NCGNE1277_COMPLETE FILE - HISTORICAL_20180814

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/v
DOC TYPE
5�, HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ L,561 �- D9 /f
YYYYMMDD

ROY COOPER
Governor
x rr„
�rwrt•
Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
August 14, 2018
Siegwerk EIC Inc.
Attn: Robert Miller
1 Qualfty Products Road
Morganton, North Carolina 28655
Subject: No Exposure Certification NCGNE1277
Siegwerk EIC UVIE8
Burke County
Dear Mr. Miller:
MICHAEL S. REGAN
Secretary
WILLIAM E. (TOBY) VINSON, JR.
Interim Director
The Division of Energy, Mineral and Land Resources has reviewed your submittal of the No Exposure
Certification for Exclusion from NPDES Stormwater Permitting form. Based on your submittal and signed
certification of no exposure at the above referenced facility as well as observations made by Isaiah Reed
with the Asheville Regional Office on August 7, 2018, the Division is granting your conditional exclusion from
permitting as provided for under 40 CFR 122.26(g), which is incorporated by reference in North Carolina
regulations. We are also hereby rescinding your current permit Certificate of Coverage, NCG090030.
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 the
No Exposure Certification, 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. You must self re -certify annually using the enclosed form or obtain NPDES permit coverage for
any stormwater discharges from your facility. The annual self re -certification does not need to be submitted
unless requested.
Your conditional exclusion from permitting 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 Isaiah Reed at [phone].
Sincerely,
Stanley E. Aik rGA
for William E. (Toby) Vinson, Jr., PE, CPESC, CPM
Interim Director
DEMLR
Enclosure
ec: Bethany Georgoulias, Environmental Engineer, Stormwater Program, bethanygeor.oR ulias(Qncdenr.gov
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
2090 US 701lighway I Swannanoa, NC 28778-8211
828 296 4500 T

Compliance Inspection Report
Permit: NCGNE1277 Effective: Expiration: Owner : Siegwerk Eic Inc
SOC: Effective: Expiration: Facility: Siegwerk EIC UVIEB
County: Burke 150 Craftsman Dr
Region: Asheville
Morganton NC 28655
Contact Person: Chad Davis Title: Phone: [phone]
Directions to Facility:
us hwy 64 s to craftsman dr on left, facility on right approx 200 yards.
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Rep rosentative(s):
Related Permits:
Inspection Date: 0810712018 EntryTime: 11.40AM Exit Time: 01:00PM
Primary inspector: Isaiah L Reed Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ® Compliant ❑ Not Compliant
Question Areas:
® Miscellaneous Questions ® Misc
(See attachment summary)
Page: 1

Permit: NCGNE1277 Owner - Facility: Siegwerk Fic Inc
Inspection Date: 08/0712016 Inspection Type : Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
The Division of Energy, Mineral and Land Resources has reviewed your submittal of the No Exposure Certification for
Exclusion from NPDES Stormwater Permitting form. Based on your submittal and signed certification of no exposure at the
above referenced facility as well as observations made by Isaiah Reed with the Asheville Regional Office on August 7, 2018,
the Division is granting your conditional exclusion from permitting as provided for under 40 CFR 122.26(g), which is
incorporated by reference in North Carolina regulations. We are also hereby rescinding your current permit Certificate of
Coverage, NCG090030.
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 the No Exposure Certification, 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. You must self re -certify annually using the enclosed form or obtain
NPDES permit coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted unless requested.
Your conditional exclusion from permitting 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 Isaiah Reed at [phone].
Page: 2

Permit: NCGNE1277 Owner - Facility: Siegwerk Eic Inc
Inspection Date: 08107I201a Inspection Type : Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
The Division of Energy, Mineral and Land Resources has reviewed your submittal of the No Exposure Certification for
Exclusion from NPDES Stormwater Permitting form. Based on your submittal and signed certification of no exposure at the
above referenced facility as well as observations made by Isaiah Reed with the Asheville Regional Office on August 7, 2016,
the Division is granting your conditional exclusion from permitting as provided for under 40 CFR 122,26(g), which is
incorporated by reference in North Carolina regulations. We are also hereby rescinding your current permit Certificate of
Coverage, NCG090030.
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 the No Exposure Certification, 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. You must self re -certify annually using the enclosed form or obtain
NPDES permit coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted unless requested.
Your conditional exclusion from permitting 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 Isaiah Reed at [phone].
Page: 2

Permit: NCGNE1277 Owner - Facility: Siegwerk Eic inc
.Inspection Date: 08/07/2018 Inspection Type : Compliance EvaluatRon
Misc
Is the facility compliant?
Comment:
Reason for Visit: Routine
Yes No NA NE
® ❑ ❑ ❑
Page: 3

permit: NCGNE1277,
Inspection Date: 08/0712016
Misc
Is the facility compliant?
Comment:
Owner - Facility: Siegwerk Eic Inc
Inspection Type : Compliance Evaluation
Reason for VislU Routine
You No NA NE
❑ ❑ ❑
Page: 3

K6-h e / a- I 7
Division of Energy, Mineral and Land Resources
J 2a -Land Quality Section
eCe- .ational Pollutant Discharge Elimination System
NO ESURE CERTIFICATION for Exclusion
Environmental , NC1"'NE0000
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
CeniHcate of Coverage
Quality *0 3 ��or MAY 17 2019
.,5e�
e D NR-LANE) 11A�%Itt
National Pollutant e— A 0;E141nation System application for exclusion fh1Fe� �v!]ibased
on NO EXPOSURE:
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.
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.
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 with locked or non -operational taps or valves; adequately maintained
vehicles used in material handling; and final products, other than products that would be mobilized in
stormwater 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 oniy­not 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
terns and conditions of 40 CFR 122.26(g).
If approved, your conditional No Exposure Exclusion has no expiration date
BUT MUST BE self re -certified at least annually.
Please look for information about re -certification under the No Exposure section on this page:
httpsa/deg. nc.gov/abouUdivisions/energy-mineral-land-resources/energy-mineral:land.permits/stormwater-
For questions, please contact the DEMLR Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of ownerloperator (address to which all certification correspondence will be mailed):
Name Siegwerk EIC Inc.
Contact Robert Miller HSE
Street Address 1 QUALITY PRODUCTS ROAD
City Morganton State NC ZiP Code 28655
Telephone No, 828 391-2314 Fax: [phone]
n
Page 1 of 7"�
r
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NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name Siegwerk EIC UV/EB
Facility Contact Chad Davis
Street Address 150 craftsman dr
City morga Mon State nc ZIP COde�'28655
County Burke
Telephone No. 828 391-2382 Fax:
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). Us Hwy 64 5 to craftsman Or on left, fadlity on right approx 200 yards
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands?0 Yes ENO
5) Is this a Federal facility? p Yes 13 No
6) Latitude 35.711029
Longitude-81.697404 (deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
C New or Proposed Facility
13 Existing
Date operation is to begin
Date operation began
0 Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ® Yes G No
If yes, what is the NPDES Permit Number? NCGO90000
9) Standard Industrial Classification:
Provide the 4-digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code:.2 8 5 1
10) Provide a brief description of the types of industrial activities and products produced at this facility:
Printing ink production no outdoor industrial activitv
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
�i No
© Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
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NCGNE0000 No Exposure Certification
a. Is secondary containment provided for single above ground storage containers 0 Yes p No ,NIA
(including drums, barrels, etc.) with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored [3 Yes d No NIA
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund p Yes ©No *N/A
Amendments and Reauthorization Act (SARA) water priority chemicals'?
d. Is secondary containment provided for hazardous substances" designated in p Yes p No •1111 NIA
40 CFR §116?
e. Are release valves on all secondary containment structures locked? p Yes M No OL NIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? E3Yes ® No p NIA
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous G Yes ® No M NIA
waste generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste G Yes ® No © NIA
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of
waste:
vendor:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport 1 disposal
Vendor address:
Footnotes to Questions 14) c. & d.
*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 de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title 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.
16) 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.
Page 4 of 7
SWU-NCGNE Last revised 9/28/2016

t 1
NCGNE0000 No Exposure Certification
Exposure Checklists (12. - 14.)
12) 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 for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where 0 Yes ki( No 0 NIA
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 0 Yes 1KNo In NIA
c. Materials or products from past industrial activity
D Yes
I No
0 NIA
d. Material handling equipment (except adequately maintained vehicles)
0 Yes
O(No
0 NIA
e. Materials or products during loading/unloading or transporting activities
0 Yes
�( No
0 NIA
f. Materials or products stored outdoors (except final products intended for outside
0 Yes
No
0 NIA
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,
0 Yes
' No
0 NIA
tanks, and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained
0 Yes
❑ No
04N/A
by the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., 0 Yes ONo 13 NIA
dumpsters])
j. Application or disposal of process wastewater (unless otherwise permitted) 0 Yes 0 No t NIA
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents 0 Yes >l�No 0 NIA
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 0 Yes -ONo 0 NIA
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers 0 Yes V�No © NIA
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or 0 Yes 0 No )kN/A
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked
shut?
14) Secondary Containment: If you answer "No" to any of the following items, you are not eligible for the
no exposure exclusion.
Page 3 of 7
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NCGNE0000 No Exposure Certification
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? p Yes "o 13 NIA
b. Does your facility have coal piles on site?
[j Yes f No 13 NIA
c. Does your facility store other fuel sources outside in piles, such as wood chips,
p Yes 121. No p NIA
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
M Yes Eff No C! NIA
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality
© Yes ® No 13 NIA
Permit? Please specify:
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
5WU-NCGNE Last revised 912812016

NCGNEOOOO No Exposure Certification
17) Certification:
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 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 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 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
must keep a copy of annual re -certifications on file at the facility.
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 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.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief
such information is true, complete, and accurate.
Printed Name of Person Signing: "Sc
Title: �/lG�oP sf✓i�/ e ��ar�
(Signature of Applicant) (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the NCDEQ
Regional Office prior to issuance. The Regional Office may inspect your facility for compliance
with no exposure conditions prior to that approval. The Regional Office may also 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 filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false
statement of a material fact 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),
There is currently no fee fora No Exposure Exclusion.
Page 6 of 7
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NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
t' This completed application and all supporting documentation.
Er. A map with the location of the facility clearly marked.
0"' If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
Mail the entire package to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office ...
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office ...
[phone]
Wilmington Office...
[phone]
Winston-Salem ......
[phone]
Central Office .......
, . [phone]
Page 7 of 7
SWU-NCGNE Last revised 9128/2016

_nvironrnental lnks _ UV latitude: 35.71029
150 Craftsman prime Longitude: - 61-697404
Morganton, NO 28655 _
Updated: 2I5f2014
Burke Coun
al srr+an Drive
, r , r r ,
f r i
! f ....._...._......, ,
r ,
Bunkermont Ave _
i '-
U S 64 1 ti�.' ` g
......._...._...
1 A�pha
1 S ipp 1n
- S
1 _
t r
1 f
' Former site of ,
mig. Buildings 1
f ! New UV 1
f {
parking Building Grass ,
r 2 Story
1
1
1 �
1 +
r �
, 1
1 +
1 +
/ +
f - ............
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-easee /
Asphalt
Parking
,
Grass f
1 _;
Quality Products Road
-� _ - property Line poney Creek Tributary

Energy, Mineral
and Land Resources
ENVIRONMENTAL QUALITY
Division of Energy, Mineral and Land Resources
Land Quality Section — Stormwater Permitting
National Pollutant Discharge Elimination System
ANNUAL NO EXPOSURE EXCLUSION SELF RE -CERTIFICATION
NCGNE0000
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 E /
1) Has the facility name or owner changed? ❑ Yes ❑ No
(if yes, please submit a separate Name/Ownership Change Form to bEMER located at:
htt :1/de .nc. ov/about/div;sions/ener -mineral-land-resources/ener -mineral-land- ermits/stormwater- ermits/n des-
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
❑ NO
c. Materials or products from past industrial activity
❑ Yes
❑ No
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes
❑ No
e. Materials or products during loading/unloading or transporting activities
❑ Yes
❑ No
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
❑ No
tanks, and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained
❑ Yes
❑ No
by the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g.,
❑ Yes
❑ NO
dumpsters])
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
❑ No
k. Particulate matter or visible deposits of residuals from roof stacks and/or Vents
❑ Yes
❑ No
not otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
1. Empty containers that previously contained materials that are not properly stored
❑ Yes
❑ No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
Page 1 of 3
5Wt1-NESR-Way2016

NCGNE0000 No Exposure Self Re -Certification
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes ❑ No
stored outside, has the facility had any releases in the past three (3) years?
3) Above Ground Storage Tanks (ASTs): 1f 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, ❑Yes❑ No ❑
or deterioration, or evidence of leaks? NIA
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑Yes❑ No ❑
cracks, holes, or evidence of leaks, and are drain valves maintained locked NIA
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 ❑Yes❑ No ❑
containers (including drums, barrels, etc.) with a capacity of more than 660- NIA
gallons?
b. Is secondary containment provided for above ground storage containers stored ❑Yes❑ No 1_1
in close proximity to each other with a combined capacity of more than 1,320- NIA
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund Dyes[] No
Amendments and Reauthorization Act (SARA) water priority chemicals'? NIA
d. Is secondary containment provided for hazardous substances" designated in ❑Yes❑ No ❑
40 CFR §116? NIA
e. Are release valves on all secondary containment structures locked? []Yes[:] No
NIA
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 may be made for de minimis amounts of certain substances, andlor other qualifiers, as described in the exemptions
from reporting requirements of Title 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.
5) 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?
b. Does your facility have coal piles on site?
c. Does your facility store other fuel sources outside in piles, such as wood chips,
sawdust, etc.?
Does your facility have air emissions associated with its industrial activity (e.g.,
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality
Permit? Please specify:
® Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑No
❑ Yes ❑ No
[]Yes[] No[]
NIA
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SW U-NE S R-Way2016

NCGNE0000 No Exposure Self Re -Certification
6) Certification:
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)).
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.
Printed Name of Person Signing:
Title:
(Signature)
(Date Signed)
Please note: The Regional Office may inspect your facility at anytime 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 fact 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 he kept on file at the facility for at least 5 years. Do not submit this
form to DEMLR unless requested.
Page 3 of 3
SWU-NESR-3May2016

Facility Nam �
Wr�/C
Permitk:
Time in/out: j
Date:
Stormwater Pollution Prevention Plan
IDoes',thelsite have'a SWPPPa�':
Does the Plan include a General Location (USGS) map?
'Doessthe, Plan mcI cl- Narrative D'esc4tion of•Practices"
Does the Plan include a detailed site map including outfall locations and drainage areas?
Does thei lan,include-a li'st]of"significant spills occurring tl6ring thie past 3 years?
Has the facility evaluated feasible alternatives
Does the.faciht rowde all necessa scondato current practices?
_ T Y p vi - rye ry,containment?
Does the Plan include a BMP summary?
T ,- - - -
Does thelPlanlmclude`a SpiII-_ Preventionand Response Plan (SPR`P)?
Does the Plan include a Preventative Maintenance and Good Housekeeping Alan?
Does the'facility pEo.ide and document-Eniployee`Training?
_ .i -
Does the Plan include a list of Responsible Party(s)?�
,Is the PlaKreviewed>and updated annually?
Does the Plan include a Stormwater Facility Inspection Program?
Has the Sformwater.Pollution Prevention Plan been implemented?
omments
Enetcgy, Mineral
and Land Resources
ENVIRONMENTAL OUALITY
Yes No N NE
IN
111
t
®
�
Qualitative Monitoring
I Yes
No
NA NE
'Hasthe,"facility.condusted,its;Qualitative'Imonitoring'semi -an nually?R,
Comments
Analytical Monitoring Yes No NA NE
Has theifacility,jdontlucted its Analytical'monitoring?.'.,.,"0,
Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas?
omments
Permit and Qutfalls Yes No NA NE
ls a copy;of the'.Permit and the Certificate of Coverage available at this site? ` I
Were all outfalls observed during the inspection?
'.. ;
If the facility has representative outfall status, is`.itpropefly documented by the Division?
Has the facility evaluated all illicit (non stormwater) discharges?
.omments and Others Present:
5cyvle I A-- -, -5 Sit-;sl 4nraal 3 b� rc �✓�<L -�r�n, bJ� c ,