NCGNE0881_COMPLETE FILE - HISTORICAL_20120906

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE OgYj'
DOC TYPE
❑HISTORICAL FILE
DOC DATE
❑ �VI���SOto
YYYYMMDD

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NC®ENR
North -Carolina. Department-ofEn*onment-ard-Natural Resources.-,-_— _
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, RE, Dee Freeman
Governor
Mr. Chris Bagley
Hickory Springs Manufacturing Company
PO Box 128
Hickory, North Carolina 28603
Dear Mr. Bagley:
Director
, %ugust 29, 2u"12
�C
SEP 06 2012
Subject: No -Exposure Certification NCGNE0881
Hickory Fabrication
2116 Highland Ave NE, Hickory, NC 28601
Catawba County
The Division has reviewed your submittal of the No -Exposure Certification form for Exclusion from NPDES Stormwater
Permitting. Based on your submittal and signed certification of no exposure at the above referenced, the site visit of
August 27, 2012, and the photo documentation of the newly installed general waste dumpster plug the Division is
granting your conditional exclusion from permitting as provided for under 40 CFR 12226(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.
You must self re -certify your No -Exposure status annually using the enclosed form or obtain NPDES permit
coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted to DWQ unless requested. 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 Marcia Allocco at [phone], or at
[e-mail].
Sincerely,
for Charles Wakild, P.E.
Enclosure: No -Exposure Self Re -certification Information sheet
Annual No -Exposure Exclusion Self Recertification form
Site inspection report
cc: Stormwater Permitting Unit No- Exposure Files (Brian Lowther)
Mooresville Regional Office One
Location: 610 East Center Ave., Suite 301 Mooresvilie, NC 28115 No thCarolina
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748 ��r� `/`rr�
Internet: www.ncwaterquality.org a [
An Equal Opportunity', Aifumative Acton Empbyer - 3C% Recycle&10% Post Consumer paper

1

Compliance Inspection Report
Permit: NCGNE0881 Effective Expiration:_ . _-. - — "Own'er: Hickory SOF gs Mfg Co
SOC: Effective: Expiration: Facility: Hickory Fabrication
County: Catawba 2116 Highland Ave Ne
Reaion: Mooresville
T Hickory NC 28601
Contact Person: Chris Bagley Title: Phone: [phone]
Ext.3280
Directions to Facility:
From 1-40 - take exit 126 - go norht on McDonald Pkwy - turn left onto 21st st SE - turn right onto Highland Ave - facility is first Bldg on
right
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 08127/2012 Entry Time: 09:22 AM Exit Time: 09:36 AM
Primary Inspector: Marcia Allocco Phone: [phone]
Ext.2204
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
■ Miscellaneous Questions
(See attachment summary)
Page: 1

It
Permit: NCGNE0881 Owner - Facility: Hickory Springs Mfg Co
-•--� .-- Inspection. Date:_W2-72012--_-_lnspec:ionType: Compliance Evaluation--_-.. ___._._...,Reason.for.Visit. Routire.,.w-
Inspection Summary:
The facility was visited through a new No -Exposure Certification request.
Stormwater at the site drains through a cut in the asphalt parking lot berm and drains to a roadside ditch :with eventual
discharge to Lyle Creek in the Catawba River basin (verified on USGS Hickory Quadrangle).
The following source of stormwater exposure was noted during the inspection:
• There was a covered general waste dumpster on the at the facility, which was missing the drain plug. Photo
documentation of the installed plug was provided to DWQ staff on August 29, 2012.
Therefore, with the installation of the dumpster drain plug the general waste dumpster at the facility meets the
requirements of "No Exposure".
Page: 2

"r
No -Exposure Self Re -Certification Information:
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. State statute provides for fines of up to $25,000 per day for
un-permitted discharges.
Your conditional no -exposure exclusion must be self re -certified at least annually as follows:
- Complete the re -certification at a minimum of once per year using the included Self Re -
Certification Form.
(additional copies can be downloaded from htfp://portal.nedenr.org/web/wq/ws/su/npdessw#No_Exposure_NPDES )
- Maintain a record of re -certifications on fife at the facility. Do not submit the re -certification to
DWQ unless requested_ If requested, submit a copy of the re -certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or local government, provide the re -certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes, or if
the facility can no longer maintain no -exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
"No exposure" means that 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. (40 CFR 122.26(g))
Information and forms related No -Exposure Certifications can be accessed on the website at:
httpa/portal.ncdenr.org/web/wq/ws/su/npdessw#No_F-xposu re_NPDES
Rev. 28.tul2010

LE
NC®ENR
Northh-Cardina Dep-art z+ v€ E-wironment ar4d -Natural-Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
August 29, 2012
Mr, Chris Bagley
Hickory Springs Manufacturing Company
PO Box 128
Hickory, North Carolina 28603
Subject: No -Exposure Certification NCGNE0881
Hickory Fabrication
2116 Highland Ave NE, Hickory, NC 28601
Catawba County
Dear Mr. Bagley:
The Division has reviewed your submittal of the No -Exposure Certification form for Exclusion from NPDES Stormwater
Permitting. Based on your submittal and signed certification of no exposure at the above referenced, the site visit of
August 27, 2012, and the photo documentation of the newly installed general waste dumpster plug the Division is
granting your conditional exclusion from permitting as provided for under 40 CFR 122.26(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.
You must self re -certify your No -Exposure status annually using the enclosed form or obtain NPDES permit
coverage for any stormwater discharges from your facility. The annual self re -certification does not need to be
submitted to DWQ unless requested. 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 Marcia Allocco at [phone], or at
marcia. [e-mail].
Sincerely,
for Charles Wakild, P,E.
Enclosure: No -Exposure Self Re -certification Information sheet
Annual No -Exposure Exclusion Self Recertification form
Site inspection report
cc: Stormwater Permitting Unit No- Exposure Files (Brian Lowther)
Mooresville Regional Cttfice One
Location: 610 East Center Ave., Suite 301 MooresvWe, NC 28115 NorthCa -olina
Phone: [phone] Fax: [phone] Customer Service: 1-877-623-6748 },r� l�
Intemet: www,nc%vaterquality.org �atK`
An Equal Opportunity'4 Affirmative Action Employer- 30% Recycledll0% Post Consumer paper

Compliance Inspection Report
Permit: NCGNE088i Effective: Ekpiration: ` ' " ` ' Owner:- Hickory Springs Mfg Co "" J
SOC: Effective: Expiration: Facility: Hickory Fabrication
County: Catawba 2116 Highland Ave Ne
Reaion: Mooresville
Hickory NC 28601
Contact Person: Chris Bagley Title: Phone: [phone]
Ext.3280
Directions to Facility:
From 1-40 - take exit 126 - go norht on McDonald Pkwy - turn left onto 21 st st SE - turn right onto Highland Ave - facility is first bldg on
right
System Classifications: ,
Primary ORC: Certification: Phone:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Inspection Date: 08/27/2012 Entry Time: 09:22 AM Exit Time: 09:36 AM
Primary Inspector: Marcia Aliocco Phone: [phone]
Ext.2204
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ® Compliant ❑ Not Compliant
Question Areas:
® Miscellaneous Questions
(See attachment summary)
Page: 1

Permit: NOGNE0881 Owner - Facility: Hickory Springs Mfg Co
rnsn�cti^r. t?�te:.CQF-?120"�-_ fnspsction Typo: Cr,', ip!iancA Eva!tation , Reason fnr Visit:-Rotlfine
Inspection Summary:
The facility was visited through a new No -Exposure Certification request.
Sto.,,rrvater at the site drains through a cut in the asphalt parking lot berm and drains to a roadside ditch with e.,en+ual
discharge to Lyle Creek in the Catawba River basin (verified on USGS Hickory Quadrangle).
The following source of stormwater exposure was noted during the inspection:
• There was a covered general waste dumpster on the at the facility, which was missing the drain plug. Photo
documentation of the installed plug was provided to DWQ staff on August 29, 2012.
Therefore, with the installation of the dumpster drain plug the general waste dumpster at the facility meets the
requirements of "No Exposure".
Page: 2

No -Exposure Self Re -Certification Information:
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. State statute provides for fines of up to $25,000 per day for
un-permitted discharges.
Your conditional no -exposure exclusion must be self re -certified at least annually as follows:
- Complete the re -certification at a minimum of once per year using the included Self Re -
Certification Form.
(additional copies can be downloaded from http://portal.ncdenr.org/web/Wgfws/su/npdessw#No_Exposure_NPDES )
- Maintain a record of re -certifications on file at the facility. Do not submit the re -certification to
DWQ unless requested. If requested, submit a copy of the re -certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or local government, provide the re -certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes, or if
the facility can no longer maintain no -exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
* "No exposure" means that 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. (40 CFR 122.26(g))
Information and forms related No -Exposure Certifications can be accessed on the website at:
http-.Hportal.ncdenr.org/web/wq/ws/su/npdessw#No—Exposure—NPDES
Rev. 28JU2010

�` S Division of Water Quality / Surface Water Protection
NCDENRNational Pollutant Discharge Elimination System
�H C�� D�� NO EXPOSURE CERTIFICATION for Exclusion
Fxvnow+r.,-r wo Hauw, a^.a,:rrs
NCGNE0000
FOR AGENCY USE ONLY
Date Remived
Year Month
Day
Certificate of Coverage
NICIGiNIF-1011518 1
RECEIVED
DIVISION OF WATER QUALITY
AUG 0 9 2012
NO EXPOSURE CERTIFICATION
SWP SFCTIr`jN
National Pollutant Discharge Elimination System application for exclusion fro mra�S.to.rmwaterfFerM t,baggd ICE
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 self re-certi our No Exposure Exclusion annual! .
For questions, please contact the DWO Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of owner/operator (address to which all certification correspondence will be mailed):
Name <,Q0, At,S IJ�A*1VFAtt�ai�I'% tomPA>n1`I
Contact _ �H ti2t� s m,l, ei
Street Address 2.NO Ads N W
City `\.A—w404M StateZIP Code 2.%-o\
Telephone No. 1Z2% L'%- LLv\ x L%o Fax: 37AJ-
Email ' 1 1040, % C--~
PFAUG
@@li Wq�
Page 1 of 7
3 2012
SW U-N E-12Aug2010

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NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name Mlc'Aok" V Ngxy %(- totl _
Facility Contact _ t\A'.tS Cnq
Facility Street Address _ 2.i1 t1r,.(iAA�A_010- Ajg- O' -
City tiit� _ State tst, ZIP Code ZU'A
County s`.A T Aw � q
Telephone No. _��5 ;it - u-.)k u 3 Z-ila � Fax: Z 8 - � Zib -�i 5y2
Email -' OOo \es 3 ,`tirr.
3) Physical location information:
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). Korn Y-4orkzb : G- °�yN tlL. )VN U> fAW' .
T 1.rc�-T b1YO 2iS1 Si• SE. tv4.4 RS�rL�54G-S9 Ol R:\ 4�1 ,� GHC.
(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 1!JI(No
5) Is this a Federal facility? ❑ Yes - %No
6) Latitude ISO
H3' 5S" N Longitude -%\' VV 9�'(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 11I1. za\-L
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
S) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes )(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: S t? �d
10) Provideta brief description of the types of industrial activities and products produced at this facility:
MQf�airu��•c�t`l u�r �hawn 5tw �f+.. 0rnJ.,�4C r.4,�� t"u�r \% "'Nta N e 40\\ r C'V S. �kjS2S. ov%a
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7
5WU-NE-QAug2olo

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 © YesNo
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 spillsAeaks ❑ Yes V No
c. Materials or products from past industrial activity
❑ Yes
K No
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes
No
e. Materials or products during loading/unloading or transporting activities
❑ Yes
fi No
f. Materials or products stored outdoors (except final products intended for outside
❑ Yes
t No
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,
❑ Yes
No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
❑ Yes
No
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes
No
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes
No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
❑ Yes
X 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
❑ Yes
No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
rn. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers
❑ Yes
No
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.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3of7
5W U-NE-12Aug2010
❑ Yes ❑ No fX NIA
❑ Yes ❑ No � NIA

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 all single above ground storage
containers (including drums, barrels, etc.) with a capacity of more than 660-
gallons?
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 Title III Section 313 Superfund
Amendments and Reauthorization Act (SARA) water oriorily, chemicals*?
d. Is secondary containment provided for hazardous substances** designated in 40
CFR §116?
e. Are release valves on all secondary containment structures locked?
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste
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.
❑ Yes ❑ No � NIA
❑ Yes ❑ No X NIA
[]Yes ❑ No NIA
❑ Yes ❑ No 0 NIA
❑ Yes ❑ No X NIA
❑ Yes No
❑ Yes No
❑ Yes X No
*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.
Page 4 of 7
S W U-N E-12AU92010

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 No
b. Does your facility have coal piles on site? ❑ Yes No
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes No
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., $Yes ❑ No
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity: V-ock%N alvino, s�uV%%)ns ey �; t a23 .4, \)h a ry �Mw-.s
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit? 1_�Yes ❑ No © NIA
Please specify: _ A,r_?Zrrn0t tso
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:
Page 5 of 7
SWU-NE-12Aug2010

NCGNE0000 No Exposure Certification
17) 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 annually self re -certify No Exposure and, if requested, submit the re -certification to
DWQ or 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 Name of Person Signing: a(t%rl�tar C. ►Y1aKRlL
Title: U -10 �'d d ocrw`ha.�-s
(Signature of 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 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 fine
not to exceed ten thousand dollars ($10,000).
There is currently no fee for a No Exposure Exclusion.
Page 6 of 7
S1NU-NE-12Aug2010

,� 4•, Y ... - ., �.

NCGNE0000 No Exposure Certification
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 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 DWO 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)
807-6300
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