NCGNE0052_COMPLETE FILE - HISTORICAL_20050420

1N Sf2�U
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
Vg-ISTORICAL FILE
DOC DATE
❑ A no 5 a y �
YYYYMMDD

F W A T� Michael F. Easley, Governor
O RQi. William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural RCSOnrces
co r Alan W. Klimek, P. F. Director
Division of Water Quality
Q Coleen 1E. Sullins, Deputy Director
Division of Walcr Quality
April 20, 2005
Harry Meredith
Avery Dennison
2305 Soabar Dr
Greensboro, NC 27406
Subject: No Exposure Certification NCGNE0052
Avery Dennison - 2100 Summit Ave
Guilford County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on September 9, 2004. We apologize for the extended period
it has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. Based on your submittal and signed certification of no exposure at the above referenced facility
the Division is granting your certification 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 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure 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 Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files — wlattachments
Stormwater Permitting knit Files
V*A
NCDENft
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone] Customer Service
1-977-623.0749

W ArF
9QG
Michael F. Easley, Governor
William G. Koss Jr., Secretary
North Carolina Department of Environment and Natural Resources
`O��
�!1
Alan W. Klimek, 1'. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
November 28, 2005
Mr. Mike Kalbaugh
Avery Dennison
2100 Summit Avenue
Greensboro, NC 27405
Subject: No Exposure Certification NCGNE0052
Avery Dennison
2305 Soabar Drive, Greensboro, NC
Guilford County
Dear Mr. Kalbaugh:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on September 9, 2004. Based on your submittal and signed
certification of no exposure at the above referenced facility, the Division is granting your certification as
provided for under 40 CFR 126.22(g), which is incorporated by reference in North Carolina regulations. We
have revised the letter to indicate the correct address, and apologize for the confusion.
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 (October 31, 2010). At that time you must re -certify
with the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure 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 Sarah Young at [phone], ext.
502, or at sarah.young @ nemail.net.
cc: Winston-Salem Regional Office
Stormwater Permitting Unit Files
Sincerely,
for Alan W. Klimek, P.E.
Central Files — w/attachments
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
KDENK
Customer Service
1-877-623-6748

Michael F. Easley, Governor
William G. Ross Jr,, Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
April 20, 2005
Harry Meredith
Avery Dennison
2305 Soabar Or
Greensboro, NC 27406
Subject: No Exposure Certification NCGNE0052
Avery Dennison - 2100 Summit Ave
Guilford County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on September 9, 2004. We apologize for the extended period
it has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. Based on your submittal and signed certification of no exposure at the above referenced facility
the Division is granting your certification 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 car. 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 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure 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 Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files — wlattachments
Stormwater Permitting Unit Files
SA
WENR
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

NCC!N�"LG"
United States Environrnental Protection Agency
NPDES A Washington, DC 20460
FORM �`Wl ��� NO EXPOSURE CERTIFICATION for Exciusion f
3510-11
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit autl
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General
of a condition of no exposure.
' �Qo,2040 0?1
��O(�g fi�[Co.2oao 01
3-Storm water
the existence
A condition of no exposure exists at an industrial facility when 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. 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 without operational taps or valves;
adequately maintained vehicles used in material handling; and
— final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying !or the .no exposure exclusion. In addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual outfails. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for ih-e no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detai!ad instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator information A
1, Name: I� itir-If I DIZIAIAI 1 5IdIAI I I _I I I i I I 1 I LI I l l 2.Phone: 13 I: S I I T ISl1ISf-1I tI
3. Mailing Address: a, Street: I ;-1 310 1 SI Is I o i- I h I,�- I r- I 18 1 r-,I t I✓ le I I I I I I I I I I I I I I__ I
b. City- 161 r I e I Z JA I S I b I* lr 10 1 1 1 _i 1 1 a f 1 1 1 f I c. State: JA) I e-1 d. Zip Code: JAI 1 114 IQ 1 6 f- I I I I I
B. Facility/Site Location Information
1. Facility Name: 141 a l e If- Y L lb Iz I A I &I 11 5 16 1^ 1 1 1
2. a. Street Address: I B I S 10 1 N 1 I S l o l` l (, I— l r l I D t- l ti I✓ l e
b. City: I I I -, 1 r o C. County: I GI -1; 1 (1-Flo I' 41 1
d. State: ) J e. Zip Code: 1 -1 T 4 1 U 6 1 -
3. Is the facility located on Indian Lands? Yes ❑ No QI
4. Is this a Federal facility? Yes ❑ No
5. a. Latitude: 431J o 1 —r LiLJ b. Longitude: j1q, 1 4111
"
5. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No ❑
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: .ZI I T 1 SI J Secondary (if applicable): l I I I
S. Total size of site associated with industrial activity: acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to quality for the no exposure exclusion? Yes ❑ No
}
bAf yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm wate ischarges from your site are likely to have
an adverse impact bn water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10-99) - -
Page 1 of 4

Nf DES m Form Approved
F('-,rM :.EPA NO EXPOSURE CERTIFICATION for Exclusion from OMB No.2040.0211
351L.'11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or"No" in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spills leaks
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during loading/unloading or transporting activities
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
exposure to storm water does not result in the discharge of pollutants)
7. Wtaterials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger
9. Waste material (except waste in covered, nen-leaking containers [e.g., dumpsters])
10. Application or disposal of process wastewater (unless otherwise permitted)
it. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(i.e., under an air quality control permit) and evident in the storm water outflow
D. Certification Statement
Yes No
❑ Q
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 storm water permitting. ,
I certify under penalty of law that there are no discharges of storm water 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 submit a no exposure certification form once every five years to the NPDES permitting authority 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 NPDES permitting authority, 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. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water 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 beiief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the passibility
of fine and imprisonment for knowing violations.
Print Name: Ib I Q F r p i t tj 1,,-I i
Print Title:
Signature:
Date:
EPA Form 3510-11 (10-99) Page 2 of 4

ATm�Approved�
United Stales Environmental Protection Agency r�JCWM96,2040-002111
NPvES Washington, DC 20460 D 4 1
35110 11 Irk NO EXPOSURE CERTIFICATION for Exclusion SS�!�M� �Q 0 91
NPDES Storm Water Permitting W7\ S
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authdriza;ion for•ita•slorm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General PXN. `elo the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when 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,,4ansportation, 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 without operational taps or valves;
- adequately maintained vehicles used in material handling; and
- final products, other than producls that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be pmv,'ded for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting Is
available.on a facility -wide basis only, not for individual oi,tfalis. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligibie for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
I ALL INFORMATION MUST BE PROVIDED ON THIS FORM,
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information
1. Name: IAI✓Iejr- lyl IQIfIAIAIr15Id1AI--1 1 1 1 1_1 11 1 L_L 1 t I 12.Phone: 3 5 6�j 7 1 Tj 11 51 If
3. Mailing Address a: Street: 0 1 S g, 1 (6a- I C 6 Ir i i vjPLL I I I I i I I I I I I I I I
b. City. 16 JP (!_ e JA I S 16 o r 10 c. State: �C d. Zip Code: f oZl T 1`4 laj 61 - 1 I I I I
B. Facility/Site Location Information
1. Facility Name: A I v iz p e I A L&LLj 5 16 1^
2. a. Street Addres s: IT-f ISlol •1,61-1rI iAlrlt I✓Ie1 1 I I I_j I I I II! I 1�
b. City: r 5 fl a f d I Ic• County: I,GI lit ' I� 4+Ir0 1 r I -A 4
d. State: L� I r-1 e. Zip Code: 11ili4LO iQ -
3. Is the facil tv located on Indian Lands? Yes ❑ No
4. Is this a Federal facility? Yes ❑ No
5. a. Latitude: L911 J I b. Longitude: ❑J ��7J [I ' I !?
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No ❑
b. If yes, enter NPDES permit number: I
7. SVActivity Codes: Primary: �I SI�J Secondary (if applicable):
...5. Total size.of site associated,with industrial activity: _ i l SiS� acres .
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to quality for the no exposure exclusion? Yes ❑ No
b.,lf yes, please indicate approxirnatety how much area was paved or rooted over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm wale ischarges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre One to five acres More than five acres ❑
EPA Form 3510.11 (10-99) Page 1 of 4

:a
N!j M NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
Ft M `w., Epp OMB No. 20a0-021 1
35�11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) rf you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
Q
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spillstleaks
3. Materials or products from past industrial activity
❑
0
4. Material handling equipment (except adequately maintained vehicles)
❑
Q
5. Materials or products during loading/unloading or transporting activities
❑
f
6. Materials or products stored outdoors (except final products intended for outside use [e.g„ new cars[ where
exposure to storm water does not result in the discharge of pollutants)
7. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
R2
S. Materials or products handled/stored on roads or rallways owned or maintained by the discharger
9. Waste material (except waste in covered, non -leaking containers (e.g., durnpsters])
0
10. Application or disposal of process wastewater (unless otherwise permitted)
El
11. Particulate matter or visible deposils of residuals from roof stacks andlor vents not otherwise regulated
P1
(i.e., under an air quality control permit) and evident in the storm water outflo%v
D. Certification Statement
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 storm water permitting,
f certify under penalty of law that there are no discharges of storm water 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 submit a no exposure certification form once every five years to the NPDES permitting authority 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 NPDES permitting authority, 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. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water 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.
Print Name: I III", r l r I r l I i i I I I i l l i I I I I I I I i
Print Title:
Signature:
Date:
EPA Forrn 3510-1 i (10-99) Page 2 of 4