NCGNE0325_COMPLETE FILE - HISTORICAL_20090324

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE C�HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑
YYYYMMDD

Am
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
RECEIVED l
Jeot of ENR
March 18,-2009 MAR 2 4 2009
Mr. Martin A. Crook _ nsccnSalam
Regional Office
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
1350 W. Fairfield Road
High Point, NC 27263
Subject: Name Change
No Exposure Certification NCGNE0325
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
Fonnerly Dairy Fresh, LLC
1350 W. Fairfield Road, High Point, NC
Guilford County
Dear Mr. Crook:
The Division has reviewed your submittal of the permit name/ownership change-form for your No-Exposure Certification,
which we received on February 9, 2009. Division personnel have reviewed and approved your request to change your name
under your Certificate of No-Exposure.
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 on May 31, 2012. 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], or at
[e-mail].
Sincerely,
for Coleen H. Sullins
cc: Central Files
Winston-Salem Regional Office
Stormwater Permitting Unit Files
Wetlands and Stormwater Branch
1617 Mail Service Center;Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604 One
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 North Carolina
Internet:www.ncwaterqualily.org
An Equal OpporlunAylAf&matye Acton Employer Naturally

colt
Ill T,r,RO Michael F.Easley,Governor
RECEIVED William G.Ross Jr.,Secretary
N.C.Dew.of ENR North Carolina Department of Environment and Natural Resources
j JUN n 4 2007 Division
E I.Sullins,Director
ry �J [ �J Division of Water Quality
Winston-Salem
June 1, 2007
Mr. Ryan Lewis
Dairy Fresh, LLC
2221 Patterson Avenue
Winston-Salem, INC 27105
Subject: No Exposure Certification NCGNE0325
Dairy Fresh, LLC
1350 W. Fairfield Road, High Point, NC
Guilford County
Dear Mr. Lewis:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on January 10, 2007. 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 (May 31, 2012). 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(919) 733-5083, ext.
502, or at [e-mail].
Sincerely,
ORIGINAL SIGNED BY
KEN PICKLE
for Coleen H. Sullins
cc Winston-Salem Regional Office; Central Files—wlattachments
Stormwater Permitting Unit Files
N DENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 2 7699-1 6 1 7 [phone] Customer Service
1-877-623-6748

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United States Environmental Protect)4A " F Approved
NPDES A Washington,DC Pro N 2040-0211
FORM '� ��� NO EXPOSURE CERTIFICATION forp�ri3 '3510-11NPDES Storm Water Perm
Submission of this No Exposure Certification constitutes notice that the entity Identified in Section A does not require permit authorization for its stone water
discharges associated with industrial activity In the State identified in Section B under EPA's Storm Water Mufti-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 rein,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. 'Sealo f
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. It 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 Instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facltity Operator Information 1.Name: D 2.Phone: I�364 M II i q
I�I
3.Mailing Address: a.Street:
b.City i_`��NL lTA"~i�7 TCL4EA& I I I -1 _j c.State: d.Zip Code: I
B. FacilitytSite Location Information
1.Facility Name: I I LkT7
r C
2.a.Street Address 1 J 01 { I I
b.City: "11 C.County:
r am
d.State: ± a.Zip Code: j a U wl_7 _1 I I I
3.Is the facility located on Indian lands? Yes❑ No k
4.Is this a Federal faciltty? Yes❑ NOR
5.a.Latitude: b.Longitude: Oko-Pic,
B.a.Was the facility or site previously covered under an NPDESEl
`(stoorm water permit? Yes No
b.If yes,enter NPDES permit number: ��0(yc � o
7.SIC/Activity Codes: Primary QQa Secondary(if appficable): I t ! I I
6.Total size of site associated with industrial activity. I0 acres
9.a.Have you paved or rooted 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 pernrMag authority may use this Information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quallity,in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than We acres ❑
EPA Form 3510-11 (11p-99) Pags 11 of 4

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Copyright(C)1998,MWech,Inc.

NPDES A Form Approved
FARM NO EXPOSURE CERTIFICATION for Exclusion from OMB No.2040.0211
a�1a11 ��, �+ 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 bo)L) If 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
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)
S. 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 El V_A]
exposure to storm water does not result in the discharge of pollutants)
7. Materials conlalned In open,deteriorated or leaking storage drums,barrels,tanks,and similar containers
a. Materials or products handled/stored on roads or railways owned ormalntalned by the discharger
9. Waste material(except waste in covered,non-leaking containers[e.g.,dumpsteml) ❑
10. Application or disposal of process wastewater(unless otherwise permitted) ❑
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated El
]
(i.e.,under an air quality control permit)and evident in the storm water outflow
D. Certification Statement :
certify under penalty of law that 1 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 live 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). 1 understand that I must
allow the NPDES permitting authority,or MS4 operator where the discharge is into the local MS4,to perform inspections to oanfirm 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 time 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 Imprisonme�ntt for knowing vioflation& 4
Print Name: itiI l i> I I I I I I 1 I I I I I I I I I I I
Print Title: &T t-
Signature:
Date: •
EPA Form 3510-1 1 (10.99) Page 2 014

pia
r®C®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 18,-2009
Mr. Martin A. Crook
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
1350 W. Fairfield Road
High Point, NC 27263
Subject: Name Change
No Exposure Certification NCGNE0325
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
Formerly Dairy Fresh, LLC
1350 W. Fairfield Road, High Point,NC
Guilford County
Dear Mr. Crook:
The Division has reviewed your submittal of the permit name/ownership change form for your No-Exposure Certification,
which Nve received on February 9, 2009. Division personnel have reviewed and approved your request to change your flame
under your Certificate of No-Exposure.
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
enforcefinent as an un-permitted discharge. Your conditional no-exposure exclusion expires on May 31, 2012. At that time
YOU Must re-certify with the Division, or obtain NPDES permit coverage for any stornnvater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental permits that fnay
be required under other federal, state, or local regulations or ordinances.
I f you have any questions or need further information, please contact Sarah Young at [phone], or at
[e-mail].
Sincerely,
for Coleen H. Sulliftis
cc: Central Files
Winston-Salem Regional Office
Stormwater Permitting Unit Files
Wetlands and Stormwater Branch
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carofna 27604 One
Phone:[phone] FAX:[phone] l Customer Service:1-877-623-6748 North Cai-ol ina
Internet www.ncwaterquality,org
Ar Equal Opportunity 1 Afflrmatlue Action Employer

NNVNJ A
Michael R Easley,Governor
William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Colcen H.Sullins,Director
Division of Water Quality
1. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N
E 1 0 1 3
11. Permit status prior to status change.
a. Permit issued to(company name): Dairy Fresh LLC
b. Person legally responsible for permit: Robert E Paxton
First MI Last
Plwit Manager
Title
2221 Patterson Avenue
Permit Holder Mailing Address
Winston-Salem NC 27105
City State Zip
(336)7149032 (336)7230353
Phone Fax
c. Facility name(discharge): Dairy
Fresh,LLC
d. Facility address: 1350 W.Fairfield Road
Address
High Point NC 27263
City State Zip
e. Facility contact person:
First /NU/Last Phone
U1. Please provide the following for the requested change(revised permit).
a. Request for change is a result of. El Change in ownership of the facility
N Name change of the facility or owner
If other please explain:
b. Permit issued to(company name): Suiza Dairy
_Group,LLC(dba Dairy Fresh,LLC)
c. Person legally responsible for permit: Martin A Crook
First MI Lag
Plant Mans er
Title
1350 W.Fairfield Road
Permit Holder Mailing Address
High Point NC 27263
City State Zip
336)4317193 m2 Lrty =2k@ eanfbodsxom
Phone E-mail Address
d. Facility name(discharge): Suiza Dairy Group,LLC(dba Dairy ir Fresh,LLC)_
e. Facility address: 1350 W.Fairfield Road
Address
flj Point NC 27263
City State Zip
f Facility contact person- Roland H Goldston
First MI Last
(336)7149016 [e-mail]
Revised 812W

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Phone Ismail Address
IV. Permit contact information(if different from the person legally responsible for the permit)
Permit contact:
First MI Cast
Title
Mailing Address
City State Zip
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
0 Yes
❑ No(please explain)
VT Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests. V- 1
Legal documentation of the transfer of ownership(such as relevant pages of a contractor a bill of sale)is required for an ownership change request. Articles of incorporationnot sufficient for an ownership change................................................................................................................. t�i
The certifications below must be completed and signed by both the permit holder prior to the change,
{
the new applicant in the case of an ownership change request. For a name change request,the signed '
Applicant's Certification is sufficient. f
PERMTTTEE CERTIFICATION(Permit holder prior to ownership change):
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 Date
APPLICANT CERTIFICATION
I,Martin A Crook.,attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. 1 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 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 7008

r 44``II II II 11 iiIIjj JAN 14 2009
2009002922
GUIL.FORD CO,NO FEE$14.00
PR.seM a AWORUE0.
01-21-2009 10:0619 AM
JEFF L.THIGPEN
REOW ER of DEWS
BY:AwREW SAOKIRS
DEPM-HP
BK: R 6967
PG: 2317-2317
CERTIFICATE OF ASSUMED NAME FOR A LIMITED LfARUM COMPACT Y
The undersigned LLC,proposing to engage in business in Guilford County,North
Carolina,under an assumed name other than its LLC name,hereby certifies that:
1. The name under which the business is to be conducted is:
Dairy Fresh,LLC
(Insert assumed name)
2. The name and address of the owner(s)of such business is(are):
Suiza Dairy Group,LLC
2515 McK.inney_Avenue.Suite_1200,Dallas,Texas 75201
(Insert name and address of LLC)
In witness whereof,this certificate is signed in the name of the LLC by its manager(s),this
day of January ,2009
gy, �. SEAL
Manager itac c A.Gonzalez, o anaa.er
By: SEAL
Manager
tty: SEAL
Manager
State of TEXAS
County efDALLAS
1 a Notary Public,do hereby certify that
Rachel A.Gonzalez,Sole Manager ,manager(s)of
Suiza Dairy Group ,LLC,personally
appeared before t __ay of Ja""aty 20 0 _-,and that they
signed the foregoing certificate on behalf of the LLC.
Witness my hand and offlcl seal,this the. day of January -- 20 09
Notary Public (AM r
My Commission Expir �,[7l0 —= " fib' 2
CATMENoia
NlYCOMM15SEWIRES
��'fih�t Jsatt►Ny24.2D1D ��
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Delaware PAGE 1
the First State
I, HARRIET SMITH WINDSOR, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY THE ATTACKED IS A TRUE AND CORRECT
COPY OF THE CERTIFICATE OF MERGER, WHICH MERGES:
"DAIRY FRESH, LLC", A DELAWARE LIMITED LIABILITY COMPANY,
WITH AND INTO "SUIZA DAIRY GROUP, LLC" UNDER THE NAME OF
"SUIZA DAIRY GROUP, LLC", A LIMITED LIABILITY COMPANY ORGANIZED
AND EXISTING UNDER THE LAWS OF THE STATE OF DELAWARE, AS
RECEIVED AND FILED IN THIS OFFICE THE TWENTY-SECOND DAY OF
DECEBBER, A.D. 2008, AT 3:52 O'CLOCK P.M_
AND I DO HEREBY FURTHER CERTIFY THAT THE EFFECTIVE DATE OF
THE AFORESAID CERTIFICATE OF MERGER IS THE THIRTY-FIRST DAY OF
DECEMBER, A.D. 2008.
8
0 do Harriet Smith Windsor,Secretary of State
3098889 8100M o AUTHENTICATION: 7046397
081220241 DATE: 12-23-08
You may verily thin certificate amine
at carp.dolawara.gov/authver.�hi�t

State of Delaware
Secretary of State
ivision off Co tions
ivered 03:52 �M 12/2212008
03;52 PM 1212212008
,wr081220241 - 3098889 N=
STATE OF DELAWARE
CERTIFICATE OF MERGER OF
DAIRY FRES$LLC
INFO
SUM DAIRY GROUP,LLC
Pmuant to Secti( m 18-209 of the Delaware Limited liability C Vimy Act,the undersigned limited
liability company executed the foIIowing C. cate of Mergea:
FIRST: The name of the surviving limited liability company is SUIZA DAIRY GROUP,LLC,a
Delaware limited liability company.-
SECOND: The name of the limited liability company being meaged into the su Wving limited
,liability cMWy is DAIRY FWIIH LLC,a Delaware limited liability many
TIHRD: An agrreanent of merger has been approved and executed by each constituent Invited
liability oompany.
FOURTH: The merger is to become effective as ofDeaembet 31,2008.
F.[1 N: The AVwment and Plan of Merger is on file at 2515 Maiwey Avme, Suite 1200,
Dallas,Texas 75201,the place of businm of the surviving limited liability company.
SIXTH: .A copy of the Agreement and Plan of Meager will be furnished by the surviving limited
liability company on request,without cost;to any mcud=of either of the m rviving limited liability
Company or the miming limited liability company.
i IN WITNM VVSEREOF,said mr lymi g Umite+d liability away has caused this ce rtv6icate to be
signed by an autho&ed person,the•l day ofDecember 2008.
SUEEA DAIRY GROUP,LLC
Rachel A.Conzdez,
Vice President,Smeary and Sole Manager
I
�:��x�omawaeamon�.. msesdorw��ryc,.��ms�n�o�+v�
I •
I
i

W A Michael F,Easley,Governor
`O�O ApG William G.Ross Jr„Secretary
North Carolina Department of Fnviromnent and Natural Resources
rColleen H.Sullins,Director
y Division of Water Quality
o �
June 1, 2007
Mr. Ryan Lewis
Dairy Fresh, LLC
2221 Patterson Avenue
Winston-Salem, NC 27105
Subject: No Exposure Certification NCGNE0325
Dairy Fresh, LLC
1350 W. Fairfield Road, High Point, NC
Guilford County
Dear Mr. Lewis:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on January 10, 2007. 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 (May 31, 2012). 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(919) 733-5083, ext.
502, or at [e-mail].
Sincerely,
4� P�t"
for Coleen H. Sullins
cc: Winston-Salem Regional Office [Central Files—wlattachments
Stormwater Permitting Unit Files
rIM
NCOEIV
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

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United States Environmental Protecti A en* Fo Approved
(NPDES A Washington, DC 20460 U N 2D4D-0211
FORM Awl ��� NO EXPOSURE CERTIFICATION for ref A
351 f-11
NPDES.Storm Water Permi
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 shaltar 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 wafer 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 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,
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facfllty Operator Informatio_n t,._1L_P W L _L LSO 0 1 7PW'E�_
( Z
1. Name: [ 151 1 2,Phone: L�36 ,ll
3. Mailing Address: a.Street: l 'h�A T t�
b.City I `} 1 f5�� �'�pi� e}�� I I l I I c.State: d.Zip Code: Ip� I CIQ �1 I I I I
B. Facility/Site Location Information y )
1.Facility Name: I —I f !
2.a.Street Address- 4
b. City: PL�rr c.County: ( ' L-Tr �f
d.State: e.Zip Code: I a lI cat 23-1 I I I— I
3. Is the facility located on Indian Lands? Yes ❑ No g
4. Is this a Federal facility? Yes ❑ No
5.a.Latitude: b. Longitude: P—I—M. PIC, I W -
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes IQ No ❑
b. If yes,enter NPDES permit number: !V
7.SIC/Activity Codes: Primary: QQcr4b Secondary(if applicable): I I I I
B.Total size of site associated with industrial activity: /0 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{raved 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 than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10-99) Page 1 of 4

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NPDES Form Approved
FORM ,EPA NO EXPOSURE CERTIFICATION for Exclusion from OMB No.2040-0211
3510-11 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.
Yes No
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. 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.,dumpsters]) ❑ v1
10. Application or disposal of process wastewater(unless otherwise permitted) ❑
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
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.
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 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 lr >f�l I -ff'9"1� S
Print T41e:
Signature: '
Date:
EPA Form 3510-11 (10.99) Page 2 of 4

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tFwd:,NCGNE's]
Subject: [Fwd: NCGNE's]
From: Corey Basinger <[e-mail]>
Date: Mon, 21 May 2007 08:35:25 -0400
To: Sarah Young <[e-mail]>
-------- Original Message --------
Subject:NCGNE's
Date:Mon, 23 Apr 2007 16:03:37 -0400
From-Corey Basinger<Corcy.Basinger a,ncmail.net>
Organization-NC DENR- Winston-Salem Regional Office
To:Sarah Young <Sarah.Younggncmail.net>
Sarah,
As discussed on the phone, here are the two (2) NCGNE's that can be processed based on my site visits
today:
(1) NCGNE0325 Dairy Fresh in High Point '
(2) NCGNE0313 Sunrise Medical DC in High Point
The other is Alcoa Extrusions, Inc in Greensboro. I plan to visit there tomorrow. I'll send a followup
email after my visit.
Sorry for the delay. As I said, these three hitched a ride via paperclip to another document and were in
the file cabinet. Had I not been looking for the other document, I would have never discovered them. Is
there any way you can look back at your files to see if there are any other outstanding NCGNE requests?
Thanks!
Corey
Corey Basinger
[e-mail]
NC DENR Division of Water Quality
585 Waughtown Street
Winston--Salem, NC 27107
(336) 771-5000
Fax (336) 771-4630
Corey Basinger
Corey.Basinger@NCmaii .net
NC DENR Division of Water Quality
585 Waughtown Street
Winston--Salem, NC 27107
(336) 771-5000
Fax (336) 771-4630
Corey Basinger<Corey.Basinger a NCmail.net>
WSRO
NC DENR
1 of 1 5/21/2007 9:10 AM