NCGNE0221_COMPLETE FILE - HISTORICAL_20051026

......... ...
STORMWATER DIVISION CODING SHEET
.NCG PERMITS
PERMIT NO.
NCGNE b,)D
DOC TYPE
t7'HISTORICAL FILE
DOC DATE
F1
YYYYMMDD

NCGNraaal- {leli��e
United States Environmental Protection Agency Form Approved
DM8 No.20411-t7211
NPDES ;' EPA
Washington, 20460
FORM `�' NO EXPOSURE CERTi1=iCATITI0N for Exclusion from
35'1 R-'19
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, 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
1.Name: 11tUINISIEIR1 ii11t IQIGlLIA151 Bill: 1116IMEAl 15]AlAli)IE 2.Phone: 110' 11r y (v ,�q D
3. Mailing Address: a. Street: 14 i 1 1 1 10 IU I I I H 16 111 n I G# I if I A I R I i4 I W! A I a I I I I I „1 —1 1 1 1
b. City j�-i IF I� 15 1 t I MI E 18 I I E I L i 1 1'1 1 1 1 1 1 1 1 1 1 j c.,State: IN 1CJ d. Zip Code: I'll PID I 1{—
B. Facilityf5lte Location Information
1. Facility Name: Wk IUINI1IrAI 10101J161LIAl51
IDICI_5Q1G IM
IE A1_.1�-1141AIDIrI51
2. a. Street Address: O1 .11 15 10 Iy r 1 ii
&J- L 110 1 6 1 rl if Ai(i( Ii K i
i A i+ I I
I I „I_ II I I
b. City: = I Ii Ic 1 M
c. County;
16O�4
d. State: )IV it e. Zip Code; a 1 9 10 1
1 I6 I— I f I I
4
3. Is the facility located on Indian Lands? Yes
No
4. Is this a Federal facility? Yes Q
No
[CD
5. a. Latitude: �� I f 61 1'5 )-j
b. Longitude:
6. a. Was the facility or site previously covered under an
NPDES storm water permit?
Yes
No r — r
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: , 1
Secondary (if applicable): I
I I
S. Total size of site associated with industrial activity; g • (n 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 UK
C.M6 ci�Y �.Ai -
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 beyrequired to obtain permit coverage.
Less than one acre 71 One to five acres ❑ More than five acres El
EPA Form 3510-11 (10-99) Page 1 of 4

I • _
NPDES NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM •- EPA DIMS 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 spills/leaks
d
3. Materials or products from past industrial activity
❑
2
4. Material handling equipment (except adequately maintained vehicles)
El
12"
5. Materials or products during loading/unloading or transporting activities
D
u
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
❑
d
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
B. Materials or products handiedlstored 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)
Q'
11, Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(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 under40 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: 161- IC ID131 E 1A)iP1Q1 /141,51n,IM I I I I I I I I I I I I ,I _I I j
Printiitle: E
Signature:
:yR 1Q CA
EPA Form 3510-11 (10-99) Page 2 of 4

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 degreeslminuteslseconds. 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 htt2://www.epa.gov/owm/sw/industry/index.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 ('), 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 (1). minutes
('), and seconds (").
a) The numbers to the left of the decimal point are the degrees: 451.
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 activity,
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 f12 to acres
Divide 54,450 ft2 by 43,560 square feet per acre:
54,450 ft2 + 43,560 ft2lacre = 1,25 acres.
FORM ,��E�ii Instructions for the NO EXPOSURE CERTIFICATION for OMB Form
o 2Approved11
351a•�i A Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. Fac111tyfSlte 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 (xi) 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 certify a condition of no
exposure. Additional guidance on completing this form can be accessed
through EPA's web site at www.epa.govlowm/sw. 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.D. Box numbers may be
used), Include the city, state, and zip code. All correspondence will
be sent to this address. 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 road/parking lot) in order to qualify for no exposure. If yes,
also indicate approximately how much area was paved or roofed over
nnand its now impervious area.
EPA Form 3510-11 (10-99) Page 3 of 4

1
NPDES
instructions for the NO EXPOSURE CERTIFICATION for OMB N Form
Approved
FORM040-211
3510-11 &EPA Exclusion from NPDES Storm Water Permitting
Section C. Exposure Checklist authority to sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
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) For a partnership or sole proprietorship: by a general partner or the
in this section, a potential for exposure exists at your site and you cannot proprietor; or
certify to a condition of no exposure. You must obtain (or already have)
coverage under an NPDES storm water permit After obtaining permit For a municipal, State, Federal, or other public facility: by either a
coverage, you can institute modifications to eliminate the potential for a principal executive or ranking elected official.
discharge of storm water exposed to industrial activity, and then certify to
a condition of no exposure. Paperwork Reduction Act Notice
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 decisions 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
EPA Form 3510-11 (10-99)
UA R Ci
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 (2)37), USEPA, 401 M Street, SW, Washington, D.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.
Page 4 of 4

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department or Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
October 7, 2005
Mr. Jacob E. Robinson
Hunter Douglas Designer Shades
201 Southrigde Parkway
Bessemer City, NC 28016
Subject: No Exposure Certification NCGNE0221
Hunter Douglas Designer Shades
201 Southridge Parkway, Bessemer City, NC
Gaston County
Dear Mr. Robinson:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 16, 2005. 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 (September 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 Sarah Young at [phone], ext.
502, or at [e-mail].
cc: Mooresville Regional Office
Stormwater Permitting Unit Files
Sincerely,
b =
for Alan W. Klimek, P.E.
Central Files -- w/attachments
N- C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
NUDEiN1R
Customer Service
1-877-623-6748

Copyright (C) 1998, Maptech, Inc.

Re: [Fwd: no -exposure apps. left behind]
Subject: Re: [Fwd: no -exposure apps. left behind]
From: Michael Parker <[e-mail]>
Date: Thu, 01 Sep 2005 15:34:51 -0400
To: [e-mail]
Sarah,
I don't have any reason why we should not move forward with issuance of the requested
NE apps. attached to this email.
Michael Parker
Subject:
no -exposure apps. left behind
From:
sarah young <[e-mail]>
Date: _
Wed, 24 Aug 2005 13:38:39 -0400
To:
Roger Edwards <[e-mail]>, Belinda Henson
<[e-mail]>, Rex Gleason <[e-mail]>, Ken Schuster
<[e-mail]>, Al Hodge <[e-mail]>, Ed Beck
<[e-mail]>. Steve Tedder <[e-mail]>
To:
Roger Edwards <[e-mail]>, Belinda Henson
<[e-mail]>, Rex Gleason <[e-mail]>, Ken Schuster
<[e-mail]>, Al Hodge <[e-mail]>, Ed Beck
<[e-mail]>, Steve Tedder <[e-mail]>
CC:
Bradley Bennett <[e-mail]>
Regional Supervisors,
Attached is a list of neglected no -exposure applications that we received in the
early part of the year. Please forward this to the appropriate person in your
region. We will wait for the "ok" before issuing these. Thank you, Sarah Young
Michael Parker - [e-mail]
Environmental Engineer II
North Carolina Dept. of Environment & Natural Resources
Division of Water Quality
610 East Center Avenue
Suite 301
Mooresville, NC 28115
Ph: [phone] Fax: [phone]
I of 1 10/5/2005 1:53 PM

United States Environmental Protection c '
y OM8 N . 040-0211
NPDES � EPA Washington, DC 20460 MA
R 1
50 M1 NO EXPOSURE m CERTIFICATION for Exclusion from 20Q5
31
NPDES Storm Water Permitting DE'NR _ WATER QUAI ITv
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, andlor 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
1. Name: I lit Uj NIT I C 1(3 1 I'DtoIUIGIl-IA151 101F15111GINIEIL 15IAIA101E1 2. Phone: I 110 M 16 1 111(61�5'1010
3. Mailing Address: a. Street: I I1011 1 15 10 10 1 1 1 K 16 11101 b 19 1 1 P I A I R I A I W I A 111 1 1 1 1 1 1 1_ .I 11
b• City: 1� I E 16 15 1 E I MI ti t fj I I C I!, I% i -1 1 1 1 i l I I, I. I I c. State: Lk_LL d. Zip Code: I a I P 10 1 1 1 L 1— I I I I I
B. FacilitylSite Location Information
1.Facility Name: M IVINIII EAI 10101U161LIAl'31
QiCi 5111& W
IE IRI 1 511.1 iAlnig 151
2. a. Street Address: Q 01 11 1 510 IV
fT 114 IN
1Z iA I G 1 ri if I N SI A I
WIA 11 I I ,I ,I_ I 1.., I II I
b. City: IQ) I'tIS151EIMIC161 1
1 1 1
1 1 1 1 1 1 1 1 1 1
1 c.County: I G I Al 5 IT 104NI I I I
d. State: in it e. Zip Code: j
I? 10 11
1t0 I— I I I I I
3. Is the facility located on Indian Lands?
Yes
No U
4. Is this a Federal facility?
Yes ❑
No E2r
5. a. Latitude: f ['S ] "
1
b. Longitude:
6. a. Was the facility or site previously covered
under an NPDES storm water permit?
Yes No id
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: i Z�4 ; j I I I Secondary (if applicable): I I I
8. Total size of site associated with industrial activity: 14. 9 (D acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify far 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 El More than five acres ❑
EPA Form 3510-11 (10-99) Page 1 of 4

NPDES A Form Approved
FORM .-,EPA NO EXPOSURE CERTIFICATION for Exclusion from 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
Q�
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
d
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
d
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., dumpsters])
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
(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: 8 E 1,10001
Print Title: I ` //' •"
Signature:
EPA Form 3510-11 (10-99) Page 2 of 4