NCGNE0091_COMPLETE FILE - HISTORICAL_20060123

STORMWATER DIVISION CODING SHEET
.NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
LX HISTORICAL FILE
DOC DATE
3
YYYYMMDD

Michael F. Fasley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Cnvironment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Homac Corporation
2727 Tucker Street Ext
Burlington, NC 27215
Subject: General Stormwater Permit Inspections
Lessona/Holt Distribution
Permit No. NCGNE0091
Alamance County
Dear Sir or Madaam:
Your facility holds a General Permit from the North Carolina Division of Water Quality to
discharge stormwater associated with industrial activities performed at your facility. Please be
advised that the Winston-Salem Regional Office will be performing NPDES Stormwater
Inspections sometime in the near future.
If this office has not previously inspected your facility, you should be prepared to demonstrate
compliance with all terms and conditions included in the Permit. Specifically, we will be
evaluating the following: Stormwater Pollution Prevention Plan, Stormwater Outfall Locations,
Qualitative and Analytical Monitoring Data and any other activities required by your permit.
Copies of the general permits and accompanying documents can be accessed from the following
webpage: httn://h2o,enr.state. nc.us/su/Forms Documents.htm#StormwaterGP.
If you have any questions, please contact Jenny Freeman in the Winston-Salem Regional Office
at [phone].
Sincerely,
r
Jenny Freeman
cc: NPS Compliance & Assistance Oversight Unit
SWP-Central Files
WSRO Files _
NonehCaro t»a
Nalurnllly
North Carolina Division of Water Quality 585 Waughtown Street Winston-Salem, NC 27107 Phone [phone] Fax [phone]
lntemet: h2o.enr.state nc.us
An Equal Opportunity/Affirmative Action Employer — 50% Recyciedll0% Post Consumer Paper

f WA]F Michael F. Easley, GOVe[nor
`O�� 9QG William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Q Coleen I I. Sullins, Deputy Director
Division of Water Quality
April 20, 2005
Ralph M Holt, Jr
Homac Corporation
PO Box 819
Burlington, NC 27216
Subject: No Exposure Certification NCGNE0091
LessonalHolt Distribution - 2727 Tucker St Ext
Alamance County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on .tune 25, 2002. We apologize for the extended period it
has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. 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 (April 30, 2010). 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 Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
OA
€ C-6EhiR
Customer Service
1-977-623-6749

NPDES
FORM
351 0-11
Form Approved
United States Environmental Protection Agency OMB No.2040-0211
Washington, DC 20460
Nm® EPA NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
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, andfor 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. Faciltty Operator Information 33 ti
1. Name: MO1h( Gl 1C1f7112tPIDI,R1l�}171 i IOI�f I I I 1 J I I1_._I I _J_j 2. Phone: 4:tRY A 7 1 klI "�0171
3. Mailing Address: a. Street: 1&2Z OIx I SIT III I I I I l l 1___l 1__1 1 1 1 1 1 1 I l 1_ _ 1 1. 1 .�
b. City. & I 1A4 A LI 1� I I t A1/1 1 1 1 1 i I I I I I I I c. State: ff d. Zip Code:Ill
B. Faciiityf51te Location Information
1. Facility Name: LL I SIC
f I thI I ISr-IT2L!
2. a. Street Address: I 11 L-I !I ITIJK l GI IqF I Til y511 i I M +h t I 1 i , I r_4
b. City: i+< A- - _Rl/-4/_limit_ I0 A I I I I I I I I I I I 1_ I
d. State: 41—VA e. Tip Code: 21 712t/ ISi-- i I I I
3. Is the facility located on Indian Lands? Yes ❑ No 9
4. Is this a Federal facility? Yes ❑ No
c. County: r! 14 A A I4111knim _ _l
5. a. Latitude: Wr 9LIJ " b. Longitude: Y I (I I k�j 4 , 13LJ
6. a. Was the facility or site previously covered under an NPMS storm water permit? Yes
b. If yes, enter NPDES permit number: NG� 0, 0300
7. SIC/Activity Codes: Primary: t3 1 16 Secondary(if applicable): 2- %
8. Total size of site associated with industrial activity: 0_2 3 . 9 acres
No ❑
Z 75.2.
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)
JUN 2 5 2002
DERR - 4YA7ER QIJ�;
POINT BRANCH

NPIDESFORM ,� p NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
3510 17 ����■ A dMB No. 2040-0211
NPDES Storm Water Permitting
C. Exposure Checkllat
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 spills/leaks
LIN
9. Materials or products from past industrial activity
�]
4. Material handling equipment (except adequately maintained vehicles)
{�
5. Materials or products during loadinglunloading or transporting activities
El
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
El
B. Materials or products handledlstored on roads or railways owned or maintained by the discharger
❑
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑
10. Application or disposal of process wastewater (unless otherwise permitted)
11
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
El
(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)),
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: AA.LH- Itf 1_ l A ig a 4r, 4, k I I I I I i l I I_ I I I I I I I
Print Title:
Signature:
�!TPIEJ /LI JI
EPA Form 3510-11 (10-99) Page 2 of 4

NPDES ft Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
3510 71 ��•EPA OMB No. 2040-021 i
Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. Facility/Site Location Information
Federal law at 40 CFR Part 122.26 prohibits point source discharges of
storm water associated with industrial activity to waters of the U.S. without
a National Pollutant Discharge Elimination System (NPDES) permit. However,
NPDES permit coverage is not required for discharges of storm water
associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)-
(Ix) and (A) if the discharger can certify that a condition of "no exposure'
exists at the industrial facility or site.
Storm water discharges from construction activities identified in 40 CFR
122.26(b)(14)(x) and (b)(15) are not eligible for the no exposure exclusion.
Obtaining and Maintaining the No Exposure Exclusion
This form is used to certify that a condition of no exposure exists at the
industrial facility or site described herein. This certification is only applicable
in jurisdictions where EPA is the NPDES permitting authority and must be
re -submitted at least once every five years.
The industrial facility operator must maintain a condition of no exposure at
its facility or site in order for the no exposure exclusion to remain applicable.
If conditions change resulting in the exposure of materials and activities to
storm water, the facility operator must obtain coverage under an NPDES
storm water permit immediately.
Where to File the No Exposure Certification Form
Mail the completed no exposure certification form to:
Storm Water No Exposure Certification (4203)
USEPA
401 M Street, SW
Washington, D.C. 20460
Completing the Form
You must type or print, using uppercase letters, in appropriate areas only.
Enter only one character per space (i.e., between the marks). Abbreviate
if necessary to stay within the number of characters allowed for each item.
Use one space for breaks between words. One form must be completed
for each facility or site for which you are seeking to cartif}+ a condition of no
exposure. Additional guidance on completing this form can be accessed
through EPA's web site at www.epa.govlowmisw. Please make sure you
have addressed all applicable questions and have made a photocopy for
your records before sending the completed form to the above address.
Section A. Facility Operator Information
1. Provide the legal name of the person, firm, public organization, or any
other entity that operates the facility or site described in this certification.
The name of the operator may or may not be the same as the name of
the facility. The operator is the legal entity that controls the facility's
operation, rather than the plant or site manager.
2. Provide the telephone number of the facility operator.
3. Provide the mailing address of the operator (P.O. Box numbers may be
used). Include the city, state, and zip code. Ail correspondence will
be sent to this address.
1. Enter the official or legal name of the facility or site.
2. Enter the complete street address (if no street address exists, provide
a geographic description [e.g., Intersection of Routes 9 and 55)), city,
county, state, and zip code. Do not use a P.O. Box number.
3. Indicate whether the facility is located on Indian Lands.
4. Indicate whether the industrial facility is operated by a department or
agency of the Federal Government (see also Section 313 of the Clean
Water Act),
5. Enter the latitude and longitude of the approximate center of the facility
or site in deg reeslminuteslseconds. Latitude and longitude can
be obtained from United States Geological Survey (USGS) quadrangle
or topographic maps, by calling 1-(888) ASK-USGS, or by accessing
EPA's web site at http:llwww.epa.gov/owm/sw/industryAndex.htm and
selecting Latitude and Longitude Finders under the Resources/Permit
section.
Latitude and longitude for a facility in decimal form must be converted
to degrees (1), minutes ('), and seconds (") for proper entry on
the certification form. To convert decimal latitude or longitude to
degreeslminuteslseconds, follow the steps in the following example.
Example: Convert decimal latitude 45.1234567 to degrees (°), minutes
('), and seconds (").
a) The numbers to the left of the decimal point are the degrees: 45°.
b) To obtain minutes, multiply the first four numbers to the right of the
decimal point by 0.006: 1234 x 0.006 = 7.404.
c) The numbers to the left of the decimal point in the result obtained
in (b) are the minutes: 7'.
d) To obtain seconds, multiply the remaining three numbers to the
right of the decimal from the result obtained in (b) by 0,06:
404 x 0.06 = 24.24. Since the numbers to the right of the decimal
point are not used, the result is 24".
e) The conversion for 45.1234567 = 45" 7' 24".
6. Indicate whether the facility was previously covered under an NPDES
storm water permit. if so, include the permit number.
7. Enter the 4-digit SIC code which Identifies the facility's primary acllvlty,
and second 4-digit SIC code identifying the facility's secondary activity,
if applicable. SIC codes can be obtained from the Standard Industrial
Classification Manual, 1987.
8. Enter the total size of the site associated with industrial activity in acres.
Acreage may be determined by dividing square footage by 43,560, as
demonstrated in the following example.
Example: Convert 54.450 ft2 to acres
Divide 54.450 ft2 by 43,560 square feet per acre:
54,450 ft2 + 43,560 ft2/acre = 1.25 acres.
9. Check "Yes" or "No" as appropriate to indicate whether you have paved
or roofed over a formerly exposed, pervious area (i.e., lawn, meadow,
dirt or gravel roadlparking lot) in order to quality for no exposure. If yes,
also indicate approximately how much area was paved or roofed over
and is now impervious area.
EPA Form 3510-11 (10-99) Page 3 of 4

NPDESFORM Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
FORM OSHA Exclusion
N0.2040-0211
3510-11 Exclusion from NPDES Storm Water Permitting
Section C. Exposure Checklist
Check "Yes" or "No" as appropriate to describe the exposure conditions at
your facility. if you answer "Yes" to ANY of the questions (1) through (11)
in this section, a potential for exposure exists at your site and you cannot
certify to a condition of no exposure. You must obtain (or already have)
coverage under an NPDES storm water permit. After obtaining permit
coverage, you can institute modifications to eliminate the potential for a
discharge of storm water exposed to industrial activity, and then certify to
a condition of no exposure.
Section D. Certification Statement
Federal statutes provide for severe penalties for submitting false information
on this application form. Federal regulations require this application to be
signed as follows:
For a corporation: by a responsible corporate officer, which means:
(i) president, secretary, treasurer, or vice-president of the corporation
in charge of a principal business function, or any other person
who performs similar policy or decision making functions for the
corporation, or
(ii) the manager of one or more manufacturing, production, or
operating facilities, provided the manager is authorized to make
management declsions which govern the operation of the
regulated facility including having the explicit or implicit duty of
making major capital investment recommendations, and initiating
and directing other comprehensive measures to assure long
term environmental compliance with environmental laws and
regulations: the manager can ensure that the necessary systems
are established or actions taken to gather complete and accurate
information for permit application requirements; and where
authority to Sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the
proprietor; or
For a municipal, State, Federal, or other public facility: by either a
principal executive or ranking elected official.
Paperwork Reduction Act Notice
Public reporting burden for this certification is estimated to average 1.0 hour
per certification, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Burden means the total time,
effort, or financial resources expended by persons to generate, maintain,
retain, or disclose to provide information to or for a Federal agency. This
includes the time needed to review instructions; develop, acquire, install,
and utilize technology and systems for the purposes of collecting, validating,
and verifying information, processing and maintaining information, and
disclosing and providing information; adjust the existing ways to comply with
any previously applicable instructions and requirements; train personnel to
be able to respond to a collection of information; search data sources;
complete and review the collection of information; and transmit or otherwise
disclose the information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding
the burden estimate, any other aspect of the collection of information, or
suggestions for improving this form, including any suggestions which may
increase or reduce this burden to: Director, OPPE Regulatory Information
Division (2137), USEPA, 401 M Street, SW, Washington, Q.C. 20460.
Include the OMB control number of this form on any correspondence. Do
not send the completed No Exposure Certification form to this address.
EPA Form 3510-11 (10-99) Page 4 of 4

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Q (CA, a
Subject: NCG030300
Date: Fri, 26 Jul 2002 13:11:33 -0400
From: Corey Basinger <[e-mail]>
Organization: NC DENR Water Quality
To: Aisha Lau <[e-mail]>, Mack Wiggins <[e-mail]>
CC: [e-mail]
Aisha & Mack,
Via this e-mail, the WSRO recommends rescission of permit NCG030300
issued to Leesona Industries, LLC in Alamance County under the No
Exposure exemption rule. I met with the owner of the facility and
conducted a final site visit on 24 July. There currently are no
materials stored outside that are exposed to stormwater. Should you
have any questions, please let me know. Thanks in advance for handling
this rescission.
Have a great weekend!
Corey
I of 1 7126102 2:56 NM

PAGE 01
08/1Ei'2002 03:17 3'67714630 i
DIV OF WATER QUALITY
AUG 2 0 2002
i
L�
i7ENR - YIA:f ER 000TY
FOIRT sr�SRCE BFi,�,"1"I�
Fax: [phone]
NORTH CAROLINA
DEPARTMENT OF
ENVIRONMENT AND
NATURAL RESOURCES
FAX TRANSMITTAL
Water Quality Section
Winston-Salem Regional OMce
585 Waughtown Street
Winston-Salem, N.C. 27107
Phone: Q36)773-4600
FAX NUNMBER: 9 !°I ) -? - -�`q f q
FROM: Co ZF-y Si,/Grgp—
DATE: l G 4Le 6;- 7At--L-
;dumber of paces (inclu lin` cover pace):
� tf- 4-3d Sao

PAGE 02
08/1Etid2a02 08:17
FROM 0L7-M08IERY
abflttIl6a3 13: 57
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3352270699 2a02,06-16
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PER." U COVERAGE
Qs : 55 #S?4 P. 02/02
PAGE 92M
RESCISSION REOUIEST FOB
National P0Uutane>< dUrgeFXwiaetloaSysmm
wastewater Gewrol Permit
Ply provide the following information.
CwL aFC0ver w 4p NCG --d - 3.r� _ �. 0
Couaty: A]. an e
F�tcfliCyNtsstte: ^r
IHaDME Address': PO Eox 819
ir, ycn 'TC 2721
Loemion Addrrss: ` 2727 Zucker�tr>asx
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permia Cp ct
Phone Number
Fax.Nunher.
F,ntail addmsv
M. Holt Jr.
�'Pha is d,e,dd� so �.rr pe,mh oerrraaRw�cc w'z7 ee nsir.q
Rtu�ofvrrestssazoarrequest; ualifies under non:—e ogure "Q=ptian
b2� system d'rachar�e terrainared: G
KEQMT ,kVD C2-XT lCATl0N
I tardfy that t}re subject waAewwer ascht<rge to sarfW,= waten *F by state has been terminated.. I, as arr
8tt8tarized PeQ('rLtareative. hereby ragw5i rescisuon of coyw%&v under the applicable NPOES'Wwewatcr
JDiseha %C Claq1I Porruit f$r the subject facility. lam Familiar with the infannazion Contained in thj5 rquest and
that to then 1 Le and belief ch irlFo is true, complete and accurate.
Signature Date $ /IS J42
>��ln� 3•t. He7.�, .Try—__ — Pzesident
Pljmor type namD of person signing aboye Thle
PSCese return ft wmpU%td n=iuion requw�st and any r6ae%%M docu mentation to:
General Ptrrrtit Coverag4 Rescisxioa
Arm. Yelcry, Swphe4s
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i3�3!] S/20Q2
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09:17 3367714530 �' DIV OF WATER QUALITY
PACE 03
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Unitet States Fnvinonmental Protection Agency t, �, r. -ril . 20 proved
rm
NPDrxS Washington, DC 2WO
SFOR
11D-II % EPA NO EXPOSURE CERTIFICATION for Exclusion from ul��� 2
NPQES Storm Water Permitting
Submission of this No Exposure Cerlific st-on constitutes notice that the onttty idontiflad in Section A does not require permit af
s 'Stomt water
discharges associated With industrial activity in the State identified in Section S under EPA's Storm Water Multi -Sector General Ue gsl�t�+�s
Of a condition of no axpagurn.
A condition of no exposure exists at an industrial facility when all industrlal materials and activities are protected by a storm resistant shatter to prevent
exposure tq rain, snow. snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activitios,
industrial machinery, raw materials, Intermediate products, by-products, final products, or waste prpduct9. Material handling activities include ttma storage,
loading amc unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product A storm resistant shelter is
not required forthe following industrial materials and activities:
— drums, bmrrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak- `Sealed'
moans banded or otherwise soaurod and without cpgmVvngl taps or voli
- ndoquately malntainod vehicles used in material handling,- and
- final products, other than products that would be rrobillzed In storm water discharges (e.g.. rock salt).
A No Exposure Cartifieation must t6 provided for each freshly qualifying for the no exposure exclusion. to addition, the exclusion from NPDES permitting Is
available on a facility -wide basis silly, not for individual outfalls. if any industrial activitios or materials are orwlll be exposed to pracipitston, thefnvility is
not efigiblafarthe no exposure excusion.
By signing and submitting this No Exposure Certification form, the entity In Section Air certifying that a condition of no exposure exists at Its fadllty of site,
and is obligated to comply with tha terms and conditions of 44 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON 7HIS FORM.
Retailed Instructions for completing this farm and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Inforrnztlon 3$
1.Nama: #i0j t,j&ez IG'�tOl2i rb1 IAI�111Gr�tii I t I 1, } ,}I _1- i )_1 2- Phone yll[71 31?a�171
3, IVlalling Address: a. Street' tit? 131(,7X 1k5 illi I
b. W. J1VALI /1941 -r]A� I t I, 1. ,.l_ I III ,I iI I c. state: I j e. Zip code: I.2I? I ?tU I4I - / I
S. Faellltyl3lts Leestlon Infofmation
1. Facility Name:
2. a. Straet Address: ' ! - /I 164 15 1 j I Jon t
b. city., Rkcf Ra L-t / A�10 * I I } f , I I I , i I I I I II I e. County:
d. State: Ali I , e. zip core; I I I
3.13 the facility located on Indian Lands? Yes ❑ Nog
A. la this a Federal facility? Yes ❑ No
5. e. Latitude: lip, b- Longitude: PIS 0 121464� f
6. a. Was the faculty or sits previously covered under an NPOE5 storm water pemtit? Yes No ❑
b. 1! yes, enter NPI?ES permit number: &d-c— 62102300
7. SfClAetivlty Codes: Primary- Secondary (if appiicable): .�_. 1z'C' 7r�i r�
S. Total size of Site associated wi'h indUstrial activity: ;_- a . L7 acres
9. a. Have you paved or roQfod ever a formerly exposed, pervious area in order to quality for the no exposure exclusion? Yea ❑ No U
b, If yes, please indicate eppro:dmately how much area was paved or roofed over. Complating this gttost W does not disqualify you for the no exposure
exclusion, However, your permitting authority may use this iniormatlon in considering whethor storm water dischargns from your atte are likely to have
an adverse impact on water quality, In whW1 case you could be required to obtain permit Coverage.
Less than one acre ❑ One to rave tames ❑ More Wei flue acres ❑
EPA Form 351U-11 (10-99) Page 1 of 4

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�F3/1� �2g07_
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03:17 3�E7714530 ' ` . 4 DIV OF WATER QUALITY
PAGE 04
NPDES I ft NO EXPOSURE CERTIFICATION for Exclusion from Frt o' ApprovedApprovedFORMI Vol �q� xcusQMD No.2C4M211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are arty of the following materials or adMtles exposed to precipitation, now or in the foreseeable future?
(Please check e'rther'Yes- or"No" in the appropriate box,) If you answer I'Yes"to any of these questions
(1) through (11), you aro not orgibie for the no exposure exduslon.
Yes
No
1, Using, staring or leaning Industrlal 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 writer intots hem spiAslleaks
91
3. Materials or products from past Industrial activity
(]
4. Material handling equipment (excelpt adequately mai ntained vehicles)
0
T�
5. Materials or products during Ioadinglunloadfng or transporting ac5vitias
0
6. Materials or products stored outdoors (except final products Intended for outs!de use (a.g., saw cars] where
expesuro to storm ester does not result In the discharge d pailutants)
7. Materials contained In open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
�(
e. Materials or products hand(ed/stered on roads or railways owned or maintained by the discharger
S. Waste material (except waste in covereld, non -leaking contain or% (e.g., dumpsters))
❑
�I
10. Appllcation or disposal of process wastewater (unless otherwise permitted)
11. PdfllCulato mottor or visible deposits of reslduals from roof stacks and/or vents not otherwise regulated
❑
(i.e., under an air quality cortmi permit) and evident in the storm water oudta v
D. Certification Statement
I certify under penalty of taw ttiat I have read and undenstand the eiigibillty requirements for claiming a Condition of `no exposure" and obtaining an
exclusion from NPDES storm water pefmlttlrg.
I cariffy under penalty of law that there are no discharges of storm water contaminated by axpasure to Industrial activities or materials from the industrial
fadllty or site td9ntifed in phis doaumerr`. (except as allowed under 30 CFR 122.26(g)(2)).
1 understand that I am obligated to submit a no exposure certification Sarin once every five years to the N PDES permitting authority mnd, if requested. to
the operator of the local munlctpal separate storm sewer system IMS4) into which the facility discharges (where appEioable). I understand that I must
allow the NPDES permitting authomty, or MS4 opevor where the discharge Is Into the local M64, tc perform inspections to confirm the condltion of no
axpesuro and to make such inspection reports publicly avallable upon rsquest I understand that i must obtain coverage under an NPORS permit prior
to orry point source discharge of storm water from the faculty.
Additionally, I certify under penalty of law that this document and all attarhmertts were prepared under my dlrectlon 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
por3ons who manage the system, or those persons Directly responsible far gathering the informatlon, the information submitted is to the best of my
knowledgo and tiellef true. ac urata and compteto. I am aware that there are significant penalties for submitting false information, inctudrrg the possibility
of fine and Imprsonment for knowing violations.
Print Name, AA1-tee; Im A a L47-1 rj 11, I I I „I „} ! ..1. 1 l I I I I.
Print Title:
Signature:
Date: I- (I C�- , -
EPA Form 3510.11 (10-1313)
Page 2of4