NCGNE1491_Application_20210824

FOR AGENCY USE ONLY
NCGNE I Li l I
Assigned to: A ceLf> '
ARO FRO MRO RRO WARO WIRO SR��� ry
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
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No Exposure Certification for Exclusion
NCGNE0000
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. Industrial materials or activities include, but are not limited to:
• material handling equipment or activities, • by-products,
• industrial machinery, • final products, or
• raw materials, • waste products.
• intermediate 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 industrial materials stored in the following container types, provided
the containers are not deteriorated and do not leak:
• drums, • tanks, and
• barrels, • similar containers.
For permitted facilities in North Carolina, DEMLR 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rescinded, your facility must continue to abide by the terms and conditions of the current permit.
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. Additionally,
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).
If approved, your conditional No Exposure Certification has no expiration date but must be self -recertified at least
annually. Please look for information about recertification under the No Exposure section on this page:
https://deg. nc.gov/about/divisions/energy-mineral-Ian d-resources/npdes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 1612 MSC, Raleigh, NC 27699-1612. The submission of this form does not guarantee
exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a site
inspection will be conducted.
Pa OP 1 of S

1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person (as signed in Item 7 below):
Tempur Sealy International
Firas Sakkijha
Street address:
City:
State
Zip Code
239 Sealy Drive
Trinity
NC
27370
Telephone number:
Email address:
[phone]
[e-mail]
Type of Ownership:
Government
❑ County ❑ Federal ❑ Municipal ❑ State
Non -government
Business (If ownership is business, a copy of NCSOS report
must be included with this application)
❑ Individual
2. Industrial Facility (facility requesting exclusion):
Facility name:
Facility environmental contact:
Sealy High Point Plant
Jorge Carrninelli
Street address:
Telephone number:
239 Sealy Drive
[phone]
Email address:
[e-mail]
City
County
State
Zip Code
Trinity
Randolph
NC
27370
Latitude of entrance: 35° 54' 28.3494" or 35.907875
Longitude of entrance: 79' 59' 34.7598" or 79.992989
Parcel Identification Number (PIN):
7708567185
Date operation began:
Standard Industrial Classification (SIC) Code:
1998
2515
Brief description of the types of industrial activities and products produced at this facility:
Light industrial, high quality mattress assembly
3. Consultant (if applicable):
Name of consultant:
Consulting firm:
Jeffrey R. Kowalski, P.G.
KF Environmental, LLC
Street address:
City:
State and zip code:
4293 Marjorie Road
Snellville
GA 30039
Telephone number:
Email address:
(678) 777-4
[e-mail]
4. Exposure Checklists
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future? If you
answer "Yes" to any of these items, you are not eligible for the no exposure exclusion.
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
stormwater
❑ Yes 0 No ❑ N/A
Materials or residuals on the ground or in stormwater inlets from spills/leaks
❑Yes 0 No ❑N/A
Materials or products from past industrial activity
❑ Yes El No ❑ N/A
Material handling equipment (except adequately maintained vehicles)
[I Yes El No ❑ N/A

Materials or products during loading/unloading or transporting activities
[I Yes El No ❑ N/A
Materials or products stored outdoors (except final products intended for outside use [e.g., new
cars] where exposure to stormwater does not result in the discharge of pollutants)
[I Yes 0 No ❑ N/A
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks,
and similar containers
❑ Yes El No ❑ N/A
Materials or products handled/stored on roads or railways owned or maintained by the discharger
[I Yes El No ❑ N/A
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
❑ Yes El No ❑ N/A
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
[--]Yes 0 No ❑ N/A
Application or disposal of process wastewater (unless otherwise permitted)
[--]Yes El No ❑ N/A
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 stormwater outflow
❑ Yes No ©N/A
Empty containers that previously contained materials that are not properly stored (i.e., not closed
and stored upside down to prevent precipitation accumulation)
❑Yes [] No ❑ N/A
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has
the facility had any releases in the past three (3) years?
❑ Yes El No ❑ N/A
'Sealed means banded or otherwise secured and with locked or non -operational taps or valves.
Above Ground Storage Tanks (ASTs) and Secondary Containment
If you answer "No" to any of the following items, you are not eligible for the no exposure exclusion.
Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or deterioration, or
®Yes ❑ No El N/A
evidence of leaks?
Is secondary containment provided for all exterior ASTs? If so, is it free of any cracks, holes, or
[:]Yes []No El N/A
evidence of leaks, and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers (including drums,
El Yes ❑No 0 N/A
barrels, etc.) with a capacity of more than 660-gallons?
Is secondary containment provided for above ground storage containers stored in close proximity
❑Yes []No [El N/A
to each other with a combined capacity of more than 1,320 gallons?
Is secondary containment provided for Title III Section 313 Superfund Amendments and
❑Yes [I No 0 N/A
Reauthorization Act (SARA) water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
❑Yes ❑No 0 N/A
Are release valves on all secondary containment structures locked?
El Yes ❑ No 0 N/A
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.
Are vehicles used in material handling in disrepair and/or leaking fluid?
❑ Yes El No ❑ N/A
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
El Yes ❑ No ❑ N/A
Does this facility have coal piles on site?
❑Yes 0 No ❑ N/A
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
0Yes El No ❑ N/A

Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, ❑ Yes 0 No ❑ N/A
plating, painting, or metal finishing)?
If yes:
Describe the industrial activity:
Are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No
Please specify:
5. Other Facility Conditions (check all that apply and explain accordingly):
❑ This facility has other NPDES permits.
If checked, list the permit numbers for all current NPDES permits:
❑ This facility has Non -Discharge permits (e.g. recycle permit).
If checked, list the permit numbers for all current Non -Discharge permits:
❑ This facility stores hazardous waste in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility is a (mark all that apply)
❑ Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility
If checked, indicate:
• Kilograms of waste generated each month:
• Type(s) of waste:
• How material is stored:
• Where material is stored:
• Number of waste shipments per year:
• Name of transport/disposal vendor:
• Transport/disposal vendor EPA ID:
• Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site.
If checked, briefly describe the site conditions:
❑ This facility is located on Native American Lands.
6. Required Items (Application will be returned unless all of the following items have been included):
I] Copy of most recent Annual Report to the NC Secretary of State (if applicable)
EI This completed application and any supporting documentation
0 Copy of county map or USGS quad sheet with the location of the facility clearly marked

7. Applicant Certification
North Carolina General Statute 143-215.6E (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
17 I am the person responsible for the industrial activity, for satisfying the requirements of this exclusion, and for any civil
or criminal penalties incurred due to violations of this exclusion.
El I have read and understand the eligibility requirements for claiming a condition of "no exposure' and obtaining an
exclusion from NPDES stormwater permitting.
p 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)).
0 I understand that I am obligated to maintain no exposure conditions and complete a Self -Recertification form at least
once each year and, if requested, provide this certification to the operator of the local municipal separate storm sewer
system (MS4) into which the facility discharges (where applicable). I understand that I must allow the North Carolina
Division of Energy, Mineral, and Land Resources, or MS4 operator where applicable, to perform inspections to confirm
the condition of no exposure and to make such inspection reports publicly available upon request. I understand I must
keep a copy of annual recertifications on file at the facility.
O I understand that in the event that the site no longer qualifies for a No Exposure Exclusion that I must obtain coverage
under an NPDES permit prior to any point source discharge of stormwater from the facility.
El The information submitted in this NO] is, to the best of my knowledge and belief, true, accurate, and complete based on
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information.
Printed Name of Person Signing:
Title:
App scant Date S ned
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612

STATE OF NORTH CAROLINA
LICENSE NO: 4411
2021
URN: NC 18
Issue: 04/05/2021
Mailing Address:
NORTH CAROLINA BEDDING MANUFACTURER'S LICENSE
NC General Statues, Chapter 106 Article 4H Beddling
02 NCAC Chapter 61 Sanitation of Bedding
SEALY MATTRESS MANUFACTURING COMPANY LLC.
SEALY MATTRESS MANUFACTURING COMPANY
LLC.
C/O LEGAL LABEL INC - MAGGIE TERRY
4 WHITES BRIDGE ROAD # 275
WINDHAM, ME 04062
EXPIRES: 2/28/2022
Plant Location:
239 SEALY DRIVE
TRINITY, NC 27370
COMMISSIONER, NCDA&CS

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239 Sealy Drive
ource: 2019 High Point East Quadrangle Trinity, Randolph County, North Carolina
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Business Corporation
Legal Name
Tempur Sealy International, Inc.
Information
Status: Reserved Name O
Citizenship: Domestic
Fiscal Month:
Annual Report Due Date: April 15th
Registered Agent: Not Listed
Addresses
Officers
Stock