NCGNE0679_COMPLETE FILE - HISTORICAL_20130327

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE 0/„n
w1
DOC TYPE
❑HISTORICAL FILE
DOC DATE
❑
YYYYMMUD

j' Division of Water Quality / Surface Water Protection 1 FOR AGENCY USE ONLY
/ • Dale Received
Year Month pay
National Pollutant Discharge Elimination System
NCDENR
e.e:rr v.�; tiw wvu� t3.a:r,e+� PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the
change is requested.
NPDES Permit
(or) Certificate of Coverage
N 10 19. 10
N I C: I G! I 1 10 10 �
II. Permit status prior to requested change.
/7
a. Permit issued to (company name):
b. Person legally responsible for permit:
First Ml Last
Title
/a 6 G� G1J� s �i A fo•� .Sf - - - -
Permit Holder Mail ng Address
at,G NC Z 730
City Slate Zip
c. Facility name (discharge):
Phone Fax
d. Facility address:
Address
730 Z
City State Zip
e. Facility contact person:
_% _ m4r, T h ,2 l S
First I MI 1 Last Phone
1II. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
❑ Change in ownership of the facility
Er Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
�n /�j�r,-e__
c. Person legally responsible for permit:
First MI Last
Title
Zo k i . r,7A�)
{�,�//f ,{/ Permit Holder Wiling Address/7 �/7 /7
/ ! !2/, QN e- �G 2, 13O `—
City State Zip
�eene_.,01'7
d. Facility
Phone E-mail Addre
name (discharge):
�, t4 lt,t
e. Facility address:
fo 5 (ry t l�p,r S
City State Zip
NT Wi
f. Facility contact person:
h 'q (S to
First Nil t
(qj� )3C)q_,q)[S e
Phone E-mail Addr ss
Revised 2012Apr23

J. NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First MI Mast
Title
Mailing Address
City State Zip
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
9 Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ , Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature
APPLICANT CERTIFICATION
Date
I, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
3 L--2-_ 13
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008

Britsch, Beverly K.
From: U.S.-Postal-Service- <[e-mail]>
Sent: Thursday, October 25, 2012 10:50 AM
To: Britsch, Beverly K.
Subject: USPS Shipment Info for 9405 5036 9930 0180 9174 49
This is a post -only message. Please do not respond.
BEVERLY K BRITSCH has requested that you receive a Track & Confirm update, as shown below.
Track & Confirm e-mail update information provided by the U.S. Postal Service.
Label Number: 9405 5036 9930 0180 9174 49
Service Type: Priority Mail Delivery Confirmation
Shipment Activity Location Date & Time
Delivered RALEIGH NC 27699 10/25/12 10:11am
Sorting Complete RALEIGH NC 27611
Arrival at Unit RALEIGH NC 27611
Depart USPS Sort RALEIGH NC 27676
Facility
Processed through USPS RALEIGH NC 27676
Sort Facility
Processed at USPS CHARLOTTE NC 28214
Origin Sort Facility
Dispatched to Sort HUNTERSVILLE NC 28078
Facility
Acceptance
Electronic Shipping
Info Received
HUNTERSVILLE NC 28078
Reminder: Track & Confirm by email
Date of email request: 10/24/12
10/25/12 9:12am
10/25/12 8:00am
10/24/12
10/25/12
10/25/12 3:08am
10/24/12 9:12pm
10/24/12 7:00pm
10/24/12 3:40pm
Future activity will continue to be emailed for up to 2 weeks from the Date of Request shown above. If you need to
initiate the Track & Confirm by email process again at the end of the 2 weeks, please do so at the USPS Track & Confirm
web site at http://www.uses.comJshippine/trackandconfirm.litrn
j

LISPS has not verified the validity of any email addresses submitted via its online Track & Confirm tool.
For more information, or if you have additional questions on Track & Confirm services and features, please visit the
Frequently Asked Questions (FAQs) section of our Track & Confirm site at
http://www.uses.com/ping/trackandconfirmfags.htm

Division of Watcr,Qtlality 15url�ace Water Protection
* ����t�p�i Natl(ltlill 11(?Illlt�tnt Discharge Iwlitt7itta[i(�n SySlcni
ills'�lLi-a�"ttT1'�^`V']'l�`3'e�Y PERMIT NAMEIOWNERSHIP CHANGE FORM
FOR AGENCY USE ONLY
pate Raeeivaa
You
t!cath Oa
I
I. Plcase enicr the ltcrmi( numhcr for which the change is requested.
ti'I'1)1 5 fermi[ (or) Certificate of'Coverage
N I C S o M1, C G N (0 0 0 10
V. I'erinil status rr for to requested eltange.
o. Permit iSSLICd tO (Company name): Prairie Packaging, Inc.
h. Person ]c�ally respultsible I't pernlil: Beverly K Britsch
I-Ir.t \II
I"I"t
NC RMC Manager
TWO
14201 Meacham Farm Drive
I'rrmh I lulder M.Lilirw Addic��
Huntersville NC
28078
ci11' state
Zip
( 704 ) 896.8954 x 2004
( 704 ) 896-8993
f'Iu+rrc
I ak
e. Facility mune (discllargc):
Prairie Packaging. Inc. NC RMC
d. Facilily addre.ws:
12801 Jamesburg Drive
Atklrvs't
Huntersvitle NC
28078
City stoic
'Lip
i. 1 ,-Wilit%. conlacl per>un:
Beverly Britsch
( 704 ) 896-8954 x 2004
Firm / iN1I / kw
I'honc
Ili. Please provide the 1'ullowing For the requeMed ehallge (r-cilsed permit).
a. Re(luesl f'nr clr.nlgc is (t resuh of-. ©Cltan0c in owncrtihip of the f':Iriliry
0 Mime change ut• the facility or owner
If wher ple-use esplaiu:
h. Permit issued to (company mine): Pacliv, LLC
c. I'ersnrl lcoafly responsible for permit: Beverly K Britsch
fir+t till 1_ast
NC RMC Manager
d. 1-'ac:ilit�' natnc (di.Ch:u'�•c•):
c. F=aeililV address:
1'. Facility colltact person:
R�:�� d 2017.A.r23
Title
14201 Meacharn Farm Drive
I'erntii Holder 10a61inv Addrom
Hunlersville NC 28078
C.:ity siate Zip
( 704 ) 896-8954 x 2004 [e-mail]
Phone E-mail Addrus:
Pacliv, LLC NC RMC
�12801 Jamesburg Drive
Atldres:
Hunlersville
NC 26078
�City��stcne��Zip
Beverly
K Britsch
Fir:ct
1%11 fact
( 70.1 ) 896-8954 x 2004
bbri([e-mail]
1,11mic
E-mail A.ldres.

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if difli:rcnt 1'1'unl the I)er.1;oll Irnally responsible ('or the permit)
Permit contact: Andrew Allen
First N I I L:,+l
Manager - Facilities
Tidi
14201 Meacham Farnl Drive
hluntersville NC 28078
City Slate %ip
(704 ) 371-5556 aallenl r7pactiv.cam
1'11une 1--mail Address
V. Will E11e perrllilte(l facility continue to conduct the s11111C inthistrial activilies condlicled prior
to this ownership or name clianc;e'.'
Yes
❑ No (please explain)
Required Items: 1111IS APPLICATION WILL 13E RI-ITRNI-D UNPROCI SSI:D IF I-I'I CIS
It1: INCONIP1. E'1'[: OR NUSSING:
© Tllis Completed application is required for tenth namC chan(IC Und/or ownership change
requests.
x❑ Legal dQCaaIllCni,16011 of the tr;tns(`cr of owncrship (such as relevant Pagcs of a eonuact (!ec(!,
Ora bill ol'sale) is remilred form ownershipcll:lrl_P_c requcsl. Articles of incorporation are
not snff icient for ;an ownership changc.
The ccrlificatinns heloa, must he completed and Signed hY Ilotli the permit holler prior to the change. ;old
the new applicant in the case of an ownership change request. Fora molt: Ch;ulge I•cyurst, the signCd
A[[pplicIIall[[t's CCnfi iratiun is,tlfFICiCnl.
qgi, ., i Slit cfi C l;irnF1C.VI'I0N (Pernllt holder prior to owllcr%hip chats-e):
1, aucst than Ellis ;Ipplication for a nanic/ownership ch.mgc Ims been reviewed and is accurate and
complete to the hest of my knowledge. I understand thal if all required parts ul this application are not
completed and that if all required supporling information is not incltacled, Ellis application pucku,-e will he
returned Its incomplete.
� Sidinature Date
APPLICANT' CF1R'FI ICA'1'ION
Beverly Britsch
I, ait"( that IhiS :gll)licatinn fora Want(/un ni rshill change has been rep iC(% ed utld is ;Ice I e and
complete to the best of nlr knrnWIC(Igc. 1 underm kaki 111:11 if:tll required p;trts ol* flik application are not
completed and that if all required supporting inl'ormutuln is not inclUdCd. 111IS;11)p(ic;ttioo package will be
returned as incomplete.
� J Signature ature Date
I'LE'ASE SILND'I'lll•: CU`II'l.,l 'I'Ii fV'I'I..ICr1'1'ION PACKAGE TO;
Division of Watc:l' Quality
Surfacc W.iter Proicclion Section
1617 flail Set -vice Center
Raleieh, North Carolina'_7G99-1017
ti? see 1t1.L03

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Cut on dotled line.
Instructions
1. Each Click-N-ShlpE) label Is unique. Labels are to be
used as printed and used only once. DO NOT PHOTO
COPY OR ALTER LABEL.
2. Place your label so it does not wrap around the edge of
the package.
3. Adhere your label to the package. A self-adhesive label
is recommended. If tape or glue is used, DO NOT TAPE
OVER BARCODE. Be sure all edges are secure.
4. To mail your package with PC Postage®, you
may schedule a Carrier Pickup online, hand to
your letter carrier, take to a Post Officer", or
drop in a LISPS collection box.
S. Mail your package on the "Ship Date" you
selected when creating this label.
Online Label Record (Label 1 of 1-)
Delivery ConfirmationTm Number:
9405 5036 9930 0180 9174 49
Paid Online
Transaction m: 245366010 Priority Maik%Postage; f4.90
Print Date: 012412012 Total: $4.90
Ship bate: 10/2412012
From: BEVERLY K BRITSCH
PACTIV
12801 JAMESBURG OR
BOX a3
HUNTERSVILLE NC 28078-5386
To: DIVISION OF WATER QUALITY
1617 MAIL SERVICE CTR
SURFACE WATER PROTECTION SECTION
RALEIGH NC 27699.1600
Commercial Base Pricing Priority M34 ralas apply. Thera is no tee fa DoIrvery
Corfrmaton servico on Priority Mail service wi-A use of this electronic rate shipping
labor Darnory information is not amilablo by pnono for Iho elewonic rate. Relunds
1w unused postage paid labels can be requested online 30 days from [ho prim date
uN1TEDSWES Thank you for shipping with the United States Postal Service!
P0S'r41_SE17V10E c
Check the status of your shipment on the Track & Confirm page at usps.com

r1
PACTIV
October 9. 2012
Mr. Bradley Bennett
N.C. Department of I�nvironmcnt and Natural Resources
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, NC 27699-1617
14201 3N-leacham Farm Drive
Huntersville, NC 28078
NCC-4rzb7�
RE: NEW I..1 GAI_ OWNEI /OPERATOR NAME AS OF 10/1/12
Pactiv. LLC. (formerly Prairie Packaging Inc.)
Certificate of Coverage: NCGNE0000
12801 1amesburg Drive, Huntersville, NC
Dcar Mr. Bennett:
Effective October 1, 2012, Prairie Packaging. Inc. merged with Pactiv, LLC and has
changed its legal name to Pactiv. LLC.
Enclosed Ire the following:
o Permit Name/Ownership Change Dorm
o Certificate of' Merger
If you have any questions or require additional mtormation, please contact Andre%\, Allen
at 704-371-5556.
Sincerely,
Beverly K Britsch
NC RMC Manager
cc: Phoebe Robb, Pactiv Corporate Environmental
Enclosures: (2)

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor
Mr. Andrew Allen, Operations Manager
Prairie Packaging
14201 Meacham Farm Drive
Huntersville, NC 28078
Dear Mr. Allen:
Director
April 5, 2010
Dee Freeman
Secretary
Subject: No -Exposure Certification NCGNE0679
Prairie Packaging — NC RMC — Huntersville
Modules E & F
Mecklenburg County
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 and a
site visit conducted on April 1, 2010, by Mr. Michael Parker with this Office, 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. This includes preventing any waste material from being disposed of in your dumpster
that may have be contaminated with solids, liquid, or powder from your industrial process areas. 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 (April 5,
2015). 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 Mr, Michael Parker at [phone], or at
Michael. [e-mail].
Sincerely,
tC--<::
for Coleen H. Sullins
cc: Mooresville Regional Office
Stormwater Permitting Unit, No -Exposure Files
MCWQP
Wetlands and Stormwater Branch One 1
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 N orthCarolf na
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604 Naturally
Prone: 919-807-53001 FAX: [phone] Customer Service: 1-877-623-6748
Internet: www,ncwatergealiy.org

:'rairie Packaging 14201 Meacham Farm Drive, Huntersville, NC 28070
A Division of
March 4, 2010
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
LIAR 2 4 2010
o
z
PncTiv
Re: No Exposure Certification for Exclusion from NPDES Storm Water Permitting (NCGNE0000)
Prairie Packaging Warehouses
WITHDRAWAL of No Exposure Certification for Pineville, NC Warehouse
REQUEST for No Exposure Certification for Huntersville, NC Warehouse
To Whom It May Concern:
Prairie Packaging previously utilized a warehouse located at 11515 Nations Ford Road in Pineville to
support its Huntersville manufacturing facility (located at 14201 Meacham Farm Drive, Huntersville). We
recently terminated our lease for the Pineville warehouse, and are now leasing a portion of a warehouse
located at 12801 Jamesburg Drive in Huntersville (Modules E and F).
Prairie Packaging previously submitted a "No Exposure Certification for Exclusion" From NPDES Storm
Water Permitting Form (NCGNE0000) for the Pineville warehouse, and was issued No Exposure
Certification NCGNE0612 by the NCDENR on July 8, 2009. Since we are no longer leasing or using this
warehouse, we are formally requesting that the NCDENR rescind the No Exposure Certification issued to
Prairie Packaging for this facility.
By submittal of this letter, we are also requesting that the NCDENR issue a No Exposure Certificate for the
newly leased Huntersville warehouse. Consequently, we are enclosing the completed "No Exposure
Certification for Exclusion'" From NPDES Storm Water Permitting Form (NCGNE0000) for the
Huntersville warehouse. As noted on the form, none of the materials or activities listed under Questions 12
through 16 of the form are exposed to precipitation at the warehouse. Consequently, the portion of the
warehouse leased by Prairie Packaging is exempt from storm water permitting.
As required in the instructions included on the form, a map showing the location of the facility is included
with the completed No Exposure form.
To maintain the status of the exclusion, Prairie Packaging will resubmit the No Exposure Certification at
least 90 days prior to the five-year anniversary date of this submittal.
A copy of the completed exclusion form will be retained at the warehouse for at least 5 years.
If you have any questions on the above issues regarding our warehouse No Exposure Certifications. please
contact me at [phone].

Prairie Packaging 14201 Meacham Form Drive, Huntersville, NC 28078
A Division of
Prairie Packaging PACTiv
Sincerely,
PRAIRIE PACKAGING, INC.
61�k t%'
Andrew Allen
Facilities Manager
Enclosure — Completed No Exposure Certification Form for Off -Site Huntersville Warehouse, including a
Location Map
cc: Mike Rehor, Pactiv Corporate Environmental

!''A
NCDENRC � Z
EN 0..v -o S�i4,l - RED lR
Division of Water Qualit-
y 1 Surface Water Protection
National Pollutant Discharge Elimination System
NO EXPOSURE CERTIFICATION for Exclusion
NCGNE0000
NO EXPOSURE CERTIFICATION
FOR AGENCY USE:ONIN
Date Reccived
Year
h[otttlt
Day
b
Certificate o1 CoNerage
NICIGIN1131
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 notification that your facility does not require a
permit for stormwater discharges associated with industrial activity in the State of North Carolina because
it qualifies for a no exposure exclusion. A condition of no exposure at an industrial facility means all
industrial materials and activities are protected by a storm resistant shelter (with some exceptions) to
prevent exposure to rain, snow, snowmelt, and/or runoff.
For permitted facilities in North Carolina, DWQ must approve your application for No
Exposure Certification before this exclusion is effective. Until you are issued a No
Exposure Certification and your NPDES permit is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products.
Material handling activities include the storage, loading and unloading, transportation, or conveyance of
any raw material, intermediate product, final product or waste product. A storm resistant shelter is not
required for the following industrial materials and activities: drums, barrels, tanks, and similar containers
that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed" means
banded or otherwise secured and with locked or non -operational taps or valves; adequately maintained
vehicles used in material handling; and final products, other than products that would be mobilized in
stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In
addition, the exclusion from NPDES permitting is available on a facility -wide basis 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, 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 are required to reapply for the No Exposure Exclusion once every five (5) years.
For questions, please contact the DWQ Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of ownerloperator (address to which all certification correspondence will be mailed):
Name f raI rr e- a K6ainna_
Contact
Street Address
City
Telephone No.
Nd rew RIle J,
f 4201 Me&chd ,, Faun A,J ve
Hupfers V. Ile State N C ZIP Code '�90716
09 '571 ~ M6 Fax: 700 371 - 5530
Page 1 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
2) Location of facility producing discharge: p
Facility Name P/'a»j'e Packapgl4g — &.'A Carottina it
Facility Contact Andy Ra55
Street Address 19901 Sames bua Pr)',le
City H Mnler5y►`l e
County Meckleribur -
Telephone No. 70 q 959 — $`f 5V t YV 2D61
3) Physical location information:
C — fVnterS :lk PC
State VC ZIP Code �2 ,? Q 7
Fax:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). Frem infersecf on o F Hwy 115 (1'1J Owy 73,
TraveI Easf orn H w v 73, 7ame5bura. DrOe is about a, m;le onle-rt, fl}ocluVE4Pair end.
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands? ❑ Yes [Er/No
5) Is this a Federal facility? ❑ Yes 03/No
6) Latitude 35 Z, �1, qbt; Longitude" 8P- 5,6• q,5911 (deg., min., 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 Decernbev- a 00
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE=
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes P/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: q � a 5
10) Provide a brief description of the types of industrial activities and products produced at this facility:
Storaand A'3r; but;an of grlasf'c c 5p� a Me Lipe►� wave .
xa)-hol" '. nips . P)afe_s . C11-tl�r-".
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
I'No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
roa kro A.
r"a 1 f-,
Page 2of7
SW U-NE-021309
Last revised 2/13/2009

NCGNE0000 No Exposure Certification
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes eNO ❑ NIA
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks
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)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks,
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes IZNo ❑ NIA
❑ Yes
M No
❑ NIA
❑ Yes
M/No
❑ NIA
❑ Yes
E(No
❑ NIA
❑ Yes
Ao
❑ NIA
❑ Yes [/ No ❑ NIA
❑ Yes G No ❑ NIA
❑ Yes EY No ❑ N/A
❑ Yes ❑ No M- /A
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes Ao ❑ N/A
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 ❑ Yes U3'No ❑ N/A
(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 ❑ No l3 N/A
stored outside, has the facility had any releases in the past three (3) years? jnauj�s EV'r
only.
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are not
eligible for the no exposure exclusion.
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No E(N/A
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No 1B N/A
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut? F
OmoaulQs �
only
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NCGNE0000 No Exposure Certification
14) Secondary Containment: If you answer "No" to any of the following items, you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for single above ground storage containers ❑ Yes ❑ No K N/A
(including drums, barrels, etc.) with a capacity of more than 660-gallons? //
b. Is secondary containment provided for above ground storage containers stored ❑ Yes El No grN/A
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund ❑ Yes ❑ No 9AN/A
Amendments and Reauthorization Act (SARA) water priority chemicals`? /
d. Is secondary containment provided for hazardous substances" designated in 40 ❑ Yes ❑ No I�` NIA
CFR §116? /
e. Are release valves on all secondary containment structures locked? ❑ Yes ElNo 10 NIA
(4 ove off )y+0 Mod�U Ec1✓ FJ
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes M No ❑ NIA
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes l/ No ❑ NIA
generated per month) of hazardous waste? /
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes [!a No ❑ NIA
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport 1 disposal vendor:
Vendor address:
Footnotes to Questions 14) c. & d.
`Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFR
§372.38.
"Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR §117.3.
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NCGNE0000 No Exposure Certification
16) Other information: If you answer "Yes" to any of the following items, you might not be eligible for the
no exposure exclusion. A more in-depth evaluation of the site circumstances may be required.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes 11(No ❑ NIA
b. Does your facility have coal piles on site? ❑ Yes C9'No ❑ NIA
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes IBTNo ❑ NIA
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., ❑ Yes RI'No ❑ NIA
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit? ❑ Yes UANo ❑ NIA
Please specify:
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
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NCGNE0000 No Exposure Certification
17) Certification:
certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no
exposure" and obtaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials from the industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once eve five 5 ears 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.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief
such information is true, complete, and accurate.
Printed Name of Person Signing:
Title:
(Signature Applicant) (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.
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 tiled 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 rutemaking proceeding or contested case under this Article: or who falsifies, tampers with, or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
(Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars ($10.000).
There is currently no fee for a No Exposure Exclusion.
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SWU-NE-021309 Last revised 2/13/2009

Figure 1 " E
5
Prairie Packaging ,•: r:,G Z.
12801 Jamesburg Drive ERM
Huntersville, NC 28078 ou�waAnaE LMATI rr

.,
NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
C1l This completed application and all supporting documentation.
V A map with the location of the facility clearly marked.
❑ If this is a renewal, indicated current NCGNE number in Question 7.
❑ If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
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 .........
[phone]
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SWU-NE-021309 Last revised 2/13/2009