NCGNE0366_COMPLETE FILE - HISTORICAL_20090130

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
El HISTORICAL FILE
DOC DATE
❑ (/�J7VI c3U
YYYYMMDD

O�OF W ATF9QG
co
Beveriv Eaves Perdue, Governor
Dee Freeman, Secrelary
North Carolina Department of Environment and Nalural Resources
s
January 30, 2009
.Mr. Jerry Swart
1000 Fedex Drive
Moon Township, PA. 15108
SUBJECT: January 26, 2009 Compliance Evaluation Inspection
Fedex Ground -Raeford
Permit No: NCGNE0366 (Industrial Storm►eater-No Exposure)
Hoke County
Dear Mr. Swart:
Coleen 1.1. Sullins, Director
Division of Water Quality
Enclosed please find a copy of the Compliance Evaluation Inspection Report from the inspection conducted on
Janaury 26 2009 by Hughie White of the Fayetteville Regional Office. The facility was found to be in Compliance
with permit NCGNE0366.
This facility has a No Exposure Certification for Industrial Stormwater. A visual inspection was conducted on
January 26, 2009 to verify proper operating procedure at this facility to meet the requirements for the No Exposure.
Certification. This inspection was perfonned without entry into the facility and no on -site personnel was contacted,
as well. This facility appears to meet the requirements for the certification.
Please refer to the enclosed inspection report for additional observations and Comments. If you have any questions,
please call me at 910-433-3308.
Sincerely,
1-lughie White
Environmental Specialist
cc: LAPS -Assistance & Compliance Oversight Unit
DWQ-Central Files
Fayetteville Files
Onc
NoIthcmolina
,Valia-al4//
North Carolina Division of Water Quality 225 Green Street— Suite 714 Fayetteville, NC 28301 -5043 Phone [phone] Customer Service
Intemet h2o.enr.state.nc.us FAX (910)4S6-0707 1-877-623-674S
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper

Beverlv Eaves Perdue, Governor
Dee Freeman, Secretary
North Carolina Department of Environment and Natural Resources
Coleen H. Sullins, Direclor
Division Of Water Quality
January 30, 2009
Mr. Jerry Swart
1000 Feder; Drive
1Aoon Township; PA 15108
SUBJECT: January 26, 2009 Compliance Evaluation Inspection
Fedex Ground -Raeford
Permit No: NCGNE0366 (Industrial Storniwater-No Exposure)
Hoke Count),
Dear. :11r. Swart:
Enclosed please find a copy of the Compliance Evaluation Inspection Report from the inspection conducted on
Janaury 26. 2009 by Hughie White of the Fayetteville Re�Lnonal Office. The facility was found to be in Compliance
with permit NCGNE0366.
This facility has a No Exposure Certification for Industrial Stormwater. A visual inspection was conducted on
January 26, 2009 to verify proper operating procedure at this facility to meet the requirements for the No Exposure
Certification. This inspection was performed without entry into the facility and no on -site personnel was contacted,
as well. This facility appears to meet the requirements for the certification.
Please refer- to the enclosed inspection report for additional observations and continents. If you have any questions,
please call nee at 910-433-3308,
Sincerely,
Hughie White
Environmental Specialist
cc: 'NTS-Assistance & Compliance Oversight Unit
DWQ-Central Files
Fayetteville Files
a��
NorthCarolina
!Nnlurrrlly
North Carolina Division of Water Quality 225 Green Street— Suite 714 Fayetteville, NC 28301-5043 Phone [phone] Customer Service
Internet: h2o.enrstate.nc.us FAX [phone]
An Equaf Opportunity/Affirmative Action Employer— 50% Recycled110% Post Consumer Paper

�0F'WArEg0
CO
o -c
Mr. Jerry C. Swart
Fedex Ground Package Sytem
1000 Fedex Drive
Moon Township, PA 15108
Dear Mr. Swart:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
August 24, 2007
Coleen H. Sullins, Director
Division of Water Quality
DE�,�:9H_FRO
J Z Z�U7
Subject: No Exposure Certification NCGNE0366
Fedex Ground
104 Midway Drive, Raeford, NC
Hoke County
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 27, 2007. Based on your submittal and signed
certification of no exposure at the above referenced facility, the Division is granting your certification as
provided for under 40 CFR 126.22(g), which is incorporated by reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (August 31, 2012), At that time you must re -certify
with the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
..Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Sarah Young at [phone], ext.
502, or at [e-mail].
Sincerely,
ORIGINAL SIGNED BY
KEN PICKLE
for Coleen H. Sullins
cc: Fayetteville Regional Office -Mike Lawyer. Central Files — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
MENR
Customer Service
1-877-623-6748

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
August 24, 2007
Mr. Jerry C. Swart
Fedex Ground Package Sytem
1000 Fedex Drive
Moon Township, PA 15108
Subject: No Exposure Certification NCGNE0366
Fedex Ground
104 Midway Drive, Raeford, NC
Hoke County
Dear Mr. Swart:
Coleen H. Sullins, Director
Division of Water Quality
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 27, 2007. Based on your submittal and signed
certification of no exposure at the above referenced facility, the Division is granting your certification as
provided for under 40 CFR 126.22(g), which is incorporated by reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to -immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (August 31, 2012). At that time you must re -certify
with the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Sarah Young at [phone], ext.
502, or at [e-mail].
Sincerely,
for Coleen H. Sullins
cc:' Fayetteville Regional Office -Mike Lawyer Central Files — wlattachments�
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
0ENR
Customer Service
1-877-623-6748

Re: next set df no -exposures
Subject: Re: next set of no -exposures
From: Mike Lawyer <[e-mail]>
Date: Mon, 11 Jun 2007 16:28:13 -0400
To: Sarah Young <[e-mail]>
CC: Belinda Henson <[e-mail]>
Sarah,
After conducting site visits to the subject facilities, I.have the following comments
on 3 out of the 4. Comments on the 4th facility will.come in a separate e-mail.
-NCGNE0365-Pepsi Bottling Ventures: I actually went to this site several weeks ago
and suggested to personnel that they would qualify for the NEC. _Please proceed with
issuance.
-NCGNE0354-Robeson County Auto Garage: Went to this site on 6/6. Small garage that
performs routine and preventative maintenance on all county -owned vehicles. No work
is performed outside and nothing is stored outside., Used oil is dumped into a pipe
located inside the building, which leads directly into a tank located outside &
adjacent to the building. This tank does have secondary containment around it with
an outlet pipe that is kept closed. Any stormwater that is released is first visually
checked for evidence of any product. Used oil in the tank is pumped out and carried
away as needed. It's my understanding that this would not disqualify the facility
from getting the NEC so unless I'm mistaken on this, please proceed with issuance._
=NCGNE0366-FedEx Ground: Went to this site on 6/11. Facility is a hub that receives
packages and then delivers them to their local destinations. Nothing is outside
except for parked trucks and trailers and a dumpster, which is kept covered. No
vehicle maintenance is conducted onsite. There are some trench drains inside the
building that carry water from truck washing to an underground oil/water separator
located outside, which according to the guy I met with, Mr. Michael Mason, Senior
Manager, is connected to sanitary sewer. _Please proceed with issuance of the NEC.'
,Mr. Mason asked to receive a copy of the NEC if issued. His copy can be sent -to his-
<attention at: FedEx Ground, 104 Midway Drive, Raeford, NC 28376.'
If you require further information on any of these facilities, please let me know.
Thanks,
Mike
Sarah Young wrote:
Here's the next set of no exposures for your region. Please let me know within 30
days if we can issue these. If you need more time just let me know. Thanks, Sarah
Michael Lawyer
Environmental Specialist
NCDENR-Division of Water Quality
Surface Water Protection Section
Fayetteville Regional Office
Direct: [phone]
Main: [phone]
Fax: [phone]
1 of 1 8/17/2007 1:40 PM

WC&NFvV%(P F Fb
United States Environmental Protection Agency Form Approved
9 Y OMB No. 2040-0211
NPDES ;'
3510-11 ��� Washington, DC 20460
FORM Awl 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 teak. "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 outfalls. If any industrial activities or materials are of 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:
2. Phone: I71 IIIU 4Y ZI 31"/ I / I
3. Mailing Address: �a. Street: I/ 1016 01 I'I PI al EI XI 014 / 1✓ I� I 14 I I I I_ I I I I rI I J I I
b. City: A 010 Vy I I r l (3, Kf Aid IX/1 / 1/" 11 1 1 1 I 1 1 I I c. state: LPIA d. Zip Code: II .� 110 1Q 1— 1 I I I I
B. Facility/Site Location Information
1. Fac'slity Name: 1f1P-1 4116XI I fIQIOI u1
NP I I I I I I I I I I I I I I I I i
2. a. Street Address: dy Q
/�I
r f Z
b. City: I#EE (1041 6) 1 1 1 1 1
1 1 1 1 1 1 1 1 I c. County: I&OIkI ei- I I I I I
I 1
d. State: tr' e. Zip Code: bU l-51
`
7 1 f71 — 1 I t I
3. Is the facility located on Indian Lands? Yes ❑
No I pi
4. Is this a Federal facility? Yes ❑
No
5. a. Latitude: LA t/J dju
b. Longitude: I
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. SIC/Activity Codes: Primary: ell �
Secondary (if applicable): I I I
6. Total size of site associated with industrial activity:
1/., / 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

&/��, � ����
� §� � ^��)� �i� � � � • � a
• ! � �
� ��: �
� .�2`

NPDES ,., NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM a-sEPq OMB IVo.2040-0211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spills/leaks
Er
3. Materials or products from past industrial activity
2-
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during load inglunloading 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
El
21-
8. Materials or products handled/stored on roads or railways c :ned or maintained by the discharger
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
LIZ
10. Application or disposal of process wastewater (unless otherwise permitted)
LC!
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
El
53"
(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:
'PriritTitle: IMI it MA4 2110 161 IY I/ P4�i 617-l0l4 I I I I I I i l I I I I I I I
Signature:
Date: 14014
EPA Form 3510-11 (10-99)
Page 2 of 4

FedEx Ground
Environmental Services
P.O. Box 108
Pittsburgh, PA 15230
PHONE [phone] FAX [phone]
l MAR 7 Lic,
7
NR - +NA�Rmnch "
LETTER OF TRANSMITTAL
SENT: FedEx CERTIFIED MAIL X
TO:
NC Division of Water Quality
DATE:
March 21, 2007
Stormwater Permitting Unit
RE:
FedEx Ground Facilities
1617 Mail Service Center
Raleigh, NC 27699-1617
Fayetteville Terminal
104 Midway Drive
Raeford, NC 28376
Hickory Terminal
1 136 Industrial Drive
Conover, NC 28613
WE ARE SENDING YOU:
X
Enclosed
File
PartiallyExecuted
Drawings
Copies
I
I Fully Executed
COPIES
DATE
DESCRIPTION
1
03/21/07
No Exposure Certification form — Fayetteville
1
03/21/07
No Exposure Certification form — Hickory
THESE ARE TRANSMITTED as checked below:
For Execution
Approved as Submitted
Return Copy(s) for File
For Your Use
Approved as Noted
Resubmit for Approval
As Requested
Returned for Correction
Return Corrected
X
As Required
Other (Returned)
For Your Signature
REMARKS:
cc: File
FROM: Nancy Beaumont
Environmental Administrator
412-262-7347
cadocuments and settings\] 5738721my documentsllolslllot - nc sw pemtitting unit - rayettvville, hickory 03-21-07.doe

Re: next set of no -exposures
Subject: Re: next set of no -exposures
From: Mike Lawyer <[e-mail]>
Date: Mon, 1 1 Jun 2007 16:28:13 -0400
To: Sarah Young <sarah.young a ncmail.net>
CC: Belinda Henson <Bellnda.Henson @ncmail.net>
BCC: Mike Lawyer <[e-mail]>
Sarah,
After conducting site visits to the subject facilities, I have the following
comments on 3 out of the 4. Comments on the 4th facility will come in a separate
e-mail.
-NCGNE0365-Pepsi Bottling Ventures: I actually went to this site several weeks ago
and suggested to personnel that they would qualify for the NEC. _Please proceed
with issuance.
-NCGNE0354-Robeson County Auto Garage: Went to this site on 6/6. Small garage that
performs routine and preventative maintenance on all county -owned vehicles. No work
is performed outside and nothing is stored outside. Used oil is dumped into a pipe
located inside the building, which leads directly into a tank located outside &
adjacent to the building. This tank does have secondary containment around it with
an outlet pipe that is kept Closed. Any stormwater that is released is first
visually checked for evidence of any product. Used oil in the tank is pumped out and
carried away as needed. _It's my understanding that this would not disqualify the
facility from getting the NEC so unless I'm mistaken on this, please proceed with
issuance.
-NCGNE0366-FedEx Ground: Went to this site on 6/11. Facility is a hub that receives
packages and then delivers them to their local destinations. Nothing is outside
except for parked trucks and trailers and a dumpster, which is kept covered. No
vehicle maintenance is conducted onsite. There are some trench drains inside the
building that carry water from truck washing to an underground oil/water separator
located outside, which according to the guy I met with, Mr. Michael Mason, Senior
Manager, is connected to sanitary sewer. _Please proceed with issuance -of the NEC._
Mr. Mason asked to receive a copy of the NEC if issued. His copy can be sent to his
attention at: FedEx Ground, 104 Midway Drive, Raeford, NC 28376.
If you require further information on any of these facilities, please let me know.
Thanks,
Mike
Sarah Young wrote:
Here's the next set of no exposures for your region. Please let me know within 30
j days if we can issue these. If you need more time just let me know. Thanks, Sarah
Michael Lawyer
Environmental Specialist
NCDENR-Division of Water Quality
Surface Water Protection Section
Fayetteville Regional office
Direct: [phone]
Main: [phone]
Fax: [phone]
3 of 1 6/15/2007 8:50 AM

Form Approved
United States Environmental Protection Agency OMB No. 2040-0211
NPDES Washington, DC 20460
FORMEPA 3510-11 `� 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 Vvater 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, snowmett, and/or runotf. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industnal 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 stieEter 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 teak. "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 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 lei ms and condi!ions of 40 CFR 122.26fa).
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: 2 Cf aC /� Ll L 0Iqlel -> / 1 1 2. Phone: I I € I 4't,791`%I ! I
3. Mailing Address: a. Street: I/ILtIC01 l�tE�l«I�%IA 1l/I`I/IVIK-P 11 1 11 t i 1 I t I�I I I I
b. City.. Y r l 01 1 All t (I Q I � �1 +/ 1,41L I I i I}. I I I I c. State-, � d. Zip Code: IA-� - 1147 A— 1 I I I
B. FacilitylSite Location Information
1.Facility Name: 1f1_ei[Ii4IX1_t 6AU14A I I i l l I I I I I I I I I I I
2. a. Street Address: I% ldly, t/A i d IA1L1hrI IP4l-1_ V1 1 I I I I I I I I I )� I I1� I I I I I
b. City: /� i s l c. County: 1 h1011� I C- I I_ i I I
d. State: Akj_ e- Zip Code:
3_ is the facility located on Indian Lands? Yes ❑ No
4. Is this a Federal facility? Yes No
5. a. Latitude: �� LA 66j" b. Longitude: L_f L Lsj n
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. SIC?Activity Codes: Primary: 16�A/_rfc Secondary (if applicabie): I I I I
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
ET-
1). 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 arse F1 One to five acres El more than five acres ❑
EPA Form 3510-11 (10-99) Page 1 of 4

A:
NPDES e, NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM ®0A ��� a#v18 f €o. 2040-0211
3510-11 NPDES Storm Water- Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either'Yes" or `No' in the appropriate box,) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
❑
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spillsfleaks
❑
!�
3. Materials or products from past industrial activity
❑
4. Material handling equipment (except adequately maintained vehicles)
❑
FLf-
5. Materials or products during loading/unloading or transporting activities
❑
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars) where
❑
exposure to storm water does not result in the discharge of pollutants)
7. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
❑
a. iviateriais or products handfed?stored on roads or railways owned or maintained by the discharger
❑
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑Liz
10. Application or disposal of process wastewater (unless otherwise permitted)
❑
11. Particulate matter or visible deposits of residuals from roof stacks andlor 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 taw that I have read and understand the eligibility requirements for claiming a condition of `no exposure" and obtaining an
exclusion from NPDFS 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)).
t 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 facifty.
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:
Print Title: IAAAIA1�il 04-1 I I, 1 1. 1 �_ I I I I I I I I I
Signature:
Date: 1601 Zt 10
EPA Form 3510-11(10-99)
Page 2 of 4

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