NCGNE0244_COMPLETE FILE - HISTORICAL_20110906

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE Oa 4
DOC TYPE
�L HISTORICAL FILE
DOC DATE
❑ -Doll O g o tP
YYYYM M DD

NC®ENit
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
September 6, 2011
JOHN R. FRAZIER JR.
TE CONNFCT[VI'I'Y
1396 CHARLOTTE HIGHWAY
FAIRVIEW, NC 28730-8544
Dee Freeman
Secretary
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0244
TE Connectivity
Formerly Tyco Electronics
1396 Charlotte Highway
Buncombe County
Dear Mr. Frazier:
The Division has reviewed your submittal of the permit name/ownership change form for the subject No -Exposure
Certification, which we received on June 30, 2011. Division personnel have reviewed and approved your request to transfer.
the exclusion from NPDES stormwater permitting requirements.
Please note that by our original acceptance of the no exposure certification and by our approval of your request to
transfer it, you are obligated to maintain no exposure conditions at your facility. If conditions change such that your
facility can no longer qualify for the 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.
Annual re -certification is required, and we have enclosed one blank Annual No Exposure Exclusion Self Re -Certification
form for your use. 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 the Stormwater Permitting Unit at [phone].
Sincerely,
for Coleen H. Sullins
cc: Asheville Regional Office
Stormwater Permitting Unit File's
Wetlands and Storrrwater Branch One
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 NorthCarofina
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 j
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748 ff// �Qtul''Qlly
Internet www.niwaterqualily.org �/
An Equal Opportunity 1 Affirmative Action Employer

1 • r
. • 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 $26,000 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 http://portal.ncdenr.org/web/wq/wsisu/npdessw#tab-5 )
- 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 conditions.
-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#tab-5

`o�aF WAT f Beverly Eaves Perdue, Governor
Dee Freeman, Secretary
>_ North Carolina Department of Environment and Natural Resources
O `C
Coleen H. Sullins, Director
Division of Water Quality
SURFACE WATER PROTECTIONSECTION
PERMIT NAME/OWN.ERS.HIP.CHANGE FORM:
Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C S A-L I I N I E 1 0 1 2 14 14
Permit status prior to requested change.
a. Permit issued to (company name): Tyco Electronics
b. Person legally responsible for pert -nit: John R. Frazier Jr.
First MI Last
To V o\" y l
c. Facility name (discharge):
d. Facility address:
EHS Coordinator II
Title
1396 Charlotte Highway
Permit Holder Mailing Address
Fairview NC 28730-8544
Cite state Zip
[phone] [phone]
Phone Fax
Tyco Electronics
1396 Charlotte Highway
Address
Fairview NC 28730-8544
City State Lip
e. Facility contact person: John R. Frazier Jr. [phone]
First / MI / Last Phone
Please Provide the following for the requested change (revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
X Name change of the facility or owner
If other please explain: Facility Contact name change
b. Permit issued to (company name): TE Connectivity
c. Person legally responsible for permit: John R. Frazier Jr.
JUN 3 0 2011
DE - WA H At
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
First MI Last
EHS Coordinator 11
Title
1396 Charlotte Highway
Permit Holder Mailing Address
Fairview NC 28730-8544
City State Zip
[phone] john.frazierpte.com
Phone E-mail Address
TE Connectivity
1396 Charlotte Highway
Address
Fairview NC 28730-8544
City State Zip
John R. Frazier Jr.
First M1 Last
[phone] john.frazierrrte.com
Phone E-mail Address
Revised 812008

s '•�r

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: John R. Frazier Jr.
First M I Fast
EHS Coordinator 11
Title
1396 Charlotte Highway
Mailing Address
Fairview NC 28730-8544
City State Zip
828 338-1004 john.frazier te.eom
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
X Yes
❑ No (please explain)
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
X This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature
APPLICANT CERTIFICATION
Date
1, John R. Frazier Jr., attest that this application for a name change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incom lete.
June 27, 2011
�Iignature Date
....................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 712008

MA ;,A
NC®ENR
North Carolina Department of Environment and Natural Resources --
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 8, 2010
JOHN R FRA%IER JR, F1I-IS COORDINATOR H
'tYCO EITCTRONiCS
1396 CHARLO'1'f1. HWY
FAIRVIEW NC 28730-8544
Dear Mr. Frazier:
Dee Freeman
Secretary
Subject: Name/Ownership Change Request
No Exposure Certification NCGNH 0244
Tyco Electronics
Formerly Tyco Electronics/CIID
1396 Charlotte Highway, Fairview
I3umcombe County
The Division has reviewed your submittal of the permit name/ownership change forni for the subject No -Exposure
Certification, which we received on September 9, 2010. Division personnel have reviewed and approved your request to
transfer the exclusion from NPDES stormwater permitting requirements.
Please note that by our original acceptance of the no exposure certification and by our approval of your request to
transfer it, you are obligated to maintain no exposure conditions at your facility. If conditions change such that your
facility can no longer qualify for the no -exposure exclusion, you are obligated to immediately obtain Nl'DI-S permit coverage
for your stormwater discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge.
Annual re -certification is required, and we have enclosed one blank Annual No Exposure Exclusion Self Re -Certification
form for your use. 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.
11-you have any questions or need further information, please contact the Stormwater Permitting Unit at [phone].
Sincerely,
fir Coieen I-1. Sullins
cc: Asheville Regional Office
Stormwater Permitting Unit Files
Wellands and Stormwater Branch One
1617 Mail Service Center, Ralegh, North Carolina 27699-1617 NorthCarol i na
Location; 512 K Salisbury St, Ralegh, North Carolina 27604
Phone: 91M07-63001 FAX: 91M07-64921 Customer Servim 1-877-623-6748 Aaturally
Internet: www,ncwaterqual4.org
An Equal Opportunity l Af€irmattve Action Ernp3oyer

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 annually as
- Complete the re -certification at a minimum of once per year using the included Self Re -
Certification Form.
(additional copies can be downloaded from http:llportal.ncdenr.org/web/wglws/su/npdessw#tab-5 )
- 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 conditions.
-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://porttit.ncdenr.org/web/wq/ws/su/tipdcssw#tab-5

J� Ir
`o�oF wATF9QG Beverly Eaves Perdue, Governor
tq Dee Freeman, Secretary
> North Carolina Department of Environment and Natural Resources
O�^C
Coleen H. Sullins, Director
Division of Water Quality
SURFACE WATER PROTECTION SECTION
PERMIT. NAMEIOWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N O S O
N 0 G N I E 10 2 4 4
H. Permit status prior to requested change.
a. Permit issued to (company name):
Tyco Electronics/CIID
b. Person legally responsible for permit:
Clinton D. Seevers
First MI Last
EHS Mana er
Title
~ 1396 Charlotte Highway
Permit ]-folder Mailing Address
Fairview NC 28730
City State Zip
[phone] [phone]
Phone Far'
c. Facility name (discharge):
Tyco ElectronicslCIID
d. Facility address:
1396 Charlotte Highway
Address
Fairview NC 28730
City State Zip
e. Facility contact person:
Clinton D. Seevers [phone]
First / MI / Last Phone
111. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
❑ Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain: Facility Contact name change
b. Permit issued to (company name):
Tyco Electronics
c. Person legally responsible for permit:
John R. Frazier Jr.
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
First MI Last
EHS Coordinator II
Title
1396 Charlotte Highway
Permit Holder Mailing Address
Fairview NC 28730-8544
City State, Zip
[phone] [e-mail] _
Phone E-mail Address
Tyco Electronics
1396 Charlotte Highway
Address
Fairview NC 28730-8544
City State Zip
John R. Frazier Jr.
First M1 Last
[phone] john.frazier atycoelectronics.com
Phone E-mail Address
Revised 8/2008

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
-- IV. Permit contact information (if different from the -person legally responsible for the permit)
Permit contact: John R. Frazier Jr.
First MI Last
EHS Coordinator 11
Title
1396 Charlotte Highway
W - Mailing Address
Fairview NC 28730-8544
City State Zip
[phone] john.frazierrrtycoelectronies.com
Phone F-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
X Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
X This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature
APPLICANT CERTIFICATION
Date
I, John R. Frazier Jr., attest that this application for a name change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
September 7, 2010
Yature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7l2008

_.�A 1N A T,`- Michael F. Easley, Governor
�D�O RpC. William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Dircoor
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
December 30, 2005
Mr. Clinton D. Seevers
Tyco Electron ics/CIID
1396 Charlotte Hwy.
Fairview, NC 28730
Subject: No Exposure Certification NCGNE0244
Tyco Electronics/CIID
1396 Charlotte Hwy., Fairview, NC
Buncombe County
Dear Mr. Seevers:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on September 15, 2005. 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 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 (December.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 Sarah Young at [phone], ext.
502, or at [e-mail].
cc: Asheville 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]
NCDENR
Customer Service
1-877-623-6748

Map of 1396 Charlotte Hwy Fairview, NC by MapQuest
Page i of 1
KA
k GA
�..r.J
1396 Charlotte Hwy Fairview, NC
28730-8544, US
All rights reserved. Use Subject to License/Copyright
This map is informational only. No representation is made or warranty given as to its content. User assumes all risk
of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use.
Web Offers:
• Schools + Real Estate • Hotels • Condos + Insurance
• Apartments + Home Mortgages + Rental Cars • Bed and Breakfast • New Cars
• Homes for Sale + Jobs • Travel • Airline Tickets + Digital Camera
http:l/www.mapquest.comlmapslmap.adp?searchtype=address&country=US&addtohistor... 10/25/2005

Issue NCGNE0244, 250, 25I, 252
Subject: Issue NCGNE0244, 250, 251, 252
From: <Sarah.Young@ncmaiLnct>
Date: Sun, 27 Nov 2005 23:50:37 -0500
To: "Sarah Young" <Sarah,[e-mail]>
Event reminder:
Issue NCGNE0244, 250, 251, 252
Date: 2005-11--28
Location:
I of 1 12/29/20(

NcGrvEoa{4- A
Form Approved
United States Environmental Protection Agency OMB No. 2040-0211
NPDES t1 Washington, DC 20460
FORM `` % EPA
NO EXPOSURE CERTIFICATION for Exclusion from
F all
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity Identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to 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, snowmeh, 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 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, the entity in Section A is certifying that a condition of no exposure exists at Its facility or she,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed InstrucUona for compFeting this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information nn �'+ T T n
1. Name: 1TIyC10 1�1Ie�� IGt,r,0 1',C,S, I�'I}IIIIP Ij�I��II II - I I ,I 12. Phone: 18 218,3131811 01010,
3. Mailing Address: a. Street: �111319I61 • IG�Iarl11c �^I 41`-'I Ili/ ••11' l.* I I I I I I I I I II I I I
b. Cityy: iFla1 i'r1v1 i1elwl 1 1 1 ! 1 1 1 11 1 1 I 1 1 c. State: NO d. Zip Code: 218E /�7 13101- I__t__1 1_ E
B. Faciiity/She Location information
1. Facility Name: Wtcg l&11e1Cltlrhon lICIS1�/,QI�IIIP_ I_ I I I I I I 1 1
2. a. StreetAddrrerss: 11,31916, jghajrllL`-'I itlef Il wll1' 1• I I I I I I 1 I II I I ice�, lI�,�,
b. City: L_Islljr�v%11�iw I I 1 _l _-! 1 11 1 1 1 1_ 1 1 l c.County: RUX1ICPln-1 —I'
d. State: Niq e. Zip Code: 12181 ! 13101 - 1 1 1 1 1
3. Is the facility located an Indian Lands? Yes No Crj Q A r'7 nn
b vV�4. Is this a Federal facility? Yes F-] No RI �
5. a. Latitude: 3,51 i3Ll b. Longitude: 8W J 07 f
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes No ❑ �� q
b. If yes, enter NPDES permit number: !'
7. SICIActivhyCodes: Primary: 3316t7 9� Secondary(ifapplicabis):
0
ti. Total size of site associated with industrial activity:3 1 . 0 6 5 acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes �✓ No
b. if 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 water discharges 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 thari one acre ✓Q One to five acres More than five acres
EPA Form 3510-11 (10-99) Page 1 of 4

.... :, r. r- _ ;. G. :q � d?A �- . - .•1 (' .. t. 1'I' UWj 11V, �F=�j ; L. d.»:. i
.1 , 1.3: I.7`' "o, i ;,'*i. 'a., J f u.. _�• , . I4 j -J.1 t ?y,. „ . pv, . , 1 41'
,.- JF+i,:.., .,�r,H ,,,ll., .,,I• yCN ..ni1•i' ytr, . . •i;, L" , t -q ,Jilt.t "A 11'YI• .Wt , j;1,nd'144 00t,. y it if ,. i,.tl-:'..j.t+. J I r:r l.n.e '
i
I0 w! '+'u'-Nh 17 _ i .; i] 'i',?:7[..Irir _+.. . IfiTrl��`, ilo.,rlN: .,CSC?Vl •!:A
{ (1 ;.li .rl. r'i. - `!' 1al F. 3 .- • V L`� -- _M,_ 1
.. , 1., '•s' rat 1. �' J1S=•]G.'(•�: CY' J , =:-1' a.� .h,l '1, I -
�. r'
� 4 LJc'v4Y, -t.�rut. _, 3t r�tl...._,.�...._.
(". ll; ., •J 1.t Al 'G!A _ ._� - . ti. _T - - -- - a,l �'� � r- i .' 1J a i .�• �' - -'-- - !�
T T'
'G'C',t' Wi TP {L+i F11�..•. � w"� .._ 1 y�- .-1,a1.., ,• ;_ - _�:{4�,�� •
1 E"'1E0 ODUL—L1utLtllJ9'i„
OF ,.:St; , Ito ("PIC4uIt. 1101, Ctlt1!"•tPipJ3 tilts C)u,1 SUy adi7icn,4 i1:r. W; c.a1:zWtV, d!'[jr-lx., UtO i)i.0,'47 4 Ci:7 LS+"le•Gd 7L L3 +~
t
I .:.+' • 11..-} rl '• cL , t- ' ,. ILI. Fs S '�,+Jy •+� :1: •; .1 :: t'' ,!�- t.
`, 7•"f sirl ,;Jt. - ��F.,r ,':E eta :It'llt-J.t.,';JS Li4lA'L, 1'r" ,.. .'F,1• L';I ... ,. p._•.It,'4. �;'.. .. i1C+' U'_;!+'- V
1
t .r r l Irk E1. sr41-t'7n q tntrra,;r I, ctil av-1:t ,r'rr u, . ., ,1. ., �: ..t, :,, Lc, e't ' to ,I•tu ,1,.r t. ryr I. 1
y •t..t-rt�i` . ,,:d ,.»c-.,,t.t. ar.',tr.l}'. �r,: ',a,• .'ja>3r>t r.. 1.' •. .1_+L1;', J ,.1f� * r�Y. , ,�r� „1_'Il.,. l�•. {
8( hV7l1•� ('.�. t ".;1',I :trt� U -, .�, yn y. . I r , 'Al
YZ - :I` r r '" . k,Er, .'r ,.� ,: .a; ,1• s . ,: ^ +trtfg114u' 74:+
f r.F=' ..: t, ..jr .,< ,i r.,I ...' I t, 1.:1i4 . . �.it:•1C'i, , .. '. nd;i .+
'Ut_ , �Lt. ��"i .'il • •r,ati t 1' t v I r. ,'r.r ti. 4. a 7 ., ,tt . �I I` -'4;3, A,
} r ',� . .,, (' b ':6 tAl .Y�+. L3 ,. t • It 1iJ�:7, . .. , .1'1•;� • . M... , [,r�rr. r,: - � t_": G1 t, .' e!lt!, q•+' ;I i- 1
" 4 III-t, d 1 i. Q . t i ti 1 'S1 : „ ., .l'.' ^.N,3 L , +' = r tW i
r L ,.(3 .. o 1' - . li' '1 6."1"1 will, (r. .•d? .r. ,'. ' , T r ,•1 s �n r t ; t ltl,' JS + A 'A
! u lair +L• .'ra r, . L r•, tr.^ tt i i i '. .ti*N.11 „ ., ;G I t 3,. ' . t.t , ' 1,rz i .., 3, L,uq 1 1 t, I ' tc' t:,r At.. L.
I _1 ar r+ , . r t ., i l ,J.l 44;}I ' W'A atl i}1PF Grate 1z�Cui ,7 C r , : r7c n,, n . , cT t, 4, art . t • i ,, y' ,h 11
4 '.ZL , 'A k+ ;L ! pA .'. Cll , t•,- 4++_ - 1V I:tHZ,t.: ,52 LOjrv`• .t #4, I1 r -' 'U [a C;t;rR1F lj s,GU' S . •.1•., rl , i Li.,
C iV r i
A0 bCCliI?� 4E�311 :fC �1:{)fJf dot sccf:t; a
�u �.0
{ s y;.r,;tA, ;, '{fP ji Jn :. rJJe 1j',>I QtU4S'lIt.. tf =i.
,

NPDES n NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
35110 11 �0EP� ` NPDES Storm Water Permitting DMs No. 2040 0211
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 ensurer "Yes" to any of these questions
(1) through (it), 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
✓0
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
El
❑✓
3. Materials or products from past industrial activity
Q
4. Material handling equipment (except adequately maintained vehicles)
Q
5. Materials or products during loading/unloading or transporting activities
6. Materials or products stored ouldoors (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
✓�
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑
✓❑
9. Waste material (except waste in covered, non -leaking containers [e.g,, dumpstersl)
Q
10. Application or disposal of process wastewater (unless otherwise permitted)
Q
11. 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
1). 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.
I certify under penally of law that there are n4 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)).
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 tine and imprisonment for knowing violations.
Print Name: V 9 r
Print Title;
Signature:
EPA Form 3510-11 (10-99) Page 2 of 4

Map of 1396 Charlotte Hwy Fairview, NC by MapQuest
Page I of I
J 1396 Charlotte Hwy Fairview, NC
28730-8544, US
All rights reserved. Use subject to License/Copyright
This map is informational only. No representation is made or warranty given as to its content. User assumes all risk
of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use.
Web Offers:
• Schools • Real Estate • Hotels • Condos • Insurance
• Apartments • Home Mortgages • Rental Cars • Bed and Breakfast* New Cars
• Homes for Sale • Jobs • Travel • Airline Tickets • D�cii ital Camera
http://www.mapquest.com/maps/map.adp?searchtypc=address&country=US&addtohistor... t0/25/2005