NCGNE0147_COMPLETE FILE - HISTORICAL_20050420

-
STORMWATER DIVISION CODING SHEET
-. NCG PERMITS
PERMIT NO, NCGNE rD y
DOC TYPE E� HISTORICAL FILE
DOC DATE ❑ b � S D y J4
YYYYM M DD

o� o�w A r-RQ�
r
April 20, 2005
Mike Clark, General Manager
Stronghaven Containers
11135 Monroe Rd
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
NWoleeTHrSullinn"SyDepru,iV iliictor
AND t''A7Division Uf,WtRQF
6f111P1rtYF-' A$ A gnw
APR 2 7 2005
Matthews, NC 28105(IN
Subject-. Subject: No Exposure Certification NCGNE0147
Stronghaven Warehouse - 433 E Johns St
Mecklenburg County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on December 4, 2002. We apologize for the extended period
it has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. 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 12622(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. It 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 (April 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
b-,
for Alan W. Klimek, P.E.
cc: Mooresville Regional Office Central Files — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
't?
RCDENR
Customer Service
1-977-623-6748

October 23, 2003
Division of Water Quality
Storm water and General Permits Unit
1617 Mail Service Center
Raleigh, North Carolina 27699
Application for a No Exposure Certification
Stronghaven Containers - Manufacturing Facility
Strata Environmental Project Number 9925400
Dear Staff Member:
Strata
ENVIRONMENTAL
,. r
LOCT 2 7 2003
Dc:t-!'A tgE75 ITY
P-i'i 0t:;ZCE
Enclosed is a completed Application for a No Exposure Certification for Stronghaven Containers'
manufacturing facility located at 11135 Monroe Road. Matthews, North Carolina. As the
environmental consultant for Stronghaven Containers, Strata Environmental is responsible for
assisting with environmental compliance issues for the company. Therefore, in addition to your
correspondence with the facility, please copy Strata Environmental on all documents related to
Stronghaven Containers. This should ensure prompt and complete attention to all environmental and
permitting issues. The address for Strata Environmental is 1 10 Perimeter Park, Suite E, Knoxville,
Tennessee 37922.
If have any questions or need additional information regarding the permit application, please contact
the undersigned at [phone]. Thank you for your assistance with the No Exposure
Certification.
Sincerely,
STRATA ENVIRONMENTAL
Timothy L. Riddle, P.G.
Senior Geologist (NC Reg. # 1710)
TLR/kmc
Enclosures
110 Perimeter Park, Suite E, Knoxville, TN 37922 • tel [phone] • fax [phone] • uww.strataenvxom
99254009.066

United States Environmental Protection Agency Form Approved
9 Y OMB No.2040-0211
NPDES aA Washington, DC 20460
FORM `0
3510-11 EPA NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, 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 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 outfails. 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. Facility Operator Information
1. Name: R V O 2. Phone: [phone] 717 141 3
3. Mailing Address: a. Street: I l I 1 I 1 1 31 3 1 1 lull 0IN I 1 OI E I I RI DI I P I OI BI Oi XI 11 1 3 10 1 0 1 1 1 1 1 1 1
b. City. IMIA IT IT I I E I WI S I I I I I I I I I I I I I I I c. State: LSTJ d. Zip Code: 12 18 1 11 015 1— I I I I I
B. Facility/Site Location Information
1. Facility Name: IS ITIR101NIGI H I A I V I E I N I IC101NITIAt I I N I EI RI SI I I I I I 1 1 1
2. a. Street Address: 11 I 1 1 31 51 1M101NI RI01E I I I D I I P101 B101XI 1 l 13 101 01 1 1 1 1 1 1
b. City: MA IT IT IH I E I WI S I I I I I I I I I I I I I I I I c. County: IMIE IC lK IL JE IN 1.131 Lit R1 G
d. State: INICI e. Zip Code: 1 2 18 1 1 10 15 1 —1 1 1 1 I
3. Is the facility located on Indian Lands? Yes ❑ No ER
4. 1s this a Federal facility? Yes ❑ No
5. a. Latitude: 13 1510 7 2 2„ b. Longitude: 10 1 810 ° 1413 I 4 2
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No
b. If yes, enter NPDES permit number:
7. SICIActivity Codes: Primary: I7 1 Fit 7 1 51 Secondary (if applicable):
8. Total size of site associated with industrial activity:
4 acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes ❑ No
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10-99) Page 1 of 4

NPDES A Form Approved
FORM .-EPA Instructions for the NO EXPOSURE CERTIFICATION for OMB No.2040-0211
3510-11 Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. Facility/Site Location Information
Federal law at 40 CFR Part 122.26 prohibits point source discharges of 1. Enter the official or legal name of the facility or site.
storm water associated with industrial activity to waters of the U.S. without
a National Pollutant Discharge Elimination System (NPDES) permit. However, 2. Enter the complete street address (if no street address exists, provide
NPDES permit coverage is not required for discharges of storm water a geographic description [e.g., Intersection of Routes 9 and 55]), city,
associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)- county, state, and zip code. Do not use a P.O. Box number.
(ix) and (xi) if the discharger can certify that a condition of "no exposure'
exists at the industrial facility or site. 3. Indicate whether the facility is located on Indian Lands.
Storm water discharges from construction activities identified in 40 CFR
122.26(b)(14)(x) and (b)(15) are not eligible for the no exposure exclusion.
Obtaining and Maintaining the No Exposure Exclusion
This form is used to certify that a condition of no exposure exists at the
industrial facility or site described herein, This certification is only applicable
in jurisdictions where EPA is the NPDES permitting authority and must be
re -submitted at least once every five years.
The industrial facility operator must maintain a condition of no exposure at
its facility or site in order for the no exposure exclusion to remain applicable.
If conditions change resulting in the exposure of materials and activities to
storm water, the facility operator must obtain coverage under. an NPDES
storm water permit immediately.
Where to File the No Exposure Certification Form
No Exposure Forms sent regular mail:
SW No Exposure Certification (4203M)
USEPA
1200 Pennsylvania Avenue, NW
Washington, D.C. 20460
Completing the Form
Forms sent ovemight/express:
SW No Exposure Certification
US EPA East Building, Rm. 7420
1201 Constitution Avenue, NW
Washington, D.C. 20004
[phone]
You must type or print, using uppercase letters, in appropriate areas only.
Enter only one character per space (i.e., between the marks). Abbreviate
if necessary to stay within the number of characters allowed for each item.
Use one space for breaks between words. One form must be completed
for each facility or site for which you are seeking to certify a condition of no
exposure. Additional guidance on completing this form can be accessed
at EPA's website: www.epa.gov/npdes/stormwater. Please make sure you
have addressed all applicable questions and have made a photocopy for
your records before sending the completed form to the above address.
Section A. Facility Operator Information
1. Provide the legal name of the person, firm, public organization, or any
other entity that operates the facility or site described in this certification.
The name of the operator may or may not be the same as the name of
the facility. The operator is the legal entity that controls the facility's
operation, rather than the plant or site manager.
2. Provide the telephone number of the facility operator.
3. Provide the mailing address of the operator (P.O. Box numbers may be
used). Include the city, state, and zip code. All correspondence will
be sent to this address.
4. Indicate whether the industrial facility is operated by a department or
agency of the Federal Government (see also Section 313 of the Clean
Water Act).
5. Enter the latitude and longitude of the approximate center of the facility
or site in degrees/minutes/seconds. Latitude and longitude can
be obtained from United States Geological Survey (USGS) quadrangle
or topographic maps, by calling 1-(888) ASK-USGS, or by accessing
the Census Bureau at: http://www.census,govlcgi-bin/gazetteer.
Latitude and longitude for a facility in decimal form must be converted
to degrees (°), minutes ('), and seconds (') for proper entry on
the certification form. To convert decimal latitude or longitude to
degreeslminuteslseconds, follow the steps in the following example.
Example: Convert decimal latitude 45.1234567 to degrees (°), minutes
('), and seconds (").
a) The numbers to the left of the decimal point are the degrees: 45°.
b) To obtain minutes, multiply the first four numbers to the right of the
decimal point by 0.006: 1234 x 0.006 = 7.404.
c) The numbers to the left of the decimal point in the result obtained
in (b) are the minutes: 7'.
d) To obtain seconds, multiply the remaining three numbers to the
right of the decimal from the result obtained in (b) by 0.06:
404 x 0.06 = 24.24. Since the numbers to the right of the decimal
point are not used, the result is 24".
e) The conversion for 45.1234567 = 45, 7' 24".
6. Indicate whether the facility was previously covered under an NPDES
storm water permit. If so, include the permit number.
7. Enter the 4-digit SIC code which identifies the facility's primary activity,
and second 4-digit SIC code identifying the facility's secondary activity,
if applicable. SIC codes can be obtained from the Standard Industrial
Classification Manual, 1967.
8. Enter the total size of the site associated with industrial activity in acres.
Acreage may be determined by dividing square footage by 43,560, as
demonstrated in the following example.
Example: Convert 54,450 ft2 to acres
Divide 54,450 ft2 by 43,560 square feet per acre:
54,450 ft2 - 43,560 ft2/acre = 1.25 acres.
9. Check `Yes' or -No" as appropriate to indicate whether you have paved
or roofed over a formerly exposed, pervious area (i.e., lawn, meadow,
dirt or gravel road/parking lot) in order to qualify for no exposure. If yes,
also indicate approximately how much area was paved or roofed over
and is now impervious area.
EPA Form 3510-11 (10-99) Page 3 of 4

NPOES FORM=,EPA NO EXPOSURE CERTIFICATION for Exclusion from OMB No.20Form Approved
0-0211
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 spillsAeaks
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during loadinglunloading 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
❑
& 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])
❑
10, Application or disposal of process wastewater (unless otherwise permitted)
El
IR
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: IMI IKILI IC,LlAIR IKI I I I I I 1 I I I I I I I I I I I I I I I I]
Print Title: I G I E I NI E I RI Al I I Ml A i NI At Q E I R I I I I I I I I I I I I I I I I I I
Signature:yN`—
Date: I 1 Y a 3
EPA Form 3510-11 (10-99) Page 2 of 4

NPDES es Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
FORM -,EPA OMB No.2040-0211
3510.11 Exclusion from NPDES Storm Water Permitting
Section C. Exposure Checklist
Check 'Yes" or "No" as appropriate to describe the exposure conditions at
your facility. If you answer 'Yes" to ANY of the questions (1) through (11)
in this section, a potential for exposure exists at your site and you cannot
certify to a condition of no exposure. You must obtain (or already have)
coverage under an NPDES storm water permit. After obtaining permit
coverage, you can institute modifications to eliminate the potential for a
discharge of storm water exposed to industrial activity, and then certify to
a condition of no exposure.
Section D. Certification Statement
Federal statutes provide for severe penalties for submitting false information
on this application form. Federal regulations require this application to be
signed as follows:
For a corporation: by a responsible corporate officer, which means:
(i) president, secretary, treasurer, or vice-president of the corporation
in charge of a principal business function, or any other person
who performs similar policy or decision making functions for the
corporation, or
(ii) the manager of one or more manufacturing, production, or
operating facilities, provided the manager is authorized to make
management decisions which govern the operation of the
regulated facility including having the explicit or implicit duty of
making major capital investment recommendations, and initiating
and directing other comprehensive measures to assure long
term environmental compliance with environmental laws and
regulations; the manager can ensure that the necessary systems
are established or actions taken to gather complete and accurate
information for permit application requirements; and where
authority to sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the
proprietor; or
For a municipal, State, Federal, or other public facility: by either a
principal executive or ranking elected official.
Paperwork Reduction Act Notice
Public reporting burden for this certification is estimated to average 1.0 hour
per certification, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Burden means the total time,
effort, or financial resources expended by persons to generate, maintain,
retain, or disclose to provide information to or for a Federal agency, This
includes the time needed to review instructions; develop, acquire, install,
and utilize technology and systems for the purposes of collecting, validating,
and verifying information, processing and maintaining information, and
disclosing and providing information; adjust the existing ways to comply with
any previously applicable instructions and requirements; train personnel to
be able to respond to a collection of information; search data sources;
complete and review the collection of information; and transmit or otherwise
disclose the information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number, Send comments regarding
the burden estimate, any other aspect of the collection of information, or
suggestions for improving this form, including any suggestions which may
increase or reduce this burden to: Director, OPPE Regulatory Information
Division (2137), USEPA, 401 M Street, SW, Washington, D.C. 20460.
Include the OMB control number of this form on any correspondence. Do
not send the completed No Exposure Certification form to this address.
EPA Form 3510-11 (10-99) Page 4 of 4

110 Perimeter Park, Suite E
=S=t:r` atla- Knoxville, TN 37922
ENVIRONMENTAL. vwwr.strataenv.com
[phone]
Fax: [phone]
November 20, 2002
Division of Water Quality
Stormwater and General Permits Unit
1617 Mail Service Center
Raleigh, North Carolina 27699
Application for a No Exposure Certification
Stronghaven Containers - Warehouse
Strata Environmentai Project Number 9925499
Dear Staff Member:
Enclosed is a completed Application for a No Exposure Certification for Stronghaven Containers"
warehouse operation located at 433 East John Street, Matthews, North Carolina. As the
environmental consultant for Stronghaven Containers, Strata Environmental is responsible for
environmental compliance issues for the company. Therefore, in addition to your correspondence
with the facility, ,please copy Strata Environmental on all documents related to Stronghaven
Containers' .'This should ensure prompt and complete attention to all environmental and permitting
issues. The address for Strata Environmental is 110 Perimeter Park, Suite E, Knoxville, Tennessee
37922.
If have any questions or need additional information regarding the permit application, please contact
the undersigned at [phone]. Thank you for your assistance with the No Exposure
Certification.
Sincerely,
STRATA ENVIRONMENTAL
Timothy L. Riddle, P.G.
Senior Geologist (NC Reg. #1710)
TLRJkmc
Enclosures
- DEC a 4 2002 I
DENR - WAITM 09] LITI'
99254007.27 1

1�
NC&NF,01 4-1 - Gee,-�m, 6
United States Environmental Protection Agency FoOMB No. o2 ¢proved
. 2040-0211
NPDES A Washington, DC 20460
FORM `�, EPA NO EXPOSURE CERTIFICATION for Exclusion from
3510.11
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, 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
— ` :al pro�acis, c;her than. produem that would be mobilized in storm waiCr discharges, (e.g., rock sait).
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. Facility Operator Information
1.Name: LSLttrIoinigihiaivieInl ICloInItIaIiInIejrIs_j__t2.Phone:L7101_41814171.71714131
3. Mailing Address: a. Street: 1111013l5i lMIoInIrIoIeL_IRIdl_j1)qAojxI3 Q Q
b.City. lMiaitltihieiwisi I_I i I I 1 1 I I I I I I I c.State: LNLCj d.ZipCode: 1218ilIQ151-1 I I I
B. Facility/Site Location Information
1.FadlityName: ISItlrlolnigihialyleini iWiairielhlolulslei I I I I I I I 1 1
2. a. Street Address: 1413131 IE,alsltlJohns S t r leje It
b.City: IMIaititihieiwiwl I I I I I I I I I I jI I 1J c.County: MIEj 1kt11elnlblurrIg
d. State: INICI e. Zip Code: 1121811 1 Q 151 - t 1 1 1 I
3. Is the facility located on Indian Lands? Yes ❑ No
4. Is this a Federal facility? Yes ❑ No n
5. a. Latitude: l3 jJ o j0I6J L4 L.7J b. Longitude: 1 1810 - �� ' 10151
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No ® .
b. If yes, enter NPDES permit number:
7. SIC1Acthrity Codes: Primary: 121 61 71 5 Secondary (if applicable): 1 I I I j
8. Total size of site associated with industrial activity: 2 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 ❑R
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 (10-99) Page 1 of 4

t
NPDES A Form Approved
FORM NO EXPOSURE CERTIFICATION for Exclusion from OMB No.2040-0211
351at1 .•EPA 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 spillsAeaks
X❑
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
❑
21
5. Materials or products during loading/untoading or transporting activities
7
FT
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
El
0
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
11
Fz1
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
El
z
10, Application or disposal of process wastewater (unless otherwise permitted)
El
1E
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
El
0
(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 NP❑ES 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). t 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 MI it kl el ICI 1f a1 ri kl I I I I I I _I I I I I I I I I I I I I I f I
Print Tilfe: I GI el n1 el rl a l l i I M, a, n] a, g, e, r l I I I I I I I I I I I I I I l l
Signature: A , Z/llr�t/F---
Date: 1)
EPA Form 3510-11 (10-99) Page 2 of 4