NCGNE0748_Self Recert Form_20240905

COPY
Division of Energy, Mineral and Land Resources
cu
Land Quality Section—Stormwater Permittingg
National Pollutant Discharge Elimination System
Energy,Mineral ANNUAL NO EXPOSURE EXCLUSION SELF RE-CERTIFICATION
and Land Resources NCGNE0000
ENVIRONMENTAL QUALITY
Do not submit this form to DEMLR unless requested.
For questions,please contact the DEMLR Regional Office for your area or the Central Office.
(Please print or type)
Facility's No Exposure Exclusion No. Date Completed (MM/DD/YYYY)
N I C I G I N I E Q 1714 1 g 1 d 6 / Z p 1,0141
1) Has the facility name or owner changed? ❑ Yes No
(if yes, please submit a separate Name/Ownership Change Form to DEMLR located at:
htto://dea.nc.o ov/about/divisions/energy-mineral-land-resources/energy-m i neral-land-perm its/stormwater-oermits/n odes-
industrial-sw)
2) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either"Yes"or"No.") If you answer"Yes"to any of these items, you are not
eligible to maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes No
residuals from using, storing or cleaning industrial machinery or equipment
remain and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes Q No
c. Materials or products from past industrial activity ❑Yes Q No
d. Material handling equipment(except adequately maintained vehicles) ❑ Yes ❑No
e. Materials or products during loading/unloading or transporting activities ❑ Yes allo
f. Materials or products stored outdoors (except final products intended for outside ❑Yes No
use [e.g., new cars]where exposure to stormwater does not result in the
discharge of pollutants)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, ❑ Yes Q No
tanks, and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained ❑Yes Q No
by the discharger
i. Waste material (except waste in covered, non-leaking containers [e.g., ❑ Yes 2-No
dumpsters])
j. Application or disposal of process wastewater(unless otherwise permitted) ❑Yes ErNo
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents ❑ Yes Q No
not otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑Yes Q No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
Page 1 of 3

NCGNE0000 No Exposure Self Re-Certification
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑Yes Q No
stored outside, has the facility had any releases in the past three(3)years?
3) Above Ground Storage Tanks (ASTs): If you answer"No"to any of the following items,you are not
eligible to maintain your no exposure exclusion,and must immediately apply for a permit from DEMLR.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, ❑S'es❑ No❑
or deterioration, or evidence of leaks? N/A
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any aes❑ No ❑
cracks, holes, or evidence of leaks, and are drain valves maintained locked N/A
shut?
4) Secondary Containment: If you answer"No" to any of the following items, you are not eligible to
maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Is secondary containment provided for all single above ground storage ayes❑ No❑
containers (including drums, barrels, etc.)with a capacity of more than 660- N/A
gallons?
b. Is secondary containment provided for above ground storage containers stored Yes❑ No❑
in close proximity to each other with a combined capacity of more than 1,320- N/A
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund ErYes❑ No ❑
Amendments and Reauthorization Act(SARA)water Priority chemicals'? N/A
d. Is secondary containment provided for hazardous substances"designated in ZYes❑ No❑
40 CFR §116? N/A
e. Are release valves on all secondary containment structures locked? ZYes❑ No❑
N/A
Footnotes to Questions 4)C.&d.
'Note that amounts below the 660-gallon (single)and 1,320-gallon(combined)bulk storage minimums require secondary containment.
However,some exceptions ma yy be made for de minimis amounts of certain substances,and/or other qualifiers, as described in the exemptions
from reporting requirements of T@le III SARA 313 in 40 CFR§372.38.
"'Note that amounts below the 660-gallon(single)and 1,320-gallon(combined)bulk storage minimums require secondary containment.
However,some exceptions may be made for amounts less than the Reportable Quantities of the hazardous substances listed in 40 CFR
§117.3.
6) Other information: If you answer"Yes"to any of the following items,and the answer if different from
how it was answered when originally applying, you might not be eligible to maintain your no exposure
exclusion. Please contact the Division if this is the case.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes Q No
b. Does your facility have coal piles on site? ❑ Yes ZINo
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes QNP
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., 0Yes ❑ No
degreasing operations, plating, pain ing d m taI fin ng' hi )? If so, describe the
industrial activity: / 007 Ks
e. If you answered yes to d., are those emissions r i ed yen Air Quality Yes❑ No❑
Permit? Please specify: �8"�qr 2 ,7 N/A
pans 9 of

NCGNE0000 No Exposure Self Re-Certification
6) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of"no
exposure"and obtaining/maintaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities or
materials from the industrial facility or site identified in this document(except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to annually self re-certify No Exposure and, if requested, submit this re-certification to
DEMLR or the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges(where
applicable). I understand that I must allow the North Carolina Division of Water Quality,or MS4 operator where the
discharge is into the local MS4,to perform inspections to confirm the condition of no exposure and to make such inspection
reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any Point source discharge of stormwater from the facility.Additionally, I certify under penalty of
law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information provided. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information,the information provided is to the best of my knowledge and belief true,accurate and complete. I am aware
that there are significant penalties for providing false information,including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this document and that to the best of my knowledge and belief
such information is true, complete, and accurate., C
Printed Name of Person�Si
Title:
(Signature) ( ate igned)
Please note:The Regional Office may inspect your facility at any time In the future for compliance
with the No Exposure Exclusion.
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation,or certification in any application, record,report,plan,or other
document fled or required to be maintained under this Article or a rule implementing this Article;or who knowingly makes a false
statement of a material fad in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management]Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($10,000).
This completed form must be kept on file at the facility for at least 5 years. Do not submit this
form to DEMLR unless requested.
Page 3 of 3

FOR AGENCY USE ONLY RE� �d 10/6/2023
NCGNE_ `C �/SD
Assigned to: v
ARO FRO MRO RRO WARD WIRO WSRO SEP 052024
DE'R-STORMWATERPROGRAM
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCG N E0000
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 new facilities, applicants should apply no earlier than 60 days before the start of operation. This will allow
DEMLR staff to verify conditions during active operation. For facilities that already have an industrial stormwater
permit 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 forthe 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).
INC DEC.Stormwater Program requires a one-time $250 application fee via check made payable to NC DEQ. There
is no annual fee once covered under a No Exposure Certification. 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-
land-resources/nodes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMI R
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.
Page 1 of 5

1. Owner/Operator(to whom all permit correspondence will be mailed):
N me of le al organi tional a ity: Legall responsi a person(as signed in Item 7 below):
o f r' �'c : s
Maih address: Ci t Statp Zip Code 2
Telephone number: Email ad ess: J
n
Type of Ownership:
Government
❑County ❑ Federal ❑ Municipal ❑ State
Non- overnment
Non
(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 envir ental contact:
Or/1Of iV �� _ NI
Street address: �{ Telephone number-
-
Email ddress:
.C 1ifh
Ci �� Cou a StateNC Zip Code
Z
Latitude of entrance: 305�$?
Longitude of entrance: — ,9¢85
Parcel Identification Number(PIN): 7718'
a29�3�
!l
Date operation began: ✓ O Standard Industrial Cla;si,�c tion(SIC)Code:
Brief desgqipti n of the es of industrial a tivities and prodygts produced q�this facility:
3. Consultant(if applicable): A/
Name of consultant: Consulting firm:
Street address: City: State and zip code:
Telephone number: Email address:
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 ❑Yes ❑ No B /A
stormwater
Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes ❑ No /A
Materials or products from past industrial activity ❑ Yes ❑ No /A
Material handling equipment(except adequately maintained vehicles) ❑ Yes❑ No R</A
Page 2 of 5

Materials or products during loading/unloading or transporting activities ❑ Yes❑ No /A
Materials or products stored outdoors(except final products intended for outside use[e.g.,new I] Yes ❑ No LKN/A
cars]where exposure to stormwater does not result in the discharge of pollutants)
Materials contained in open,deteriorated,non-sealed',or leaking storage drums barrels,tanks, ❑ Yes ❑ No B</A
and similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑ Yes ❑ No /A
Final products that would be mobilized in stormwater discharges(e.g.,rock salt) ❑ Yes ❑ No /A
Waste material(except waste in covered,non-leaking containers[e.g.,dumpsters]) ❑Yes ❑ No /A
Application or disposal of process wastewater(unless otherwise permitted) ❑Yes ❑ No R1/A
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise ❑Yes❑ No f9 N A
regulated(i.e.under an air quality control permit)and evident in the stormwater outflow
Empty containers that previously contained materials that are not properly stored(i.e.,not closed ❑ Yes ❑ No R /A
and stored upside down to prevent precipitation accumulation)
For any exterior ASTs,as well as drums,barrels,tanks and similar containers stored outside,has ❑ yes [ .do 'LTN/A
the facility had any releases in the past three(3)years?
'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 7 Yes❑No C�l'IV/A
evidence of leaks? ��
Is secondary containment provided for all exterior ASTs?If so,is it free of any cracks,holes,or p yes❑No L7N/A
evidence of leaks,and are drain valves maintained locked shut?
Is secondary containment provided for single above ground storage containers(including drums, p Yes❑No L9'N%A
barrels,etc.)with a capacity of more than 660-gallons? B Is secondary containment provided for above ground storage containers stored in close proximity Yes❑ No LfN/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❑No LrIN/A
Reauthorization Act(SARA)water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR 4116? ❑Yes❑No L9 N/A
Are release valves on all secondary containment structures locked? ❑Yes❑No /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 o❑ N/A
Does this facility store used,recycled,or otherwise reclaimed pallets outside? OM ❑Yes No❑ N/A
Does this facility have coal piles on site? ❑Yes ial1o'❑ N/A
Does this facility store other fuel sources outside in piles,such as wood chips,sawdust,etc.? ❑Yes 6+Wo❑ N/A
Page 3 of 5

Does this facility have air emissions associated with industrial activity(e.g.,degreasing operations, Yes❑ No❑ N A
plating,painting,or metal finishing)? 7
If yes: n� / ,/� t4/)I NQ,
Describe the industrial activity: F �l Air 011 � lT6/h 06O1)11, �� �$7
Ly/t/� Co�(�fiBY►
Are those emissions permitted by an Air Quali Permi ? Yes ❑ No
Please specify: 03/4.3R—D �LG I ,6cozb j,.j1.b/e
S. Other Facility Conditions (check all that apply and expl in accordingly):
❑This facility has other NPDES permits. , /q
If checked,list the permit numbers for all current NPDES permits: AIA
❑ 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) �l')
❑ Hazardous Waste Generation Facility r��l
❑ 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. A/ff
If checked,briefly describe the site conditions: /V#
❑This facility is located on Native American Lands. MAL
6. Required Items (Application will be returned unless all of the following items have been included):
El"C'heck for$250 made payable to NCDEQ
❑ Copy of most recent Annual Report to the NC Secretary of State(if applicable) /]
&?This completed application and any supporting documentation
9;<0`py of county map or USGS quad sheet with the location of the facility clearly marked
Page 4 of 5

7. Applicant Certification
North Carolina General Statute 143-215.68(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:
EK 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.
7 I have read and understand the eligibility requirements for claiming a condition of"no exposure"and obtaining an
exclusion from NPDES stormwater permitting.
0 There are no discharges of stormwater contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document(except as allowed under 40 CFR 122.26(g)(2)).
®'�I understand that I am obligated to 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,
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.
B'�The information submitted in this NOI 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: ��/ �✓IA►lL( /`��n�
3a '�wj
Signature plicant Date6ined
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh,NC 27699-1612
Page 5 of 5

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