NCGNE0617_COMPLETE FILE - HISTORICAL_20140819

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE U 6
DOC TYPE
EP/HISTORICAL FILE
DOC DATE
❑ Q�'
YYYYM M D D

� RR�
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor
July 22, 2014 �UG 9 2014 �J
Mr. James Reason
Xellia Pharaceuticals USA, LLC
8900 Capitol Blvd NC DENR Raleigh Regional office
Raleigh, N.C. 27616
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0617
Xellia Pharmaceuticals USA LLC
Formerly Fresenius Kabi USA, LLC
Wake County
Dear Mr. Reason:
The Division has reviewed your submittal of the permit name/ownership change form
for the subject No -Exposure Certification, which we received on July 22, 2014. Division
personnel have reviewed and approved your request to transfer the exclusion from NPDES
stormwater permitting requirements.
Please note that by our original acceptance of the No -Exposure Certification and by our
approval of your request to transfer it, you are obligated to maintain no -exposure conditions at
your facility. If conditions change such that your facility can no longer qualify for the 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.
Annual re -certification is required, and we have enclosed one blank Annual No
Exposure Exclusion Self Re -Certification form for your use. 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.
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 - Internet: httli llportal.ncdenr.org/webllrl
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ML-7-3
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If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
ORIGINAL SIGNED BY
BETHANY GEORGOULIAS
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Raleigh Regional Office, D. Parnell
Stormwater Permitting Program Files
Central Files

NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
Mr. James Reason
Xellia Pharaceuticals USA, LLC
8900 Capitol Blvd
Raleigh, N.C. 27616
Dear Mr. Reason:
John E. Skvarla, III
Secretary
July 22,2014 RECEIVED
AUG 14 2014
CENTRAL FILES
DWQIBOG
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0617
Xellia Pharmaceuticals USA LLC
Formerly Fresenius Kabi USA, LLC
Wake County
The Division has reviewed your submittal of the permit name/ownership change form
for the subject No -Exposure Certification, which we received on July 22, 2014. Division
personnel have reviewed and approved your request to transfer the exclusion from NPDES
stormwater permitting requirements.
Please note that by our original acceptance of the No -Exposure Certification and by our
approval of your request to transfer it, you are obligated to maintain no -exposure conditions at
your facility. If conditions change such that your facility can no longer qualify for the 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 on -
permitted discharge.
Annual re -certification is required, and we have enclosed one blank Annual No
Exposure Exclusion Self Re -Certification form for your use. 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.
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 - Internet: http://portal.ncdenr.org/web/Ir/
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
/or Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Raleigh Regional Office, D. Parnell
Stormwater Permitting Program Files
Central Files

Division of Energy, Mineral &Land Resources FORACENcvusEONw
�A Land Quality Section/Stormwater Permitting
Date Receivetl
i� g Year Month Day
National Pollutant Discharge Elimination System
NCDENR
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the perinit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
tr G o N c: GNcb
II. Permit status rim- to requested change.
a. Penn it issued to (company name):
b. Person legally responsible for permit:
First MI Last
RECEIVED E H s>z-
'hiue
JUL 22 2014 q'9 'A -Pt m- LJ�
Pennit Molder Mai hg Address
DENR-LAND QUALITY cz ZCI 6-N C/ ;) 7 S-g '7
STORMWATER PERMITTING City State zip
(9A9) 3,27z-f 7_Lozd�
Phone Pas
a Facility name-t (discharge): 1L�- -
L
d. Facility address: �
&pJL OL 31-/-A
Address
State Zip
e. Facility contact person: JPMss mow (e,tot ) -'�2-? 54 ��
First / MI / Last Phone
III. Please provide the following for the requested c , nge (revised permit).
a. Request for change is a result of: Change in ownership of the facility
❑ Ntune change of the facility or owner
Ifo7her please eaplcrrtt:
b. Permit issued to (company name): n�—;1 — .,(/ -/ -
c. Person legally responsible for permit:
Cx
W
,%ryM
First
eAl 91
MI last
f ff5
eeO.et)i Ai
de
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oL
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•
Permit
Bolder NlailiiAddress
City
State
Zip
/ �+) 3 2 7- S-4 z r-1 J,�.-.�...
r�asv ��''"'".�'"G•
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Phone
E-mail Address
�i,a
d. Facility name (discharge):
_ t
Cc.-'-
LUA LLCM
e. Facility address:
Address//
f. Facility
City
�A
State
-
Zip
contact person:
rvtN
_
First
i�eSD�
MI
r
last
_�%�N� )3.27-stZ�
�oroe i'�usonr�4'n.sen,'r,s-kaV'.,C.rr!i-
Phone
E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27, 2014

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NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
-J/I d/l) 119,
i
First MI Last
rile
—Ono e�iz8e- ,&%d c)
Mailing dcJress
41,
City State Zip
(119) 9.27-
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
too-t,h*ownership or name change?
Yes
❑ No (please explain)
V1 Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE COMPLETE OR MISSING:
This completed application is required for both name change and/or ownership change
quests.
9-- Legal documentation of the transfer ol'ownership (such as relevant pages of a contract (Ieed,
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 sign: d by both the permit holder prior to the change, and
the new applicant in the case of an ownership chan c reque'st. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holdct pi for to ownership change):
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 undersl;ind Thal 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 incomolcte 1
Permit contact:
Signature
CERTIFICATION
Date
1, , attest that this application for a nannJuwnctsaiit change has been reviewed and is accurate and
complete to the best of my knowledge. I undcrsland f all required parts of this application are not
completed and that if all required supporting inli>nn:ttion is not included, this application package will be
ret as ine plete. /
Signature Date
PLEASE SEND THE COiNII'LI:'I i,: APPLICATION PACKAGE TO:
Division of Encn . N4i:;cial and Land Resources
Stormw:ucr Pcnuining Program
1612 \4niI Sc: ice Center
Raleigh, Norih Curoliva 27699-1612
Revised Jan. 27, 2014

PURCHASE AND SALE AGREEMEN"C
by and among
FRESENIUS KABI USA, LLC,
XELLIA PHARMACEUTICALS USA LLC
and
XELLIA PHARMACEUTICALS APS
Dated as of July 3, 2014
RECEIVED
JUL 22 2014
DENR-LAND QUALITY
STQRMWATER PERMITTING
709310158
Execution Version

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�1 �J�l 11 q�4�.����3�
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IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
and delivered by their respective officers thereunto duly authorized, as applicable, as of the date
first written above.
SELLER
FRESENIUS KABI USA, LLC
Name: Jack C. Silhavy
Title: Executive Vice President, Gencr: 1 Counscl
and Secretary
13y:
Name: Steven R. Nowicki
Title: Vice President, Manufacturing and
Quality Control
70Y310153 (Signature Page to Purchase and Sale Agreement]

IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
and delivered by their respective officers rh-'reunto duly authorized, as applicable, as of the date
first written above.
SELLER
FRESENIUS KABI USA, LLC
Name: Jack C. Silhavy
Title: Executive Vice President, General Counsel
and Secretary q /
By. "'P,lV"J'
Name: Steven R. Nowicki
Title: Vice President, Manufacturing and
Quality Control
709310138 (Signature Page to Purchase and Sale Agreement)

PURCHASER
XI'.LLIA PHARMACEUIICAI—S USA I_LC;
RY: (%f
Name:
Ti11e:
PURCHASER GUARAN 014
X6LLIA PHARNIM-FUTICAL.S APS
13
Tile:
fSigonnu c P.+grro P",, uuJ Sn,r: Ig,' "em/
%o�tlrilSN

Fill
r
NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. James Reason
Catalent Pharma Solutions
8900 Capital Blvd
Raleigh, NC 27616
Dear Mr. Reason:
Division of Water Quality
Coleen H. Sullins
Director
June 24, 2009 z
�q
Ot
m_�1
t
Subject: No -Exposure Certification°NGGNE6617
Catalent Pharma Solution'-
VT
Raleigh
Wake County
Freeman
Secretary
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. We are also hereby rescinding your current permit Certificate
of Coverage, NCG060218.
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 unpermitted discharge (subject to civil penalties of
up to $25,000 per day). Your conditional no -exposure exclusion expires in five years (June 30, 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 Myrl Nisely at [phone] or at
[e-mail]
erely, /
for Coleen H./ullins
cc: RRO Stormwater Permitting File NCG060218 Fran McPherson -Budget Office
rStormwater Permitting Unit No -Exposure Files City of Raleigh Stormwater Unit
Wake County Stormwater Unit
North Carolina Division of Water Quality 1628 Mail Service Center Raleigh, NC 27699-1628 Phone [phone]
Internet: v,M1vw.ncvratercualitv.orc Location: 3800 Barrett Drive Raleigh, INC 27609 Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10°/ Post Consumer Paper
Nne
orth Carolina
1111atllrallY
Customer service
1-877-623-6748

® Division of Water Quality
❑ Division of Soil and Water Conservation
❑ Other Agency
Facility Number: Facility Status: Active Permit: NCGNE0617 ❑ Denied Access
Inspection Type: Stormwater Inactive or Closed Date:
Reason for Visit: Routine County: Wake Region: Raleigh
Date of Visit: 06/19/2009 Entry Time:08:05 AM Exit Time: 08:30 AM Incident #:
Farm Name: Catalent Pharma Solutions LLC Owner Email: saundra.granade0cat
Owner: Catalent Pharma Solutions LLC Phone: [phone]
Mailing Address: 8900 Caoital Blvd Raleigh NC 27616
Physical Address: 8900 Canital Blvd Raleigh NC 27616
Facility Status: ® Compliant ❑ Not Compliant Integrator:
Location of Farm: Latitude: 35°54'05" Longitude: 78°33'28"
Question Areas:
Certified Operator: Operator Certification Number:
Secondary OIC(s):
On -Site Representative(s): Name Title Phone
Primary Inspector: Myrl Nisely Phone:
Inspector Signature: Date:
Secondary Inspector(s):
QE=_CEIVFD
Inspection Summary: This facility is completely free of potential stormwater pollutants. Beautifully landscJb9d, Merla'rNS industrial activities outside the
buildings, no petroleum storage tanks, nothing of concern. They clearly qualify for No Exposure.
Information Processing Unit
DWO/BOG
Page: 1

North Carolina
Beverly Eaves Perdue
Governor
Mr. James Reason
Catalent Pharma Solutions
8900 Capital Blvd
Raleigh, NC 27616
Dear Mr. Reason:
Aj�
KA LiD
S/
NC®ENR
Department of Environment and Natural Resources
Division of Water Quality
Coleen H. Sullins Dee Freeman
Director Secretary
June 24, 2009
Subject: No -Exposure Certification NCGNE0617
Catalent Pharma Solutions
Raleigh
Wake 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, 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. We are also hereby rescinding your current permit Certificate
of Coverage, NCG060218.
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 unpermitted discharge (subject to civil penalties of
up to $25,000 per day). Your conditional no -exposure exclusion expires in five years (June 30, 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 Myrl Nisely at [phone] or at
[e-mail]
erely,
for Coleen H. ullins
cc: kRO Stormwater Permitting File NCG060218) Fran McPherson -Budget Office
Stormwater Permitting Unit No -Exposure Files City of Raleigh Stormwater Unit
Wake County Stormwater Unit
One arolIna
�1�attrrrrll�
North Carolina Division of Water Quality 1628 Mail Service Center Raleigh, NC 27699-1628 Phone [phone] Customer Service
Internet: www.ncwatercualitv.oro Location: 3800 Barrett Drive Raleigh, NC 27609 Fax [phone]
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® Division of Water Quality
Division of Soil and Water Conservation
❑ Other Agency
Facility Number: Facility Status: Active Permit: NCGNE0617 ❑ Denied Access
Inspection Type: Stormwater Inactive or Closed Date:
Reason for Visit: Routine County: Wake Region: Raleigh
Date of Visit: 06/19/2009 Entry Time:48:05 AM Exit Time: 08:30 AM Incident #:
Farm Name: Catalent Pharma Solutions LLC Owner Email: saundra.oranadeoncat
Owner: Catalent Pharma Solutions LLC Phone: [phone]
Mailing Address: 8900 Capital Blvd Raleiah NC 27616
Physical Address: 8900 Capital Blvd Raleigh NC 27616
Facility Status: E Compliant ❑ Not Compliant
Location of Farm:
Question Areas:
Integrator:
Latitude:35°54'05" Longitude:78°33'28"
Certified Operator: Operator Certification Number:
Secondary OIC(s):
On -Site Representative(s): Name Title Phone
Primary Inspector: Myrl Nisely Phone:
Inspector Signature: Date:
Secondary Inspector(s)
Inspection Summary:
This facility is completely free of potential stormwater pollutants. Beautifully landscaped, there are no industrial activities outside the
buildings, no petroleum storage tanks, nothing of concern. They clearly qualify for No Exposure.
Page: 1

P(CaSe ✓ o �Cti�S aG� lii y rS
CtT✓rP✓T114 Cove, .d "*J-D'L NCGW1oIvOZ18. (�
�ro e s l ss�• -Smy
A
y' a Division of Water Quality / Surface Water Protection
NCDENRNational Pollutant Discharge Elimination System
NO EXPOSURE CERTIFICATION for Exclusion
NCGNE0000
FOR AGENCY USE ONLY
Ume Received
Year Momh
Ou
0
aiific=of Covcru e
N 0
NO EXPOSURE CERTIFICATION PleaPlea e check here if this is a 'renewal ❑`RENEWALI
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit based
on NO EXPOSURE:-7=
Submission of this No Exposure Certification constitutes notification. that your facility does nt(I
quite a
permit for stormwater discharges associated with industrial activity in the State of North Carof7n'S
L5use
it qualifies for a no exposure exclusion. A condition of no exposure at an industrial facility miin
all Z
industrial materials and activities are protected by a storm resistant shelter (with some except
tom'
prevent exposure to rain, snow, snowmelt, and/or runoff. 71
A
D
For permitted facilities in North Carolina, DWQ must approve your application
^'
No
Exposure Certification before this exclusion is effective. Until you are issued
Exposure Certification and your NPDES permit is rescinded, your facility must
ntinue I
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. 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).
You are required to reapply for the No Exposure Exclusion once every five (5) years.
For questions, please contact the DWO Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of
Name
Contact
Street Address
City
Telephone No.
pz
SWU-NE-021309 IIM _ 2009
Page 1 of 7
State /V C ZIP Code bL / 0 / ('
Fax: 0)/07 V'7/- 0.300/
Last revised 2/13/2009

NCGNE0000 No Exposure Certification
2) Location of facility producing discharge
Facility Name
R I & N1 -
Facility Contact
—F(VI
w,,eZ
Street Address
9 6 0
City
_
County
Telephone No. 9 in '3 a'7 Z V Fax:
3) Physical location information:
Please provide a narrative description of how to get to the facility (use
distance and direction front a roadway intersection). _ U.¢ I /v
names, state road numbers, and
(A copy of a map with the facility clearly 16cated on it should be included with the certification application.)
4) Is the facility located on Native American Lands? 17 /�es ❑ No
5) Is this a Federal facility? ❑ Yes t,Jo
6) Latitude Longitude (deg., min., seconds) v'""�pt A-Cn8 — 33U
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 _
❑ Renewal of existing No Exposure Certification Certification No.: NCG
8) Was this facility or site ever covered under an NPDES Stormwater Permit? dyes ❑ No
If yes, what is the NPDES Permit Number? NCG ) (po a) 2
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: -
10) ProvJa brief descriptlion ofl��jle types of industrial activities and products produced at this facility:
!%i7./h11L6(k-✓� Z lam\
11) Does this facility have any Non -Discharge permits (ex: recycle permits)?
fd'lqo—
❑ Yes
If yes, list the permit numbers for all current Non -Discharge permits for this facility:
Page 2 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
.73
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 2<01 O 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 VKO ❑ N/A
c. Materials or products from past industrial activity
❑ Yes 17'No ❑ N/A
d. Material handling equipment (except adequately maintained vehicles)
❑ Yes V No ❑ N/A
e. Materials or products during loading/unloading or transporting activities
❑ Yes gKo ❑ N/A
f. Materials or products stored outdoors (except final products intended for outside
❑ Yes eNo ❑ 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 B<o ❑ N/A
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by
❑ Yes EV<o ❑ N/A
the discharger
i. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes 21KO ❑ N/A
j. Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes GYNo ❑ N/A
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not
ElYes EW<o ❑ 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, V No ❑ N/A
(i.e., not closed and stored upside down to prevent precipitation accumulation)
/No
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers
❑ Yes ❑ 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 ❑ Yes Qd No ❑ N/A
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes CTNo ❑ N/A
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SWU-NE-021309 Last revised 2/13/2009

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
ID Yes ❑ No
"IA
(including drums, barrels, etc.) with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored
❑ Yes ❑ No
R N/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
Gf IN/A
Amendments and Reauthorization Act (SARA) water priority chemicals'?
'es
d. Is secondary containment provided for hazardous substances" designated in 40
all'? ❑ No
❑ N/A
CFR §116?
e. Are release valves on all secondary containment structures locked?
es ❑ No
❑ N/A
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? Yes ❑ No ❑ N/A
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste aleess ❑ No ❑ N/A
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes ❑ No V<A
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 sti
Where is material
How many disposal shipments per year:
Name of transport / 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.
Page 4 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNEOOOO 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 IZNNoo ❑ N/A
b. Does your facility have coal piles on site? ❑ Yes W o 0 N/A
c. Does your facility store other fuel sources outside in piles, such as wood chips,
❑ Yes R No ❑ N/A
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g.,
O Yes cir o ❑ N/A
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 ❑ No "IA
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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SWU-NE-021309 Last revised 2/13/2009

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. cu
Printed Name of Person Signing: J R m Ca nnSOA-)
Title:
QU QZ Ug
(Sigril 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.
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SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
C3 This completed application and all supporting documentation.
C' A map with the location of the facility clearly marked.
d If this is a renewal, indicated current NCGNE number in Question 7.
B� If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question B.
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
Page 7 of 7
SWU-NE-021309 Last revised 2/13/2009

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