NCGNE0551_COMPLETE FILE - HISTORICAL_20090227

s
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
F� HISTORICAL FILE
DOC DATE
❑ c� b 0Lo,-J- �- -�
YYYY MM DD

0
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality Fzh'' rw
Beverly Eaves Perdue Coleen N. Sullins Fi-oDee�Fre man
;�-� �'
Governor Director Secretor
February 27, 2009 MAR 3 0 2009
Ms. Allyson Bristow
International Paper Company 141r ItiiL:
6400 Poplar Avenue ��f
Memphis, TN 38197 M-Surface Wbter Frolec ion
Subject: No -Exposure Certification NCGNE0551
Charlotte Retail Center
10601 Westlake Dr., Charlotte, NC 28273
Mecklenburg County
Dear Ms. Bristow:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES Stormwater
Permitting form. Based on your submittal and signed certification of no exposure at the above referenced facility, the
Division.is granting your conditional exclusion from permitting 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 (February 26, 2014). At that time you must re -certify with the Division, or
obtain NPDES permit coverage for any stormwater discharges from your facility.
Your conditional exclusion from permitting does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Robert Patterson at [phone], or at
robert. patterson@ncmail. net.
Sincerely,
l
for Coleen H. Sullins
cc: Mooresville Regional Office -Michael Parker Mecklenburg County
Stormwater Permitting Unit No- Exposure Files
Wetlands and Stormwater Branch
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Ralegh, North Carolina 27604
Phone: 91 H07-63001 FAX: 91 H07-64941 Customer Service: 1-877-623-6748
Intemet: www.ncwaterquality.org
An Equal opportunity l Affirmative Action Employer
Nor thCarolina
Naturally

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Ate%
NCDENR
V�r(tn ( [`ewmrKvr
FM VfgVMIYT yin Netiny. ReSdJXFA
Division of Water Quality 1 Surface Water Protection
National Pollutant Discharge Elimination System
. IN F
FOR AGENCY USE ONLY
Date Received
Year I Month
I Day
% CW
111"015R
Cenificatc'of c %v&age.
91'CIGINID �`r
NO EXPOSURE CERTIFICATION for Exclusion N.),IV
NO EXPOSURE CERTIFICATION
NCGNE0000
OCT 2 4 2008
Please check here if this is a renewal: ❑ RENEWAL
National Pollutant Discharge Elimination System application for exclusion from a Stormwater PermiC,'4:)
based on NO EXPOSURE:
i V%., uctY,% IVi�L �r
nti r rn ►%_ _r _ _ _ u r-A
Submission of this No Exposure Certification constitutes notice that your facility dti�estir'ot rregcsire permit
authorization for its Stormwater discharges associated with industrial activity in the State of North
Carolina because it qualifies for a no exposure exclusion. A condition of no exposure at an industrial
facility means all industrial materials and activities are protected by a storm resistant shelter (with some
exceptions) to prevent exposure to rain, snow, snowmelt, and/or runoff.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste
products. Material handling activities include the storage, loading and unloading, transportation; ors
conveyance of any raw material, intermediate product, final product or waste product. A storm resistan
shelter is not required for the following industrial materials and activities: drums, barrels, tapm , an�
similar containers that are tightly sealed, provided those containers are not deteriorated and-gi no€gea .
"Sealed" means banded or otherwise secured and with locked or non -operational taps or valves;
<t
adequately maintained vehicles used in material handling; and final products, other than products tgat
would be mobilized in Stormwater discharges (e.g., rock salt). � xl
A No Exposure Certification must be provided for each _faci ty qualifying for the no exposure e�ciusic
In addition, the exclusion from NPDES permitting is available on a facility -wide basis only—n6t ?bG�
individual outfalls. If any industrial activities or materials are, or will be, exposed to precipitation, the
_,
facility is not eligible for the no exposure exclusion. By signing and submitting this No Exposure
Certification form, you certify that a condition of no exposure exists at this facility or site and are
obligated to comply with the terms and conditions of 40 CFR 122.26(g).
You must re -apply for the No Exposure Exclusion once every five (5) years.
For questions, please contact the DWQ Regional Office for your area. (See page 5)
(Please print or type)
1) Mailing address of owner/operator address to which all certification correspondence will be -mailed):
Name �h�r�d�wi K. COAT rs
Contact Ali so'& ri�Tdc,1
Street Address "
City StateZIP Cade -3 'Vq 7
Telephone No. Fax:
2) Location of facility producing
_discharge,
Facility Name Gkhh /� 1 �
Facility Contact Co l GS7'�
Street Address
City if/ State .zl,&�-ZIP Code 7,
County,
Telephone No. -70�t . tl Fax: :22 ,T -ZfZ
Page 1 of 5
SWU-NE-060508 tvc�' -�"� P" - Last revised 06/05/2008

0
it
7

NCGNE0000 No Exposure Certification
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road numbey� ,
distance and direction from a roadway intersection). F
M q
(A copy df a map with the facility clearly located on it should be included`with the certification application.)
4) is the facility located on Native American Lands? ❑ Yes 'RN0
5) Is this a Federal facility? ❑ Yes )<No 4- '1 r r /I ,ale$
6) Latitude ^�0+ 76 517 Longitude :3•Sa / �W?' (deg` in., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin Existing Date operation began / +L r� ,
�3
/❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes /;!5,No
If yes, what is the NPDES Permit Number?.
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 16
S
10) Provide a brief description of the types of industrial activities and products produced at this facility:
Mpw .aG --,p//aA-,-,r1G✓`5 ��.� A,#Alllor_
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
XNo
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks
c. Materials or products from past industrial activity
d. Material handling equipment (except adequately maintained vehicles)
e. Materials or products during loading/unloading or transporting activities
f. Materials or products stored outdoors (except final products intended for outside
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
❑ Yes XNo
❑ Yes XNo
❑ Yes XNo
❑ Yes • XNo
❑ Yes �( No
Page 2 of 5
SWU-NE-060508 Last revised 06/05/2008

NCGNEOOOO No Exposure Certification
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks,
❑ Yes
)(No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
❑ Yes
1XQNo
the discharger
L Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes
I
�(No
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
"XNo
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
❑ Yes
�No
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
1. Empty containers that previously contained materials that are not properly stored
❑ Yes
XNO
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers
❑ Yes
XNo
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible for the no exposure exclusion./1/JT �j�fG ,/ -x/v _4�S & 4- , Fle--
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No
deterioration, or evidence of leaks?
b. is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
14) Secondary Containment: If you answer "No" to -any of the following items, you are not eligible for the
no exposure exclusion. ( if�5�`icC 4) !�1 "1 sy—F-Q:pe_ ho*- al lli&,&� _ � � rG H r�Pfal�
a. is secondary containment provided for single above ground storage container/s ❑ Yes ❑ No /�
(including drums, barrels, etc.) with a capacity of more than 660-gallons? -o`eg �� n c15e- %',L-S IIA- 1�e_
b. Is secondary containment provided for above ground storage containers stored
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. is secondary containment provided for any amount of Title III Section 313
Superfund Amendments and Reauthorization Act (SARA) water priority
chemicals?
d. is secondary containment provided for Iny amount of hazardous substances?
e. Are release valves on all secondary containment structures locked?
15) Hazardous Waste:
1
LJ Ye5 ❑ NO
© Yes ❑ No
�(Yes ❑ No
❑ Yes ❑ No
Page 3 of 5
SWU-NE-060508 Last revised 06/05/2008

NCGNE0000 No Exposure Certification
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes �No
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste XYes ❑ No
generated per month) of hazardous waste? XNO
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste: !NQ'Si4-- ca-/, &-a F-kh�W-sceA--l'y
How is material stored: i f_ Y,.r; iA s , &i ,-,G Q: Se1-.,K.j&•7r /sir fra
Where is material stored: ti '
How many disposal shipments per yea(- t5Q Olf �t trc— Mast
Name of transport /disposal wgndor:
Vendor address: �394 Oa d.ei /X.// Are_- Ale—
16) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no
exposure' and obtaining an exclusion from NPDES stormwater permitting.
certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five 5) years to the North Carolina
Division of Water Quality 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 North Carolina Division of Water
Quality, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm_ the condition of no
exposure and to make such inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater from the facility. Additionally, I certify under penalty
of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based
on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is to the best of my knowledge and belief true, accurate and complete. I am aware
that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed Name oJ Person Signing:
Title: led'v -tDic 7 t:�/
S� i /off
(Signatur of pplicant) U (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at any in the future for compliance with the No Exposure Exclusion.
Page 4 of 5
SWU-NE-060508 Last revised 06/051200B

NCGNE0000 No Exposure Certification
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a tine
not to exceed ten thousand dollars ($10,000).
There is currently no fee for a No Exposure Exclusion.
Final Checklist
This application should include the following items:
❑ This completed application and all supporting documentation.
❑ A map with the location of the facility clearly marked.
❑ If this is a renewal, indicated current NCGNE number in Question 7.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Asheville Office ......
[phone]
Fayetteville Office .:.
[phone]
Mooresville Office ...
[phone]
Raleigh Office ........
[phone]
Washington Office ...(252)
946-6481
Wilmington Office ...
[phone]
Winston-Salem ......
[phone]
Central Office .........(919)
733-5083
Page 5 of 5
SWU-NE-060508 Last revised 06/05/2008

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movies, businesses & mores 990-CALL-411.
http://maps.live.com/print.aspx?mkt=en-us&z=17&s=a&cp=pvglgz87kkjc&poi=10601 Westlak... 11/17/2008

l�Cklenburg County, NC POLARIS
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public records and data. Users of this map are hereby notified that the aformentioned
public primary information sources should be consulted for verification. Mecklenburg
County and its mapping contractors assume no legal responsibility for the information
contained herein.
Legend
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NCDENR
FH1.*O NFVT yr, N� RF9o.;x Fs
Division of Water Quality / Surface Water Protection
National Pollutant Discharge Elimination System
NO EXPOSURE CERTIFICATION for Exclusion
NCGNE0000
NO EXPOSURE CERTIFICATION
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Day
05
Cenificate of Cvverege
NICIGINIEID '
Please check here if this is a renewal: ❑ RENEWAL
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit
based on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notice that your facility does not require permit
authorization for its stormwater discharges associated with industrial activity in the State of North
Carolina because if qualifies for a no exposure exclusion. A condition of no exposure at an industrial
facility means all industrial materials and activities are protected by a storm resistant shelter (with some
exceptions) to prevent exposure to rain, snow, snowmelt, and/or runoff.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste
products. Material handling activities include the storage, loading and unloading, transportation; ors'
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, tdpkks ano
similar containers that are tightly sealed, provided those containers are not deteriorated and; do no eak?
"Sealed" means banded or otherwise secured and with locked or non -operational taps or valves;
adequately maintained vehicles used in material handling; and final products, other than products th't
would be mobilized in stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposuW'di lush
In addition, the exclusion from NPDES permitting is available on a facility -wide basis only—notbr,
individual outfalls. If any industrial activities or materials are, or will be, exposed to precipitation, the
facility is not eligible for the no exposure exclusion. By signing and submitting this No Exposure --
Certification form, you certify that a condition of no exposure exists at this facility or site and are
obligated to comply with the terms and conditions of 40 CFR 122.26(g)_
You must re -apply for the No Exposure Exclusion once every five (5) years.
For questions, please contact the DWQ Regional Office for your area. (See page 5)
(Please print or type)
1) Mailing address of owner/operator address to which all certifical
Name uor-/' ef'Ds
Contact r411So-h- /3rI&1Oral
Street Address 1jeP IA4' v
City c-10 P /,-i
Telephone No.
State ZIP Code
Fax:
2) Location of facility producing discharge:
Facility Name Gil /a j}� A&;h,41 L��
Facility Contact
Street Address
City
County
Telephone No,
Page 1 of 5
t
SW U-NE-060508
Last revised 06/05/2008

NCGNE0000 No Exposure Certification
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road num
distance and direction from a roadway intersection). FtZ 7Z, a! _ 7, - 4. _6 7xjA&✓i5!
(A copy of a map with the facility clearly located on it shout be included with the certification appli(
4) Is the facility located on Native American Lands? ❑ Yes 'RKN0
5) Is this a Federal facility? ❑ Yes ,XNo rr / � 4-
6) Latitude — :90s 74"7 Longitude 350 / �U (deg(-�rhin., seconds) !
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
�( Existing Date operation began I / 9-003
/❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes XNo
If yes, what is the NPDES Permit Number?
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: �, 6 5-
10) Provide a brief description of the types of industrial activities and products produced at this facility:
/J'1!� �G %v /Y'� %tk� r� w�.• � �,f:5 � n-.� ,� /I L'+%%r�xy`' ��Ii�'�,/
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
><No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes XNo
c. Materials or products from past industrial activity ❑ Yes XNo
d. Material handling equipment (except adequately maintained vehicles) ElYes XNo
e. Materials or products during loading/unloading or transporting activities ❑ Yes >(No
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes XN 0
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
Page 2 of 5
SWU-NE-060508 Last revised 06/05/2008

fm
NCGNE0000 No Exposure Certification
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks,
❑ Yes
IN 0
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
❑ Yes
XNo
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes
NIXNo
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
XN 0
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
❑ Yes
�No
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored
Cl Yes
XN 0
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers
❑ Yes
XNo
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible for the no exposure exclusion./f/gfi / —yd ��5 & t- �F
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
14) Secondary Containment: If you answer "No" to any of the following items, you are not eligible for the
no exposure exclusion. airesl,-r6u,j 4) Ai C� cf-FecAe_- /1B�d`�� �G_ � .� r"aK. ✓$
a. Is secondary containment provided for single above ground storage containers ❑ Yes ❑ No �J
(including drums, barrels, etc.) with a capacity of more than 660-gallons? -rO A h (f{ Se- /,a.-5-
b. Is secondary containment provided for above ground storage containers stored Ir Yes ❑ No
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for gny amount of Title III Section 313 ❑ Yes ❑ No
Superfund Amendments and Reauthorization Act (SARA) water priority
chemicals?
d. Is secondary containment provided for any amount of hazardous substances? Yes ❑ No
e. Are release valves on all secondary containment structures locked? ❑ Yes ❑ No
15) Hazardous Waste:
Page 3 of 5
SWU-NE-060508 Last revised 06/05/2008

NCGNE0000 No Exposure Certification
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? © Yes �<No
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste XYes ❑ No
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes XNO
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste: Po--174-- cr/S494,&6 cLAJ
How is material stored: /d -t S . ,(/, e
Where is material stored: /v
How many disposal shipments per year
Name of transport / disposal v ndor:
Vendor address: 3a 0,4Q 1it-
16) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no
exposure" and obtaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five (5) years to the North Carolina
Division of Water Quality 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 North Carolina Division of Water
Quality, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater from the facility. Additionally, I certify under penalty
of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information 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.
certify that I am familiar with the information contained in this application and that to the best of my knowledge and
belief such information is true, complete, and accurate.
Printed tjame oJ Person Signing:
Title: % ltlYGi4-i1DJL
(Signaturfi(of
?/f /o$'
(Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at any time in the future for compliance with the No Exposure Exclusion.
Page 4 of 5
SWU-NE-060508 Last revised 06/05/2008

NCGNE0000 No Exposure Certification
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other
document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsities, tampers with, or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars ($10.000).
There is currently no fee for a No Exposure Exclusion.
Final Checklist
This application should include the following items:
❑ This completed application and all supporting documentation.
❑ A map with the location of the facility clearly marked.
❑ If this is a renewal, indicated current NCGNE number in Question 7.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWO Regional Office Contact Information:
Asheville Office ...... [phone]
Fayetteville Office
... [phone]
Mooresville Office
... [phone]
Raleigh Office ........
[phone]
Washington Office
...[phone]
Wilmington Office
... [phone]
Winston-Salem ......
[phone]
Central Office .........(919)
733-5083
Page 5 of 5
SWU-NE-060508 Last revised 06/05/2008

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