NCGNE0764_COMPLETE FILE - HISTORICAL_20110328

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

NCDENR
North Carolina Department: of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Jim Sipe
Carolina Foam, LLC
15 West Holly Street
Maiden, North Carolina 28650
Dear Mr. Sipe:
Divisicn cf'OIaier 'uality
Coleen ,', Sullins
0irector
March 23, 2011
Dee Freeman
Secr�tar�
Subject: No -Exposure Certification NCGNE0764
Carolina Foam, LLC — Maiden Plant
15 West Holly Street, Maiden, NC 28650
Catawba County
The Division has reviewed your submittal of the No -Exposure Certification form for Exclusion from NPDES Stormwater
Permitting. Based on your submittal and signed certification of no exposure at the above referenced facility and the site
visit of March, 10, 2011, the Division is granting your conditional exclusion from permitting as provided for under 40
CFR 122.26(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.
You must self re -certify your No -Exposure status annually using the included form or obtain NPDES permit
coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted to DWQ unless requested.
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 Marcia Allocco at [phone], or at [e-mail].
Sincerely,
�� } ,c-,
for Coleen H. Sullins
cc:
Stormwater Permitting Unit No- Exposure Files (Brian Lowther)
APR 0 4 2011
Mooresville Regional Cifce
Location: 510 East Center Ave., Suite 301 Mooresville. NC 28115
Phone: [phone] Fax: (704) 66MO401 Customer Service: 1-877-623-6748
Internet: www.ncwaterqualit .org
NorthCarofina
A17tul-ally

Permit: NCGNE0764 Effective
SOC: Effective
County: Catawba
Region: Mcoresville
Contact Person: Jim Sipe
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Compliance Inspection Report
Expiration: Owner: Carolina Foam LLC - Maiden Plant
Expiration: Facility: Carolina Foam LLC
15 W Hclly St
Title:
.Inspection late: 03/1012011 Entry Time: 09:30 AM
Primary Inspector: Marcia Allocco
Secondary Inspector(s):
Maiden NC 28650
Phone: [phone]
Certification
Exit Time: 09:40 AM
Phone:
Phone: [phone]
Ext.2204
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ■ Compliant n Not Compliant
Question Areas:
® Miscellaneous Questions
(See attachment summary)
Page: 1

No -Exposure Self Re -Certification information:
You are obligated to maintain no -exposure* conditions at your facility. If conditions chance 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. State statute provides for fines of up to $25,000 per day for
un-permitted discharges.
Your conditional no -exposure exclusion must be self re -certified at least annually as follows:
- Complete the re -certification at a minimum of once per year using the included Self Re -
Certification Form_
{additional copies can be downloaded From httpJlpertal.ncdenr_org/webhr;gl.orslsu/npdessv:7No_Exposure_!iPDES }
-.tulaintain a record of re -certifications on file at the facility. Do not submit the re -certification to
DWQ unless requested. If requested, submit a copy of the re -certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or iocal government, provide the re -certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes, or if
the facility can no longer maintain no -exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
""No exposure" means that all industrial materials and activities are protected by a storm resistant shelter to
prevent exposure to rain, snow, snowmeft, 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. (40 CFR 122.26(g))
Information and forms related No -Exposure Certifications can be accessed on the website at:
http://portal.ncdenr.org/web/wq/ws/su/npdessw#No_Exposure—NPDES
Rev. 28J u120 i 0

NCDNR
W_wTh �-1JN �:�CYI
Division of Water Quality I Surface Water Protection
National Pollutant Discharge Elimination System
ANNUAL NO EXPOSURE EXCLUSION SELF RE -CERTIFICATION
N CGNT0004
Do not submit this form to DWQ unless requested.
For questions, please contact the DWQ Regional Office for your area or the Central Office.
(Please print or type)
Facility's No Exposure Exclusion No. Bate Completed (MM/DD/YYYY)
N I C I G I N I E /
1) Has the facility name or owner changed? ❑ Yes ❑ No
(if yes, please submit a separate Name/Ownership Change Form to DWQ located at
http://portal. ncdenr.org/web/wq/ws/su/npdess,rr#Appl ication_Forms_N P D ES)
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 DWQ.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes ❑ 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 ❑ No
c. Materials or products from past industrial activity - ❑ Yes ❑ No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes ❑ No
e. Materials or products during loadinglunloading or transporting activities ❑ Yes ❑ No
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes ❑ 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 ❑ No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes ❑ No
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters]) ❑ Yes ❑ No
j. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes ❑ No
k. Particulate matter or visible deposits of residuals from roof stacks andlor vents not ❑ Yes ❑ No
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 ❑ No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
Page t of 3
SWU-NESR-29JU2010

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 conditicn of "no
exposure" and obtaining/maintalning an exclusion from NPDES stormwater permitting.
I certify under penalty of law that :here are no discharges of stormwater ccntaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 CPn t 22.26(g)(2))
I understand that I am obligated to annuatly self re -certify No Exposure and, if requested, submit this re -certification to
DWQ or the operator of the local municipal separate storm sewer system (tvIS4) into which the facility discharges (where
applicable). I understand that I must allow the North Carolina Division of Water Quality, or MSI 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
taw 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 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:
Title:
(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 whe 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 Glass 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 DWO unless requested.
Page 3 of 3
SWU-NE5R-29Ju12010

a
WDENR
North Carolina Department of Environment and
;2ivisicn of VNater Cl:aliEy
everly E--ves '.perdue Coleen ,-L Sullins
Governor Director
March 28, 2011
Mr. Jim Sipe
Carolina Foam, LLC.
15 West Holly Street
Maiden, North Carolina 28650
Natural Resources
Dee Freeman
Sec*etar/
Subject: No -Exposure Certification NCGNE0764
Carolina Foam, LLC - Maiden Plant
15 West Holly Street, Maiden, NC 28650
Catawba County
Dear Mr. Sipe:
The Division has reviewed your submittal of the No -Exposure Certification form for Exclusion from NPDES Stormwater
Permitting.. Based on your submittal and signed certification of no exposure at the above referenced facility and the site
visit of March, 10, 2011, the Division is granting your conditional exclusion from permitting as provided for under 40
CFR 122.26(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.
You must self re -certify your No -Exposure status annually using the included form or obtain NPDES permit
coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted to DWQ unless requested.
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 Marcia Allocco at [phone], or at [e-mail].
Sincerely,
for Coleen H. Sullins
cc:
Stormwater Permitting Unit No- Exposure Files (Brian Lowther)
Mooresville Regional Office One
Location: 610 East Center Ave , Suite 301 Mooresville, NC 28115 NorthCarolina
Phone: [phone] Fax: (704) 663a401 Customer Service: 1-877-623-6748 NaturallyInternet: www.ncwaterquality.org .

Permit: NCGNE0764
SOC:
County: Catawba
Region: Mooresville
Contact Person: Jim Sipe
Directions to Facility:
System Classifications:
Primary ORC:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Compliance Inspection Report
Effective: Expiration: Owner: Carolina Foam LLC - Maiden Plant
Effective: Expiration: Facility: Carolina Foam LLC
15 API Holly St
Title:
Inspection Date: 03/10/2011 Entry Time: 09:30 AM
Primary Inspector: Marcia Allocco
Secondary Inspector(s):
Maiden NC 28650
Phone: [phone]
Certification
Exit Time: 09:40 AM
Phone:
Phone: [phone]
Ext.2204
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ® Compliant f] Not Compliant
Question Areas:
® Miscellaneous Questions
(See attachment summary)
7�
Page: 1

No -Exposure Self Re -Certification Information:
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. State statute provides for fines of up to $25,000 per day for
un-permitted discharges.
Your conditional no -exposure exclusion must be self re -certified at least annual) as follows:
- Complete the re -certification at a minimum of once per year using the included Self Re -
Certification Form.
(additional copies can be downloaded trom http://portal.ncdenr.orghveb/,r:glvls/su/npdesswnNo_Exposure_NPDES )
- Maintain a record of re -certifications on file at the facility. Do not submit the re -certification to
DWQ unless requested. If requested, submit a copy of the re -certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or local government, provide the re -certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes; or if
the facility can no longer maintain no -exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
""No exposure" means that 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. (40 CFR 122.26(g))
Information and forms related No -Exposure Certifications can be accessed on the website at:
http://portal.ncdenr.org/web/wq/ws/su/npdessw#No—Exposure_NPDE S
Rev. 28,1u12010

C®ENR
Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
AINNUAL NO EXPOSURE EXCLUSION SELF RE -CERTIFICATION
NCGNE0000
Do not submit this form to DWQ unless requested.
For questions, please contact the DWQ Regional Office for your area or the Central Office.
(Please print or type)
Facility's No Exposure Exclusion No. Date Completed (rv1M/DD/YYYY)
N C I G N I E
1) Has the facility name or owner changed? ❑ Yes ❑ No
(if yes, please submit a separate Name/Ownership Change Form to DWO"located at
http://portal. ncdenr.org/web/wq/ws/su/n pdessw#Appl ication_Forms_NPD ES)
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 DWQ.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes ❑ No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormvvater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes ❑ No
c. Materials or products from past industrial activity ❑ Yes ❑ No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes ❑ No
e. Materials or products during loading/unloading or transporting activities ❑ Yes ❑ No
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes ❑ 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 ❑ No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes ❑ No
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters]) ❑ Yes ❑ No
]. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes ❑ No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes ❑ No
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
L Empty containers that previously contained materials that are not properly stored ❑ Yes ❑ No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
Page 1 of 3
SWU-NESR-29Jui2010

NCGNE0000 No Exposure Self Re -Certification
6) Certification:
f cerify under penally of law that I have read and understand the eligibility requirements far claiming a condition of "no
exposure" and obtaining/maintaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law :hat there are no discharges cf stormwater contaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 GR= 122.26(g)(2)).
I understand that I am obligated to annually self re -certify No Exposure and, 4 requested, submit this re -certification to
DWQ or the operator of the local municipal separate storm sewer system (MSA) into which the facility discharges (where
applicable). I understand that ! must allow the North Carolina Division of Water Quality, or M54 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 gathered and evaluated the information 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 informatlon, 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:
Title:
(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 maces a taise
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsities, 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 4lanagementl 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 DWO unless requested.
Page 3 of 3
SWU-NESR-29Ju12010

FOR AGFNCY USi:
• U='t Itecci�cJ
+ Division of Water Quality / Surface Water 1'rotection tau i n1m�n Day
2-f t l
',:.Id iclac x covrracc
�C® ,4 \'c�tio�tal l'c�fluttuit Discharge E�lin�ination System N I -. 1, - Q, µ p
NO EXPOSU1Z[��C(Ei(1�T�1F�IC(�>l>/T�IlON fc++ >✓rclusic�n DIVISION OF WATtR QUALITY
r..: n^..�•,., .r+uasw nr, �.ra4 1\T l.. L7i�ITl�l1 �iU �i
FEB 2 2 2011
NO EXPOSURE CERTIFICATION SWP SECTION
National Pollutant Discharge Elimination System application for exclusion from a St�rQrRit+�lPe�rt�igL OFFICE
on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notification that your facility does not require a
permit for stormwater discharges associated with 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, 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 4
banded or otherwise secured and with locked or non -operational taps or valves; adequately maintained
vehicles used in material handling; and final products, other than products that would be mobilized in
stormwater 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 an a facility -wide basis only —not for individual
outfalls, 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, you
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 self re -certify your No Exposure Exclusion annually.
For questions, please contact the DWO Regional Office for your area. (See page 6)
(Please print or type)
1) (:4ailing address of owner/ erator ddress to which all certification Correspondence will be mailed):
Narni c Ca ro /i .n -L
Contact TTr'" 5f e _ —
Street Address !.S WeSf' Holt 574ee
city Made', I- —� State NC ZIP Code -48 6 Jr,6
Telephone No, S 2-6 q 5-9 — /0 36 Fa:c 87-8 Lf Yr-17 1 ! 0 y
Email
Page i of 7 FEB I I
2011
SVIU-NE-12Aug2010 DENR " ,
Wetla
wt►ATEK QUALTY

NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name Caro/1.ia Foam, LLC - Maldeg p14., �~ -
Facility Contact ' ." 5t p.e _
Facility Street Address S West- 6�Elk Strc{
City M� �y _ State _ il! C- ZIP Code 7-
County c-a' 6 4-
Telephone No. 07-8 L "— 10 3 4- Fax: 8 ZS Ys"— !I o y
Email
3) Physical location information:
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). 5-e a t4,LAa-c17 IL A ,
(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 Native American Lands? 0 Yes d6l0
5) Is this a Federal facility? O Yes to
6) Latitude 35'* 3 `i 1'i. z t "/-' Longitude 91 � 13 a`f• (2 w(deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
0 New or Proposed Facility
Existing
Date operation is to begin
Date operation began 33 Znoo
0 Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? 0 Yes (S No
If yes. what is the NPDES Permit Number?
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 3 4 0
10) Provide a brief description of the types of industrial activities and products prod ed at this facility:
Nl a., k �xt cf� rei t�a.6rara led _J-10/VL4o-e- {-ssaof
Co ^iA�•�CH�S �r' c r�iJ`t�re t� [��$ t7"'y .
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
J No
t6zks
It yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7
SWU-NI-12Au92010
AIC
No. ��o75Rof

NCGNEOOOO No Exposure Certification
Exposure 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.") 11 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 0 Yes GYNo
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 IV40
c. Materials or products from past industrial activity
❑ Yes
rX0
d. Material handling equipment (except adequately maintained vehicles)
fa Yes
1"0
e. Materials or products during loading/unloading or transporting activities
© Yes
iRl!No
I. Materials or products stored outdoors (except final products intended for outside
❑ Yes
5ANO
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
g. Matcrials contained in open, deteriorated or leaking storage drums, barrels; tanks,
❑ Yes
WNo
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
0 Yes
tit<
the discharger
Waste
Yes
i. material (except waste in covered, non -leaking containers (e.g., dumpsters])
❑
v- No
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
ti:40
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
❑ Yes
VK//D
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
k Empty containers that previously contained materials that are not properly stored
0 Yes
IV No
(i e., not closed and stored upside down to prevent precipitation accumulation)
�o
m. For any exterior ASTs. as well as drums, barrels, tanks, and similar containers
C3 Yes
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 and piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No - <tA
deter ioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any © Yes 0 No &-4A
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SwU-NE-r2Aug20iO

NCGNE0000 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 all single above ground storage
❑ Yes
//
G No - N/A
containers (including drums, barrels, etc.) with a capacity of more than 660-
gallons?
b. Is secondary containment provided for above ground storage containers stored
0 Yes
© No f>XN/A
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
❑ Yes
❑ No r--A/A
Amendments and Reauthorization Act (SARA) water2riority chemicals'?
d, is secondary containment provided for hazardous substances- designated in 40
❑ Yes
❑ No IiAUA
CFR §116?
e. Are release valves on all secondary containment structures locked?
❑ Yes
0 No ' 3 A
15) Hazardous Waste:
a. is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste
generated per month) of hazardous waste?
c. is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Types) of waste: . -- -
How is material stored: Where is material stored__
How many disposal shipments per year:
Name of transport; disposal vendor:
`vendor address:
Footnotes to Questions '14) c. & d.
❑ Yes Ufa
o Yes taKo
❑ Yes VfO
" No, e 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 is 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 fcr amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR §117.3,
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NCGNE0000 No Exposure Certification
16) Other information: It 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 required.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? r,_.3' Yes DV40
b. Does your facility have coal piles on site? ❑ Yes Cvf 0
c. Does your facility store other fuel sources outside in piles, such as wood chips. 73 Yes �o
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
degreasing operations, plating,
painting and metal finishing)? so, describe the
industrial activity: S r"
LIf
rA_dhesti4c OA[/es.oL31
e. If you answered yes to d., are those
emissions permitted by an Air Quality Permit?
Please specify: _ AAQQ&Qerna,`f-
Na, O a p
I. Please list any other environmen'al
program permits (federal, state, etc.) not
specified earlier in this application
(such as Hazardous Waste Permits, etc.):
Permit:
Program:
Permit.
Program:
Permit:
Program:
Permit:
Program:
Permit:
Program:
Permit:
Program:
Permit:
Program:
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SWU-N E. 12Aug 20 t o
VY es ❑ No
tV<'es 13 No L3 N/A

NCGNEOOOO No Exposure Certification
17) Certification:
I cerlily under penalty of law that t have read and understand the eligibility requirements for claiming a condition of "no
exposure" and obtaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormavaler contaminated by exposure to industrial activitir~s
or materials from the industrial facility or site fderntiffed in this document (except as allowed under 40 CFR t 22.21
understand that I am obligated to annuals self re -certify No Exposure and, if requested, submit the re -certification to
DINO 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 fvAS4, 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 oofnsource discharge of stomlwater from the facility. Additionally, I certify under penaify of
taw 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 oil 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
knotiLing violations.
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_ T1 m 5 p
Title: MC&,nLZ e,-
(Sirnarur of Applicant) (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 B(i) provides that:
Any person wild �nowfilgly makes any false statement, representation, or certification in any appticaainn, record, report, plan, or other
(JoCurne .l hied or required to be maintained under this Article or a rule implementing this Article; or who lkno%vingly makes a false
statement at a material fact in a rulernaking proceeding or contested case under this Article; or veho falsifies, tampers with: or trnowingiy
renders inaccurale any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
lEnwronmeniat K-tanagernent) Commission irrrparnenling this Article shall be guilty el a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars {.$Io,000).
C-- There is currently no fee for a No Exposure Exclusion..,
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NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
This completed application and all supporting docuanentation.
U/ A map with the location of the facility clearly marked.
C. If the site currently has an NP17ES Stormwater Permit, be sure to indicate the permit number in Question 8.
Mail the entire package to:
Storniwaier 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 OWO Regional Office for your area.
DWO Regional 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
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