NCGNE0283_COMPLETE FILE - HISTORICAL_20060606

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE Uq��
DOC TYPE
❑HISTORICAL FILE
DOC DATE
❑ (/� � b � � U �a
YYYYMMDD

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
Coleen H. Sullins, Deputy Director
Division of Way Q G
A�,, Lo— t . -- �1rV'fltt]Plti>'e�ttt�
AND I urcr.t.,t-SO :tRCES
MOORESVILLE F=C.ONAL OFFICE
June 2, 2006
Mr. Lynwood Scott
Bassett Furniture Industries
PO Box 626
Bassett, VA 24055
Subject: No Exposure Certification NCGNE0283
Bassett Furniture Industries -Plant 31
1111 E. 20th Street, Newton, NC
Catawba County
S f.J `p)-L
Dear Mr. Scott:
SUN 0 6 200'
WATER QUALITY ST101
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on May 18, 2006. 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, and
subsequently, rescinding your former Certificate of Coverage number NCG180127.
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, 2011). 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], ext.
502, or at [e-mail].
cc: Mooresville Regional Office
Stormwater Permitting Unit Files
Sincerely,
ORIGINAL SIGNED BY
KEN PICKLE
for Alan W. Klimek, P.E.
Central Files — wlattachments
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
NCDENR
Customer Service
1-877-623-0748

- F i�1 A TF
Michael E. Easley, Governor
`I , 9pG William G. Ross 1r., Secretary
North Carolina Department of Environment and Natural Resources
�!] Alan W. Klimek, P. E. Director
Division of Water Quality
0 Coleen 14. Sullins. Deputy Director
Division of Water Quality
June 2, 2006
Mr. Lynwood Scott
Bassett Furniture Industries
PO Box 626
Bassett, VA 24055
Subject: No Exposure Certification NCGNE0283
Bassett Furniture Industries -Plant 31
1111 E. 20'1" Street, Newton, NC
Catawba County
Dear Mr. Scott:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on May 18, 2006. 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, and
subsequently, rescinding your former Certificate of Coverage number NCG180127.
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, 2011). 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], ext.
502, or at [e-mail].
cc: Mooresville Regional Office
Stormwater Permitting Unit Files
Sincerely,
4 P�
for Alan W. Klimek, P.E.
Central Files -- w/attachments
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
v
NGDI_NR
Customer Service
1-877-623-6748

IY N J
NCB���5
Form Approved
United States Environmental Protection Agency OMB No 2040-0211
kPQES �� EPA Washington, DC 20460
3510-11
FARM 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, andlor 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 unkrading, 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 NPI]ES permitting is
available on a faciilty-wide basis only, not for individual outfalts. 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 an pages 3 and 4.
A. Facllfty Operator Info, nm Y-'C onpp
1. Name: �SL`S1Pt-1 `}} - l I�Irf�-ItI�rI` ~I IIinfdl5l - r i e,s, 1 2. Phone: [phone]i
3. Mailing Address: a. Street: IP101 IE�` xj 16,2,6, 1 1 1 1 1 1 1 i I I I! I I I I I I I IC I
b. CAy S S [ v �l C. State: d. Tap Code: 121410t 5151- 1 1 1 1
B. FacllitylSke Location Information
1. Facility Name: �34S4SIeltitl IF
Ijjrri, IIAcli IPI1Ic-4qtl _ 13, ` 4 i 1 1 1
2. a. Street Address: 111111111 IE1 2,0,TE S,t,rlelel , I I I I I # I I I I I I I
b. City: INIeIwItl` p7F I I I I I I I I I I 1 1 1 1 1 c. County: QAtlAwJbi4
d. state: NC a. Zip Code:Z8653i-t
3. Is the facility locates — Indian Lands? Yes
4. Is this a Federal facility?Yes
El
5. a Latitude: 13151 4, 0J
No
No © b. Longitude: 1018
I - 1112� ,
6. a Was the facility or site previously covered under an NPDES storm water permit? Yes 0 No
b, tf yes, eater NPI)ES permit number. NCG18 0 12
SIUActivity Codes: Primary: 2 L5~ 112 Secondary (if applicable): �J
8. Total size of site associated with industrial activity: 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
ti. If yes, please indicate approximately how much area was paved or roofed over. Compieting 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 El
EPA Form 3510-11 (10-99) Page 1 of 4

r
NPDES ,� NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM �r,�pq OMB Na.2040-0211
3510-11 - NPDES Storm Water Permitting
C. Exposure ChecklW
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes' or "Na in the appropriate box.) tf 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 spillslleaks
3_ Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during badinglunloading 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 handledistored on roads or railways owned or maintained by the discharger
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpstersn
10. Application or disposal of process wastewater (unless otherwise permitted) El Z
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
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.certtfy under penalty of taw 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 property 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 Use information, including the possibility
of fine and imprisonment far knowing violations.
Print Name: �I- ylw i gq I.S qq}} :I }} :t I I I I I I I I I j_ I I I I I I I I I
Print Title:
Signature:
Date:
EPA Form 3510-11 (10-99)
Page 2 of 4

r►
r ,
Folly Instructions for the NO EXPOSURE CERTIFICATION for OMs Form
200440p-0211
351041 .AVEPA Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. FacilitylSlte 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 551}, 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 (A) 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)(14xx) 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 roust obtain coverage under an NPDES
storm water permit immediately.
Where to Fife the No Exposure Certification Form
No Exposure Forms sent regular mail:
SW No Exposure Certification (4203M)
USEPA
1200 Pennsylvania Avenue, NW
Washington, Q.C. 20460
Completing t1he Form
Forms sent ovemightlexpress:
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.govinpdeslstormwater. 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 arty
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 (PD. 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 Govemment (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 deg reeslminuteslseconds. 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:llwww.oensus.gov/ogi-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
degreeslminutes/seoonds, follow the steps in the following example.
Exam : Convert decimal latitude 45.1234567 to degrees ('), minutes
('), and seconds (").
a) The numbers to the left of the decimal point are the degrees: 450.
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: T.
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 = 450 T 24".
B. 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, 1987.
8. Enter the total size of the site associated with industrial act" 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 [at) 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

NPDES A Form Approved
FORM Instructions Instructions for the NO EXPOSURE CERTIFICATION for OMB No.2040-0211
3510-11 Exclusion from NPDES Storm Water Permitting
Section C. Exposure Checklist authority to sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
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) For a partnership or sole proprietorship: by a general partner or the
in this section, a potential for exposure exists at your site and you cannot proprietor; or
certify to a condition of no exposure. You must obtain (or already have)
coverage under an NPDES storm water permit. After obtaining permit For a municipal, State, Federal, or other public facility: by either a
coverage, you can institute modifications to eliminate the potential for a principal executive or ranking elected official.
discharge of storm water exposed to industrial activity, and then certify to
a condition of no exposure. Paperwork Reduction Act Notice
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:
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
tern environmental compliance with environmental laws and
regulations; the manager can ensure that the necessary systems
are established or actions taken to gathercomplete and accurate
information for permit application requirements; and where
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

Form Approved
United States Environmental Protection Agency OMB No. 2040-0211
NPDES t1 Washington, DC 20460
3510-11
FORM `o' 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 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 fallowing 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 mobil¢ed in storm water discharges (e.g., rodc salt).
A No Exposure Certification must be provided fir 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 Informaatiioon}. pp 7,
1. Name:Tt`'"Ialsis,(EtI ttl IFL�rinti,tlgrIe' IIA dI` s,t,ri e,s, 1 2. Phone: [2.1 I1616L2_ t9161010[01
3. Marling Address: a_ Street: jPjL6 2 6
b: City AasisigtitC. State: I v A d. Zip Code: -
B. Facility/Site Location information
1. Facility Name: I]B1a151gE �- tit, I�`IrA Ilndplprl}ll�ti 1316, 1 f I__1_
2. a. Street Address: . 11,11111, g 12,0,TA IS,t,r1�� `1 1 1 I I I I I L_L_l I I I
b. City: "le Wltl`-'A 1 1 pp i `I j. I_ i 1 1 1 L t_ 1 1 I c. County: a t a w a
d. State: /Y C .. e. Zip Code: 12tOi6i5 ,. �1__ t I J �~
3. Is the facility located on Indian Lands? Yes ❑
4. Is this a Federal facility? Yes ❑
5. a. Latitude: 13 i.o A01
No
No
1n 0
b. Longitude: 11121 2 2
6. a. Was the fadlity or site previously covered under an NPDES storm water pe'r-mi�t?/�� Yps�QQ No ❑
b. If yes, enter NPDES permit number: NCG 1 S 0 1 2 5 �� �-'
7. SIC/Activity Codes: Primary: �J . Secondary (if applicable): I I I 1 1
8. Total size of site associated with industrial activity: 20 acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to quality fir the no exposure exclusion?
7D
Yes❑ No©
h 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 rase 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 NO EXPOSURE CERTIFICATION for Exclusion from OMB No 204p-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
RIV
3. Materials or products from past industrial activity
91
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during Ioadinglunloading or transporting activities
❑
10
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
❑
W]
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))
❑
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 l 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 far knowing violations.
Print Name: JT yiY wQgc _I IGq :l :i 11 I I [ I I I I I I I I I I I I I I
Print Title: lD;r(elgtiq 1�1nlVilri„i�i"TPI I��l I 1„ I I I I E 9 I j
Signature:
Date: . 0,5 i0,5 0,61
EPA Form 3510-11 (10-99) Page 2 of 4

1
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 mall: Forms sent ovemighUexpress:
SW No Exposure Certification (4203M)
USEPA
1200 Pennsylvania Avenue, NW
Washington, D.C. 20460
Completing the Form
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.govinpdeslstormwater. 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 degreeslminuteslseconds. 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:llwww.census.gov/cgi-binigazetteer.
Latitude and longitude for a facility in decimal form must be converted
to degrees (°), minutes ('), and seconds O for proper entry on
the certification form. To convert decimal latitude or longitude to
degreeslminutestseconds, follow the steps in the following example.
Example: Convert decimal latitude 45.1234567 to degrees (1), minutes
('), and seconds (').
a) The numbers to the left of the decimal point are the degrees: 450.
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: 'r.
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 = 46, 7' 24'.
6. Indicate whether the facility was previously covered under an NPDES
r 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, 1987.
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 roadiparking 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

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
Section C. Exposure Checklist authority to sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
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) For a partnership or sole proprietorship: by a general partner or the
in this section, a potential for exposure exists at your site and you cannot proprietor; or
certify to a condition of no exposure. You must obtain (or already have)
coverage under an NPDES storm water permit. After obtaining permit For a municipal, State, Federal, or other public facility: by either a.
coverage, you can institute modifications to eliminate the potential for a principal executive or ranking elected official.
discharge of storm water exposed to industrial activity, and then certify to
a condition of no exposure. Paperwork Reduction Act Notice
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
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 (i0-99) Page 4 of 4

Re: NCGNE0283
Subject: Re: NCGNE0283
From: Michael Parker <Michael.Parker@nemaiLnet>
Date: Tue, 23 May 2006 08:0&52 -0400
To: sarah young <[e-mail]>
Feel free to issue the no -exposure.
Mi ke
Sarah young wrote:
Ianother no -exposure
Michael Parker <Michael,Parker@ncmaiLnet>
Environmental Engineer 11
i
Department of Environment and Natural Resources
1 of 1 6/5/2006 U5 AM