responsible person as signed in Item(7)below:
Liquid Environmental Solutions Tom Hillstrom
Street address: City: State: Zi Code:
7651 Esters Blvd, Suite 200 Irving TX 7063
Telephone number: Email address:
[phone] [e-mail]
Type of Ownership:
Government
❑County ❑Federal ❑Municipal ❑State
Non-government
CK Business(If ownership is business,a copy of NCSOS report must be included with this application)
❑ Individual
2. Industrial Facility(facility being permitted):
Facility name: Facility environmental contact:
Liquid Environmental Solutions Louis Humphrey
Street address: City: State: Zip Code:
750 Palmer Lane Winston-Salem NC 27107
Parcel Identification Number(PIN): County:
6833-69-3681 Forsyth
Telephone number: Email address:
[phone] [e-mail]
4-digit SIC code: Facility is: Date operation is to begin or began:
495: 1 [] New ❑ Proposed M Existing
Latitude of entrance: Longitude of entrance:
K 36, 3' 3" 1 7 W, �s0a Q>' liCq
Page 1 of 5

Brief description of the types of industrial activities and products manufactured at this facility:
Non-hazardous liquid waste collection, hauling, recycling, processing, and treatment
If the stormwater discharges to a municipal separate storm sewer system(MS4),name the operator of the MS4:
❑ N/A Winston-Salem MS4
3. Consultant(if applicable):
Name of consultant: Consulting firm:
Caleb Couch Alta Environmental & Infrastructure
Street address: City: State: Zip Code:
4940 S. Wandler Dr. Suite#150 Tempe AZ 85282
Telephone number: Email address:
480-656-1517 caleb.couch altaei.com
4. Outfali(s)At least one outfall is required to be eligible for coverage.
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
Unnamed Stream N/A ❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
36°03'01.0"N 80013'49.7"W
Brief description of the industrial activities that drain to this outfall:
Unloading/receiving
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑ Yes ❑No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
3-4 digit identifier: Name of receiving water: Classification: ❑This water is impaired.
❑This watershed has a TMDL.
Latitude of outfall: Longitude of outfall:
Brief description of the industrial activities that drain to this outfall:
Do Vehicle Maintenance Activities occur in the drainage area of this outfall? ❑Yes ❑ No
If yes,how many gallons of new motor oil are used each month when averaged over the calendar year?
All outfalls must be listed and at least one outfall is required.Additional outfalls may be added in the section
"Additional Outfalls"found on the last page of this N01.
Page 2 of 5

S. Other Facility Conditions (check all that apply and explain accordingly):
❑This facility has other NPDES permits.
If checked,list the permit numbers for all current NPDES permits:
❑This facility has Non-Discharge permits(e.g. recycle permit).
If checked,list the permit numbers for all current Non-Discharge permits:
X)This facility uses best management practices or structural stormwater control measures.
If checked,briefly describe the practices/measures and show on site diagram:
secondary containment for>55 gal.containers,spill kits, overhead/flow protection, routine site inspections
N This facility has a Stormwater Pollution Prevention Plan(SWPPP).
If checked, please list the date the SWPPP was implemented:September 2025
❑This facility stores hazardous waste in the 300-year floodplain.
If checked,describe how the area is protected from flooding:
❑This facility is a(mark all that apply)
❑ Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked,indicate:
Kilograms of waste generated each month: Type(s)of waste:
How material is stored: Where material is stored:
Number of waste shipments per year: Name of transport/disposal vendor:
Transport/disposal vendor EPA ID: Vendor address:
❑This facility is located on a Brownfield or Superfund site
If checked,briefly describe the site conditions
6. Required Items(Application will be returned unless all of the following items have been included):
K Check for$120 made payable to NCDEQ
$I Copy of most recent Annual Report to the NC Secretary of State
KI This completed application and any supporting documentation
KI A site diagram showing,at a minimum,existing and proposed:
a) outline of drainage areas
b) surface waters
c) stormwater management structures
d) location of stormwater outfalls corresponding to the drainage areas
e) runoff conveyance features
f) areas where industrial process materials are stored
g) impervious areas
h) site property lines
91 Copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 3 of 5

7. Applicant Certification:
North Carolina General Statute 143-215.68(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...shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).
Under penalty of law,I certify that:
ffi I am the person responsible for the permitted industrial activity,for satisfying the requirements of this permit,and for any
civil or criminal penalties incurred due to violations of this permit.
Bl The information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,and complete based on
my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the
information.
K] I will abide by all conditions of the NCGIIOODO permit.I understand that coverage under this permit will constitute the
permit requirements for the discharge(s)and is enforceable in the same manner as an individual permit.
J�J I hereby request coverage under the NCGI10000 General Permit.
Printed Name of Applicant: Tom Hillstrom
Title: Vi resi Treatment O rations
4/3a/z s
(Signature of Appli (Date Signed)
MaiItheentirepac eto: DEMLR—Storm water Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh,NC 27699-1612
Page 4 of 5

Jwi
IrA.j LIMITED LIABILITY COMPANY ANNUAL REPORT
V6 022
NAME OF LIMITED LIABILITY COMPANY: Liquid Environmental Solutions of Georqia, LLC
Filing Office Use only
SECRETARY OF STATE ID NUMBER: 1440562 STATE OF FORMATION: DE E-Fled Annual Reped
taw5e2
CA202503607711
REPORT FOR THE CALENDAR YEAR: 2025 2;sr202507:32
SECTION A:REGISTERED AGENTS INFORMATION ❑Changes
1.NAME OF REGISTERED AGENT: Corporation Service Company
2.SIGNATURE OF THE NEW REGISTERED AGENT:
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS&COUNTY 4.REGISTERED AGENT OFFICE MAILING ADDRESS
2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550
Raleigh, NC 27608 Wake County Raleigh, NC 27608
SECTION B:PRINCIPAL OFFICE INFORMATION
1.DESCRIPTION OF NATURE OF BUSINESS: Non-hazardous liquid waste collection,hauling,recycling,processing,.and treatment
2.PRINCIPAL OFFICE PHONE NUMBER: [phone] 3.PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS 6.PRINCIPAL OFFICE MAILING ADDRESS
7651 Esters Blvd Suite 200 7651 Esters Blvd Suite 200
Irving,TX 75063 Irving,TX 75063
6.Select one of the following if applicable. (Optional see instructions)
❑ The Company is a veteran-owned small business
❑ The company is a service-disabled veteran-owned small business
SECTION C:COMPANY OFFICIALS(Enter additional company officials in Section E)
NAME: Toffy Rosback NAME: Brian Bidelspach NAME: Jerry Sheridan
TITLE: Manager TITLE: Manager TITLE: Manager
ADDRESS: ADDRESS: ADDRESS:
7651 Esters Blvd Suite 200 7651 Esters Blvd Suite 200 7651 Esters Blvd Suite 200
--Irving,-TX 75063- Irving,TX 75063 Irving,TX 75063
SECTION D:CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Mike Smith 2/5/2025
SIGNATURE DATE
Form must be signed by a Company Official listed under Section C of This form.
Mike Smith Manager
Print or Type Name of Company Offcal Print or Type Title of Company Official
MAILTO:Secretary of State, Business Registration Division,Post Office Box 29525.Raleigh,NC 276260525

SECTION E: ADDITIONAL COMPANY OFFICIALS
NAME: Troy Fee NAME Mike Smith NAME: c�gwa��� o.,�smmao:cu,poariau
TITLE: Manager TITLE: Manager TITLE: Member
ADDRESS: ADDRESS: ADDRESS:
7651 Esters Blvd Suite 200 7651 Esters Blvd Suite 200 7651 Esters Blvd Suite 200
Irving,TX 75063 Irving,TX 75063 Irving,TX 75063
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: - NAME: Name:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:
NAME: NAME: NAME:
TITLE: TITLE: TITLE:
ADDRESS: ADDRESS: ADDRESS:

KEY
10 Office 3a 1,000-Gallon SIS Water
ank
2 EleWical Room
33 Mier Roan 0 Tm,anter(CE400)
36 Heat Exohanger(2)
- _- -- 1 a Processing O
5 Rewivin9 (2)B -Gallllon Pre Min Tan
well
6 Maintenance
Scomma(2TOU1) ao F eCabiret
13 Empty Duum1` tom,8 Tole$lora9e q1 Reshoom I ; 9 Misc.Stowe
Fire
10 Palling Nee rwinguisher
Q First
1 it Waste Sta Mo Nee
1 1 9 Syll Kit
@ Wastewater Menitonng Pont
®Drains
1 ; i3 SomlWsaed Gas Cylinder ®Flume Drain
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104�
W B���ater Chemical •Bdlard
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15 EyewasNShower
1 \ I Chemical Drum Storage
Area^ Concrete
O 1 16 Used Oil Stooge•• O NaW ca e Landspe
i) 9T6(kallon PaH Di aNe esel Fuel L-, NdNre Sail
= Roll-UP Door
era T 108 6,000-Ga11on Lime Foy PST
• I is 25.000-Gallon Sentinel AST Fence
(TK-0O-G.11 —Wall ntainment
iO j 1 20 25.000-Gallon S.minel AST Wall
•O (tK4M2)- 163'D ment Pit
31 ® 30 Oj 16, 3 2TS, oo-canon$anr 9l AST __1 " a 17 _�— 1 tTK-003)••• -Nee BourWary
` � • , 35 27 36 36 33 1,000-Gallan Cdoker(C!( 0) ---BAoppr .ate Site
1 • ` 20, 1ap((O 100)Raw Material Eodosad Building
N 1 . w 28 37 I 21
I � lAOST on)Heated Grease ®Framtli Drain
2 02
U) I+' . © 25 38 I 1 ]s 1,000-Gellan Cleaned Grease cont.tmo.m
Y I I Surge AST(TK-105)
55-Ga1flon Oil Drum
O O J I 26 2 000.Gallon Raw Matenal Storage
L I 32 I AST(TK-202) '
I I 1 1 » DoublaWalletl
O I 4O 1 I ]T Gallon Grease$team AST construction
I AST(TK-301)
41 41 iq O O i 26 AST(cK405)inisbetl Grease
2 12 1 1 2B 2WGaIt..Water Steam roe„
I Surge AST(TK-310)
M 20 wloa Brown Grease
I 10_ 1 Surge AST(TKd01)
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