NCGNE0817_COMPLETE FILE - HISTORICAL_20111021

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE U�� ✓�
DOC TYPE
❑HISTORICAL FILE
DOC DATE
O �UIu Ii D� I
YYYYMMDD

�7
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
Fred Comer
Pinnacle Furniture Co. Inc.
PO Box 147
Newton, NC 28658
Dear Mr. Comer, -
October 21, 2011
Subject: No -Exposure Certification NCGNE0�817
Pinnacle Furniture
20 E 19th Street
Newton, NC 28658
Catawba, County
Dee Freeman
Secretary
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, the site
visit of October 20, 2011 and written response, including pictures, to the compliance evaluation inspection performed on
August 11, 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. We are also hereby rescinding your current
permit Certificate of Coverage, NCG180060.
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; however, please retain records for review by DWQ at the 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 Donna Hood at [phone], or at
donna. [e-mail]
Sincerely,
for Coleen H. Sullins
cc'. Stormwater Permitting Unit No- Exposure Files (Cory Larsen)
Fran McPherson -Budget Office
Stormwater Permitting File NCG180060
Mooresville Regional Office One
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115 NorthCarolina
Phone: [phone] i Fax: [phone] Customer Service: 1-877-623-6748 ��
Internet: mwi.ncwaterqualit�rrall�
y.org Kl
An Equal Oppertuni[y 1 Affirmative Acton Enrptayer— 3n Recyctedrl0% Past Consumer paper

AS*
NCDENR
Nw— c ,o De rM * of
EKviROHMEart —D NRV Re .C[
Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
ANNUAL 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 (MM/DD/YYYY)
N I C I G I N I E I I I I / /
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. ncden r.org/web/wq/ws/su/npdessw#Application_Form s_NPDES)
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 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
j. 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
I. 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
6
SWU-NESR-29Ju12010

NCGNE0000 No Exposure Self Re -Certification -
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes ❑ 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 DWQ.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or ❑Yes❑ No ❑ NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? - If so, is it free of any [:]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 DWQ.
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.
❑Yes❑ No ❑ NIA
❑Yes❑ No ❑ NIA
[--]Yes[:] No ❑ NIA
❑Yes❑ No ❑ NIA
❑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? ❑ Yes [:]No
b. Does your facility have coal piles on site? 1 ❑ Yes ❑ No
Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes ❑No
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., ❑ Yes ❑ No
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? [:]Yes[:] No❑NIA
Please specify:
Page 2 of 3
SWU-NESR-29Ju12010

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)).
I understand that I am obligated to annually 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 (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 fagi . 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 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 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 DWQ unless requested.
Page 3 of 3
SWU-NESR-29JO2010

r
4 NA
NCBR F�LE
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
October 21, 2011
Fred Comer
Pinnacle Furniture Co. Inc.
PO Box 147
Newton, NC 28658
Subject: No -Exposure Certification NCGNE00817
Pinnacle Furniture
20 E 19th Street
Newton, NC 28658
Catawba, County
Dear Mr. Comer:
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, the site
visit of October 20, 2011 and written response, including pictures, to the compliance evaluation inspection performed on
August 11, 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. We are also hereby rescinding your current
permit Certificate of Coverage, NCG180060.
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; however, please retain records for review by DWQ at the 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 Donna Hood at [phone], or at
[e-mail]&
Sincerely,
for Coleen H. Sullins
cc'. Stormwater Permitting Unit No- Exposure Files (Cory Larsen)
Fran McPherson -Budget Office
Stormwater Permitting File NCG180060
Mooresville Regional Office One
Location: 610 East Center Ave., Suite 301 Mooresville, NC 28115 Noy thCat olina
Phone: [phone] Fax: [phone] Customer Service: 1-677-623-6748 ����llY�
Internet'. mm-ricwaterquality.org Na
An Equii Opportunity i Affirmative Acon Emp;oyer - 30% Racycled110% Rost Consumer paper

Division of Water Quality / Surface Water Protection
NCDENR
NonT Co,- DeP T*EnT or
Enviao« mo Narvn RE Rcm
National Pollutant Discharge Elimination System
ANNUAL 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 (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
hftp:llportal. ncdenr.org/web/wglwslsu/npdessw#Application_Forms_N PDES)
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 and/or 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 1 of 3
SWU-NESR-29Jul2010

NCGNE0000 No Exposure Self Re -Certification
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes ❑ 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 DWQ.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or [:]Yes[] No ❑ NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑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 DWQ.
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.
❑Yes❑ No ❑ NIA
❑Yes❑ No ❑ NIA
[:]Yes[:] No ❑ NIA
❑Yes❑ No ❑ NIA
[:]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.?
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 ❑ No
[]Yes ❑ No
❑ Yes ❑No
❑ Yes ❑ No
❑Yes❑ No❑N/A
Page 2 of 3
SWU-NESR-29Ju12010

NCGNEOOOO 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)).
I understand that I am obligated to annually 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 (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 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 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 DWQ unless requested.
Page 3of3
SWU-NESR-29Ju12010

A
FOR .AGENCY USE ONLY �
AiF Rrce
°AK � Division of Water Quality 1 Surface Water Protection VA Year Date�Receired Day
KI
D
�� National Pollutant Discharge Elimination System Cenitica:eofcoverage
�i NCG air
NO EXPOSURE CERTIFICATION for Exclusion DIVISION OF WATER QUALITY
frrr vrr�r ..r,u Hcvr� r �a.::�cFa
NCGNE0000
OCT 14 2011
NO EXPOSURE CERTIFICATION SWP SECTION
p�r1QRFS;/�1.1 C f3rC'�� 'AI. gFFICE
National Pollutant Discharge Elimination System application for exclusion from a 5tormwater Permlt`b�ase
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
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_facilify qualifying for the no exposure exclusion. In
addition, the exclusion from NPDES permitting is available on 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-certifV your No Exposure Exclusion annually.
For questions, please contact the DWQ Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of owner/operator addreSs to
Name t)/x ri fie , h '(
Contact
Street Address
City
Telephone No. 4
Email o 4rin
Page 1 of 7
ion corresr)ond
State' IVJ�ZIP Code
Fax:
7 0
OCT 1 0 2911
DENR - WATER DUALITY
WEiLWDS AND STORMWNATER BPAKH
SWU-NE-12Aug2010

NCGNE0000 'No Exposure Certification
2) Location of facility 1
Facility Name
Facility Contact
Facility Street Addres
City
County
Telephone No,
Email
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state roa numbers, and
distance apd direction from a roadway intersectioA).
(A copy of a map with the facility clearly located on it should be irzcludecl'with the certification application.)
'4) Is the facility located on Native American Lands? ❑ Yes,No
5) Is this a Federal facility? ❑ Yes )?�No
6) Latitude 3Sd y0,N)Longitude ��f � 3/ AI1 V�/ (deg.,'min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
Existing Date operation began
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes ❑ No
If yes, .what is the NPDES Permit Number?—Na & 1 20_0�2
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: �z y
10) Provide a brief description of the types of industrial activkties and products produced at this facility:
i
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
k No
tl Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7
SWU-NE-12Aug2010

NCGNE0000 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.") 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 K
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
�ll No
' \
e. Materials or products during loading/unloading or transporting activities
❑ Yes
No
I. Materials or products stored outdoors (except final products intended for outside
© Yes
J 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
,f No
and similar containers
"1
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)
El Yes
No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
❑ Yes
1 No
otherwise regulated (i.e., under an air quality control permit) and evident in the
11
stormwater outflow
I. 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)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers
❑ Yes`]
No
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): It 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 XNIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
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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
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?
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 f0owing information:
Type(s) 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 ❑ No NIA
❑ Yes ❑ No X NIA
❑ Yes ❑ No X NIA
❑ Yes © No X1 NIA
0 Yes ❑ No 'NIA
❑ Yes No
❑ Yes No
❑ Yes No
*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 do 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 §1 17.3.
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NCGNE0000 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 required.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside?
❑ Yes kN 0
b. Does your facility have coal piles on site?
© Yes WNo
c. Does your facility store other fuel sources outside in piles, such as wood chips,
❑ Yes �No
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
❑ Yes No
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?
U Yes ❑ 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:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
v�
`NCG fgooco ;g ,
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NCGNE0000 No Exposure Certification
17) 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 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 tfle industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to annually self re -certify No Exposure and, if requested, submit the re -certification to
DWQ 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 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 there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing 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 accurat .
Printed Name of Person Signing:
(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 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).
There is currently no fee for a No Exposure Exclusion.
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NCGNE0000 No Exposure Certification
Final r'hae'klict
This application should include the following items:
2/ This completed application and all supporting documentation.
pJ A map with the location of the facility clearly marked.
l� If 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 DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office
...[phone]
Wilmington Office .-.
[phone]
Winston-Salem ...,..,
[phone]
Central Office ......: [phone]
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