NCGNE0589_COMPLETE FILE - HISTORICAL_20161122

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE OSC�
DOC TYPE
❑HISTORICAL FILE
DOC DATE
❑
YYYYMMDD

Energy, rtlinerat
and Land Resources
ENVIRONMEN T FL. OUAL.IT-
Division of Energy, Mineral and Land Resources
Land Quality Section — Stormwater Permitting
National Pollutant Discharge Elimination System �dV D,.h 2z?016
ANNUAL NO EXPOSURE EXCLUSION SELF RE-CERTIFICATIOND
NCGNE0000 'V+VVArERPSRM1rrNc
Do not submit this form to DEMLR unless requested.
For questions, please contact the DEMLR Regional Office for your area or the Central Office.
(Please print or type)
Facility's No Exposure Exclusion No. Date Completed (MM/DD/YYYY)
N I C I G I N I E 1 0 5 1 8 1 9 1 1 1 / 1 1 1 7 1 / 1 2 0 1 1 6
1) Has the facility name or owner changed? ❑ Yes X No
(if yes, please submit a separate Name/Ownership Change Form to DEMLR located at:
http://deg.nc.,qovlabout/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-permits/npdes-
industrial-sw )
2) Are any of the following materials or activities exposed to precipitation,. now or in the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible to maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where [:]Yes X No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks
❑ Yes
X No
c. Materials or products from past industrial activity
❑ Yes
X No
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes
X No
e. Materials or products during loading/unloading or transporting activities
❑ Yes
X No
f. Materials or products stored outdoors (except final products intended for outside
❑ Yes
X No
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks,
❑ Yes
X No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
❑ Yes
X No
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes
x No
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
x No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes x No
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑ Yes x No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
Page 1 of 3
SWU-NESR-3May2016

NCGNE0000 No Exposure Self Re -Certification
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes x No
stored outside, has the facility had any releases in the past three (3) years?
3) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible to maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or X Yes No NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any X Yes No NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
4) Secondary Containment: If you answer "No" to any of the following items, you are not eligible to
maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Is secondary containment provided for all single above ground storage
containers (including drums, barrels, etc.) with a capacity of more than 660-
gallons?
b. Is secondary containment provided for above ground storage containers stored
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund
Amendments and Reauthorization Act (SARA) water priority chemicals*?
d. Is secondary containment provided for hazardous substances** designated in 40
CFR §116?
e. Are release valves on all secondary containment structures locked?
Footnotes to Questions 4) c. & d.
X Yes No ❑ NIA
X Yes No ❑ NIA
X Yes No ❑ NIA
X Yes No ❑ NIA
X Yes No ❑ NIA
*Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require secondary containment.
However, some exceptions may be made for de minimis amounts of certain substances, and/or other qualifiers, as described in the exemptions
from reporting requirements of Title III SARA 313 in 40 CFR §372.38.
"Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require secondary containment.
However, some exceptions may be made for amounts less than the Reportable Quantities of the hazardous substances listed in 40 CFR
§117.3.
5) Other information: If you answer "Yes" to any of the following items, and the answer if different from
how it was answered when originally applying, you might not be eligible to maintain your no exposure
exclusion. Please contact the Division if this is the case.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside?
b. Does your facility have coal piles on site?
c. Does your facility store other fuel sources outside in piles, such as wood chips,
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality
Permit? Please specify:
❑ Yes X No
❑ Yes X No
❑ Yes X No
❑ Yes X No
[:]Yes[:] No❑NIA
Page 2 of 3
SWU-NESR-Way2016

NCGNE0000 No Exposure Self Re -Certification
6) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no
exposure" and obtaining/maintaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater 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)).
understand that 1 am obligated to annually self re -certify No Exposure and, if requested, submit this re -certification to
DEMLR or 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 North Carolina Division of Water Quality, 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.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater 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 to assure that qualified personnel properly gath-Bred and evaluated the informa*ion provided. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information provided is to the best of my knowledge and belief true, accurate and complete. I am aware
that there are significant penalties for providing false information, including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this document and that to the best of my knowledge and belief
such information is true, complete, and accurate.
Printed Name of Person Signing: �' C `� >✓ i� v i ! T
Title: 6 i K- l l 1'Za �C• F��T
[ 1-17,1G
(Signature) (Date Signed)
Please note: the Regional Office may inspect your facility at any time in the future for
compliance with the No Exposure Exclusion.
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).
This completed form must be kept on file at the facility for at least 5 years. Do not submit this
form to DEMLR unless requested.
Page 3 of 3
SWU-NESR-3May2016

AigL*A.
NC®ENR
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
April 16, 2009
Mr. Eric Blankenship, General Manager
Union Corrugating
101 Lexington Street
Spencer, NC 28159
Resources
Subject: No -Exposure Certification NCGNE0589
Union Corrugating — Spencer Division
Rowan County
Dear Mr. Blankenship:
Dee Freeman
Secretary
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES Stormwater
Permitting form. Based on your submittal and signed certification of no exposure at the above referenced facility, the
Division is granting your conditional exclusion from permitting as provided for under 40 CFR 12622(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 16, 2014). At that time you must re -certify with the Division, or
obtain NPDES permit coverage for any stormwater discharges from your facility.
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 Mr. Michael Parker at [phone], or at
Michael. [e-mail].
Sincerely,
for Coleen H. Sullins
cc: Mooresville Regional Office
Stormwater Permitting Unit, No -Exposure Files
Wetlands and Stormwaler Branch
1617 Maii Service Center, Raiegh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: 9IM07-6300 1 FAX: [phone] Customer Service: 1-877-623-6748
intemeL www rimaterquality.org
I- C......i f5..­. ;k, 1 Aif,­l;,,. A fin CmrJn
Nor thCarolina
;Vaturallry

7-;YA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
April 16, 2009
Mr, Eric Blankenship, General Manager
Union Corrugating
101 Lexington Street
Spencer, NC 28159
Subject: No -Exposure Certification NCGNE0589
Union Corrugating -- Spencer Division
Rowan County
Dear Mr. Blankenship:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES Stormwater
Permitting form. Based on your submittal and signed certification of no exposure at the above referenced facility, the
Division is granting your conditional -exclusion from permitting 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 16, 2014). At that time you must re -certify with the Division, or
obtain NPDES permit coverage for any stormwater discharges from your facility.
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 Mr. Michael Parker at [phone], or at
Michael. [e-mail].
Sincerely,
for Coleen H. Sullins
cc: Mooresville Regional Office
Stormwater Permitting Unit, No -Exposure Files
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] L FAX: [phone] Customer Service: 1-877.623-6748
lntemet: www.ncwaterqua4lty.org
NonhCarolina
Naturally

NCIDENR
fhWN�iM7.�T LM ;jAll1N. f'.fr7tfYl0
Division of Water Quality 1 Surface Water Protection
National Pollutant Discharge Elimination System
NO EXPOSURE CERTIFICATION for Exclusion
NCGNEoaoo
TOR 7OFNCY U58 ONLY
DoteRceiLs -�.
Year Nnah Day
3
ccii ium orcoM
L'LCLQJba& In
NO EXPOSURE CERTIFICATION Pleasa check here if this is a renewal., ❑ RENEWAL
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit based
on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notification that your facility does not require a
permit for stormwater discharges associated wlth industrial activity in the State of North Carolina because
It qualifies for a no exposure exclusion_ A condition of no exposure at an industrial facility means all
Industrial materials and activities are protected by a storm resistant shelter (with some exceptions) to
prevent exposure to rain, snow, snowmelt, and/or runoff.
For permitted facilities in North Carolina, DWQ must approve your application for No
Exposure Certification before this exclusion is effective. Until you are issued a No
Exposure Certification and your NPDES permit Is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
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, lnmrmedlate product, final product or waste product. A storm resistant shelter Is t
required for the folio wing industrial materials and activities: drums, barrels, tanks, and similar con
that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed" m
banded or otherwise secured and with locked or non -operational taps or valves; adequately mainta �e
vehicles used in material handling; and final products, other than products that would be mobilize
stormwater discharges (e.g.,, rock salt).
A No Exposure Certification must be provided for eacl)'ftility qualifying for the no exposure excl m . In
addition, the exclusion from NPDES permitting is avallable on a facility -wide basis only —not for in ualt
outfalls. if any Industrial activities or materials are, or will be, exposed to precipitation, the facility t--
eligible for the no exposure exclusion. By signing and submitting this No l�xposure Certification f�
certify that a condition of no exposure exists at this facility or site and are obligated to comply with the
terms and conditions of 40 CFR 122.26(g).
You are reQuired to reapp!y for the No Exposure Exclusion once every five (5) years.
For questions, please contact the DWQ 14egional oftice for your area. (See page 6)
(Please print or type)
1) Mailing address of i
Name
Contact
Street Address
City
Telephone No.
Page 1 of 7
MAR Z 0 ?n,ng
SWU-NE-021309 Last reviaad 211SMD09
D`� -Su U-, ' ti GiOr Pro'coi-on

NCGNE0000 No Exposure'Certification
2) Location of facility producing discharge:
Facility Name
Facility Contact
Street Address
City
County
Telephone No.
3) physical location Information:
State,,,,, ZIP Code
Fax:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway Intersection).-rAXE EXIT 74 0, �ovrN
7UlN_J711,�r a -OLr 6a 7D Z"`��-7cG.��iTT��d/7�ur�T Td�.v .ergT 0'l Lt,YlnK70N -�
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Dative American Lands? G Yes M'PIa
5) Is this a Federal facility? ❑ Yes ii 1Ca
6) Latitude 351°iq J6 W_ Longitude �0 Zs�/8 ~w (deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility
IW' Existing
Date operation Is to begin
Date operation began / �&' S
d Renewal of existing No Exposure Certification Certification No•: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? 2'fes ❑ No
If yes, what is the NPDES Permit Number? If/CC 030,000 — Ni�60.3dSZ j Mrf-
n {,1
9) Standard industrial Classification: s y
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary Industrial
activity at this facility
SIC Code:.3
10) Provide a brief description of the types of industrial activities and products produced at this facility:
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
�a
El Yes
It yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7
SWU-NE-021309 Last revised 2/IMD09

NCGNE0000 No Exposure Certification
Ex oaure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or In the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion. a. Using, storing, or cleaning industrial machinery or equipment, and areas where © Yes V<O ❑ NIA
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or In stormwater Inlets from spills/leaks
c. Materials or products from past industrial activity
d, Material handling equipment (except adequately maintained vehicles)
e. Materials or products during loading/unloading or transporting activities
f. Materials or products stored outdoors (except final products intended for outside
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks,
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
the discharger
❑ Yes W o ❑ N/A
❑ Yes 7<0 0 NIA
❑ Yes tlrt`lo ❑ N/A
❑ Yes M`i��va ❑ NIA
❑ Yes ®'No ❑ NIA
❑ Yes li <0 ❑ NIA
❑ Yes F o Q NIA
1. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters)) Cl Yes &'No o NIA
J. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes M'Na ❑ NIA
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes " ❑ NIA
otherwise regulated (i,e., under an air quality control permit) and evident in the
stormwater outflow
1, Empty containers that previously contained materials that are not properly stored ❑ Yes Vfvo i + NIA
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m- for any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes 2<01 © N/A
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or V es ❑ No ❑ NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any es ❑ No Q NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SWU-NS-021309 Last revised 2/13/2009

NCGNEQ00p No Exposure Certification
14) Secondary Containment: If you answer "No" to any of the following Items, you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for single above ground storage containers
2'Ye5 ❑ No ❑ NIA
(including drums, barrels, etc.) with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored
7Yes ❑ No ❑ NIA
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund
940s © No ❑ NIA
Amendments and Reauthorization Act (SARA) water priority chemicals"?
d. is secondary containment provided for hazardous substances"' designated in 40
tiYYes ❑ No ❑ NIA
CFR §116?
e. Are release valves on all secondary containment structures locked?
21 s ©No © NIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes VI(O ❑ NIA
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes 0<0 0 NIA
generated per month) of hazardous waste?
c. is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste O Yes 2r<O ❑ NIA
generated per month) of hazardous waste?
If you answered yes to questions b. or c,, please provide the following Informatlon:
Type(s) of Waste:
How is materlal stored:
Where is material stored: _
How many disposal shipments per year:
Name of transport / disposal vendor: _
Vendor address:
Footnotes to Questions 14) C. & d.
'Note that amounts below the 560-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SARA 313 In 40 CFR
§372.38.
"Note that amounts below the 660-9allon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR §117.3.
Page 4 of 7
SWU NE; 021309 Last revised 2113/2009

U.:)/ UYo GUUJ 1 r . Jv WC- I "11W Jn Gu .+ ' _U
NCGNEOOOO No Exposure Certification
16) Other information: If you answer `Yes" to any of the following items, you might not be eligible for the
no exposure exclusion. A more In-depth evaluation of the site circumstances may be requird
a_ Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes ;�� ❑ NIA
b. Does your facility have coal piles on site? ❑ Yes M'Na ❑ NIA
c. Does your facility store other fuel sources outside in piles, such as wood chips, © Yes 6a'No ❑ NIA
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., ❑ Yes ❑ NIA
degreasing operations, plating, painting and metal finishing)? It so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit? o Yes o No ❑ NIA
Please specify: _
f, Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit; Program:
Permit: Program:
Permit. , Program:
Permll: Program:
Permit: , Program:
Permit: _ Program:
Permit: Program.
Page 5 of 7
SWU-NE•021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
17) Certificatfoni
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 stormwater permuting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials from the industrial facfllty or site Identified In this document (except as allowed under 40 CFR 122.2G(g)(2)).
I understand that i am obligated to submlt_a no e(cation form once every tivo(5) veaCs to the North Carolina
Division of Water Quality 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 North Carolina Division of Water
Quality, or MS4 operator where the discharge is into the local MS4, to perform inspectlons to confirm the condition of no
exposure and to mako such inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that l must obtain coverage under
an NPDI~S permit prior to any point source discharge of stormwater from the facility. Additlonally, 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 to assure that qualified personnel 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 thorn are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
i certify that I am famillar 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: �� %�- �L1i✓uX��Sf7fl!' _ ___
rtle: C7EivEii� L /�i/fi✓-4C�EI2
(Signature ofApplioant)
3 12- 0 q
(Date Signed)
Please note: 'This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
Inspect your facility at any time in the future for compliance with the No Exposure Exclusion.
North Carolina General Statute 143-215.6 13(1) provides that:
Any person who knowingly makes any false statement, reprepentatlon, or certllicaticn in any applicatlon, record, report, plan, or other
document filed or required to be mainialnod under thits Article or a rule implamemIng thfs Article; or who knowingly makos a false
statement of a material fact In a rulemaking proceeding or contested case undar this Article: or who falsfflcs, tampers with, or knowingly
renders Inacourale 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 Glass 2 misdemeanor which may Include a fine
not to exceod ten thousand dollars ($10.000).
There is currently no fee for a No Exposure Exclusion.
Page 6of7
SW U-NE-021309 fast revised 2/13/2009

•..v• yam. a,vyJ a..vy Ja ivy, V'tJ� YTL4 F'II IL ..,111F4 LI\I-11 lVll 11"I4 L.- VV! VV
NCCNE0000 No Exposure Certification
Final Checklist
This application should Include the following Items:
© This completed application and all supporting documentation.
D A map with the location pf the facility clearly marked.
❑ li this is a renewal, indicated ourrent NCGNE number in Question 7.
❑ It the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number In Question 8.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the Issuance of a No Exposure Exclusion.
For questions, please contact the i7WQ Regional Office for your area.
DWGI_Reglonal Office Contact Information`
Asheville Office. _..
[phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office ...(252)
946-6481
Wilmington Office ..,
[phone]
Winston-Salem ......
[phone]
Central Office .........(919)
807-6300
Page 7 of 7
SWU-NE•021309 Last revised 211312009