NCGNE0436_COMPLETE FILE - HISTORICAL_20171220

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE U y 3
DOC TYPE
VHISTORICAL FILE
DOC DATE
❑_
YYYYMMDD

Energy. Mineral
and Land Resources
ENVIRONMENTAL QUALITY
Division of Energy, Mineral and Land Resources
Land Quality Section
National 13011ulant Discharge Elimination System
NO EXPOSURE CERTIFICATION for Exclusion
NCGNE0000
FOR AGENCY I1513 ONI.
Date Received 01
Year
M110mh
Da-
C
Cenilicaw of Coverige c
N N I'
20 t'
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 col -'^^%/%* means all
industrial materials and activities are protecte options) to
prevent exposure to rain, snow, snowmelt, an
For permitted facilities in North Caroli
Exposure Certification before this ex(
Exposure Certification and your NPDI
to abide by the terms and conditions
Industrial materials or activities include, but
industrial machinery, raw materials, intermel
Material handling activities include the stora
any raw material, intermediate product, final
required for the following industrial materia,
that are tightly sealed, provided those conte
banded or otherwise secured and with lock.
vehicles used in material handling; and fine
stormwater discharges (e.g., rock salt).
ation for No
ed a No
ust continue
nt or activities,
r waste products.
7� conveyance of
shelter is not
imilar containers
)ealed" means
ely maintained
I mobilized in
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. Ir
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).
If approved, your conditional no -exposure exclusion must be self re -certified at least annually.
Please see information here:
For questions, please contact the DEMLR 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 PBM Graphics, an RR Donnelley Company
Contact
Tim Holt
Street Address
3700 S. Miami Blvd.
City
Durham
Telephone No.
919-595-7628
State NC _ ZIP Code 27703
Fax:[phone]
Page 1 of 7

NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name PBM Graphics
Facility Contact
David Eastwood
Street Address
3700 S. Miami Blvd.
City
Durham
County
Durham Co.
Telephone No.
919-595-7535
3) Physical location information:
NOV 02011
State NC _ ZIP Code: 27703
Fax:[phone]
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). Going east on NC 54, turn left onto Davis Drive. Then
turn right onto Cornwallis Rd then turn left onto Miami Blvd. Site is on the left.
(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 IxI No
5) Is this a Federal facility? . ❑ Yes O No
6) Latitude 350 55' 0.47 » Longitude -78 ° 51' 4.13 » (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
-
IF] Existing Date operation began May 2008
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑O Yes ❑ No
If yes, what is the NPDES Permit Number? NCGNE 0436
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: 323111
10) Provide a brief description of the types of industrial activities and products produced at this facility:
Various type printed material
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
EI No
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7

NCGNE,0000 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 ONo ❑ N/A
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 ONo ❑ N/A
c. Materials or products from past industrial activity
❑ Yes O No ❑ N/A
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes ONo ❑ N/A
e. Materials or products during loading/unloading or transporting activities
❑ Yes ONo ❑ N/A
f. Materials or products stored outdoors (except final products intended for outside
❑ Yes ONo ❑ N/A
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 ONo ❑ N/A
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes O No ❑ N/A
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters]) ❑ Yes ONo ❑ N/A
j. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes ONo ❑ N/A
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes ONo ❑ 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 ONo ❑ 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 O No ❑ N/A
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 or 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?
❑ Yes ❑ No O N/A
❑ Yes ❑ No O N/A
Page 3 of 7

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
(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 priority 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: Unused aqueous coating for printing
How is material stored: Items are stored in sealed plastic drums
Where is material stored: Items are stored in a sealed chemical holding room
How many disposal shipments per year: 4 times/yr
Name of transport / disposal vendor: Nexeo Solutions
Vendor address: 3930 Glennwood Drive, Charolette, NC 28208
Footnotes to Questions 14) c. & d.
❑ Yes ❑ No 17 N/A
O Yes ❑ No ❑ N/A
❑ Yes ❑ No 21 N/A
❑ Yes ❑ No 21 N/A
El Yes ❑ No 0 N/A
❑ Yes 17No ❑ N/A
OYes ❑ No ❑ N/A
❑ Yes O No ❑ N/A
`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

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 ❑O N/A
b. Does your facility have coal piles on site?
❑ Yes ❑ No ON/A
c. Does your facility store other fuel sources outside in piles, such as wood chips,
❑ Yes ❑ No 191 N/A
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
❑O Yes ❑ No ❑ N/A
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity: Sheetfed and offset web printing trim collection
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit?
OYes ❑ No ❑ N/A
Please specify: Permit # 07167R15
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: NCCESQG05302 , Program: Hazardous Waste
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7

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 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.
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: Timothy S. Holt
Title: President
of
s
(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

NCGNE000O No Exposure Certification
Final Checklist
This application should include the following items:
I// This completed application and all supporting documentation.
O' A map with the location of the facility clearly marked.
[[ � f the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
PCZ
Mail the entire package to:
Stormwater Permitting Unit Program _
Division of Energy, Mineral and Land Resources
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DEMLR Regional Office for your area.
DEMLR Regional Office Contact Information:
Asheville Office ......
Fayetteville Office ...
Mooresville Office ...
Raleigh Office ........
Washington Office ..
Wilmington Office ...
Winston-Salem ......
Central Office ........
[phone]
[phone]
[phone]
[phone]
[phone]
[phone]
[phone]
.[phone]
Page 7 of 7

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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
January 4, 2008
Mr. Larry M. Pegram
PBM Graphics, Inc.
3700.South Miami Blvd.
Durham, NC 27703
Subject: No Exposure Certification NCGNE0436
PBM Graphics, Inc.
3700 South Miami Blvd., Durham, NC
Durham County
Dear Mr. Pegram:
Coleen H. Sullins, Director
Division of Water Quality
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on June 8, 2007. Based on your submittal and signed
certification of no exposure at the above referenced facility, the Division is granting your certification as
provided for under 40 CFR 126.22(g), which is incorporated by reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (December 31, 2012). At that time you must re -certify
with the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Sarah Young at [phone], ext.
502, or at [e-mail].
Sincerely,
for Coleen H. Sullins
cc: Raleigh Regional Office -Danny Smith Central Files — w/attachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
9MENR
Customer Service
1-877-623-6748

DURHAM
INS�S0o�o4e /
l 8 6 9 CITY OF DURHAM
Cm OFMENCINE DEPARTMENT OF PUBLIC WORKS
101 CITY HALL PLAZA • DURHAM, NC 27701
919.560.4326 • fax [phone]
www.durhamnc.gov
May 91h, 2007
�( v�+ c�
Larry Pegram I(',
PBM Graphics, Inc. N t' )�O7
P.O. Box 13603 L (
Research Triangle Park, NC 27709 oeNr, ,.: :E:N QUgLITr
'•ntlanA. x:yn"WR.mr fjp,,
Mr. Pegram,
0 Engineering
0 Storm Water
Services
0 Street
Maintenance
0 Transportation
On April 24, 2007, your facility and its operations were inspected for compliance with city, state, and federal
storm water regulations. No violations or action items were observed at the time of inspection. Before your
facility can be deemed to be in compliance with all applicable storm water regulations, the following items must
be addressed:
1. Your facility may be required to obtain a National Pollutant Discharge Elimination System (NPDES)
Permit. Please contact the NCDWQ Storm Water Permitting Section for a determination.
2. Upon inspection of the facility exterior, a number of open pipes were noticed protruding from the
brickwork.. The sources of these pipes must be identified.
3. Whereas the condensate generated by air conditioning systems is deemed permitted by rule, if it is
treated with bacticides/fungicides/algicides, the condensate may not be discharged into the storm
drainage system. Please indicate if condensate is treated in such a way.
Response to these issues must be received within 30 businessSWs of receipt of this letter. Failure to respond
within the allotted time period will result in a Notice of Violation, as well as other administrative and/or civil
actions, as allowed by City Ordinance.
As a reminder, all industrial facilities are subject to random inspection for compliance with storm water
regulations.
Thank you for your time and cooperation.
Sincerely,
Jim Azarelo
Industrial Storm Water Inspector
City of Durham
Public Works Department/Storm Water Services Division
101 City Hall Plaza
Durham, NC 27701
[phone] x226
[e-mail]
Good Things Are Happening In Durham

CC�N 3�
United Stales Environmental Protection A Form Approved
Agency
NPDES Washington, Washington, DC 20460 g OMB No. 2040-02t1
FORM \Awt NO EXPOSURE CERTIFICATION for Exclusion from
3510-11 E PANPDES Storm Water Permitting QRD
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities include the storage,
loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product. A storm resistant shelter is
not required for the following industrial materials and activities:
— drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational taps or valves;
— adequately maintained vehicles used in material handling; and
— final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual outfalls. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed Instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information I
1. Name: Ir IUt�IMI I AAu"Pil Ic-ISionxic1•I I i I I 12.Phonne: l�l/I� sl r'1'14 �I ZIZI ZI
3. Mailing Address: a. Street: 13171 0101 1 LGiuJiAli Ab A✓111 / 1 I81 01U I L-i EIV IA I N DI I I I I I
b. W. I DI U T A ki AAi I I I I I I I I I I I I I I I I c. State: VVI GJ d. Zip Code: 1217171 CI 31- I I I I I
B. Facility/Site Location Information
1. Facility Name: P 18101 [n /ciAl/ IAII I �-I SL�J 1/ 11 Li • 1 1 I 1 1 1 i I I I I 1 1
2. a. Street Address: 131'110101 IS1 01 Ul?I HI ✓fllr IAiM1ri L/g101 U I L-i EI1IA 1A n1 I�A1I I I I I
b. City: IDiyiAWAlM 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I c. County: �101 A,AIMI 11 1
d. State: 1N/ g e. Zip Code: �.I 7171 , 31 —1 1 1 1
3. Is the facility located on Indian Lands? Yes ❑ No
4. Is this a Federal facility? Yes ❑ No
5. a. Lafitude: BLS �� ISJ" b. Longitude:
i 6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No ❑ D oN t �xJ u "t
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: 1211151Secondary (if applicable): I I 1 1
8. Total size of site associated with industrial activity: (0, T/O acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes ❑ No
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre ❑ One to five acres ❑ More than five acres ❑
EPA Form 3510-11 10-99 f"' `5 t./
( ) I I� fi>,./ I ... Page 1 of
J U N i (- win
DENF

NPDES NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM EPA
OMB No. 2040.0211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1.
Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
❑
or cleaning industrial machinery or equipment remain and are exposed to storm water .
2.
Materials or residuals on the ground or in storm water inlets from spillslleaks
❑
3.
Materials or products from past industrial activity
❑
4.
Material handling equipment (except adequately maintained vehicles)
❑
5.
Materials or products during loading/unloading or transporting activities
❑
6.
Materials or products stored outdoors (except final products intended for outside use (e.g., new cars] where
❑
exposure to storm water does not result in the discharge of pollutants)
7.
Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
❑
8.
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑
9.
Waste material (except waste in covered, non -leaking containers [e.g., dumpstersi)
❑
10.
Application or disposal of process wastewater (unless otherwise permitted)
❑
11.
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
❑
Nz
(i.e.. under an air quality control permit) and evident in the storm water outflow
D. Certification Statement
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES storm water permitting.
I certify under penalty of law that there are no discharges of storm water contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, if requested, to
the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I understand that I must
allow the NPDES permitting authority, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water from the facility.
Additionally, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my
knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name: LIAA(ZiA IWI IPIr-i6iAAM I I I I I I I I I I I I I I I I I I
Print Title:
Signature:
Date: 1 "I S� 0I y 10 l0
EPA Form 3510-11 (10-99) Page 2 of 4

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