NCGNE1605_Application_20230406

FOR AGENCY�USE ONLY RFe_3EI V E®
1
NCGNE S2/0 5 APR
Assigned to: C
ARO FRO 0 RRO WARO WIRO WSRO DEMLR-StormwaterProgram
Division of Energy, Mineral, and Land Resources
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCG N E0000
Submission of this No Exposure Certification constitutes notification that your facility does not require a permit for
stormwater discharges associated with industrial activity in the State of North Carolina because it qualifies for a no
exposure exclusion. A condition of no exposure at an industrial facility means all industrial materials and activities
are protected by a storm resistant shelter (with some exceptions) to prevent exposure to rain, snow, snowmelt,
and/or runoff. Industrial materials or activities include, but are not limited to:
• material handling equipment or activities, • by-products,
• industrial machinery, • final products, or
• raw materials, • waste products.
• intermediate 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 industrial materials stored in the following container types, provided
the containers are not deteriorated and do not leak:
• drums,
• barrels,
• tanks, and
• similar containers.
For new facilities, applicants should apply no earlier than 60 days before the start of operation. This will allow
DEMLR staff to verify conditions during active operation. For facilities that already have an industrial stormwater
permit in North Carolina, DEMUR must approve your application for No Exposure Certification before this exclusion
is effective. Until you are issued a No Exposure Certification and your NPDES permit is rescinded, your facility must
continue to abide by the terms and conditions of the current permit.
A No Exposure Certification must be provided for each facility qualifying forthe no exposure exclusion. Additionally,
the exclusion from NPDES permitting is available on a facility -wide basis only — not for individual outfalls. If any
industrial activities or materials are, orwill be, exposed to precipitation, the facility is not eligible forthe 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).
For new facilities, applicants should not apply more than 60 days before the start of operation date. This
If approved, your conditional No Exposure Certification has no expiration date but must be self-rece
annually. Please look for information about recertification under the No Exposure section
https•//decinc gov/about/divisions/energy-mineral-land-resources/nodes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed a,
Stormwater Program, 1612 MSC, Raleigh, NC 27699-1612. The submission of this
exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES storm
inspection will be conducted.
Page 1 of 6

1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person (as signed in Item 7 below):
S �`1 LLL
�4d aw. A) I:
Street address:
City:
State
Zip Code
C 1 ' A
lv78S I�reS� RI Ml�t q7
D&I1,3
T
% S
Telephone number:
Email address:
-104 - 332
si,. '„ncs. COw�
Type of Ownership:
Government -
❑ County ❑ Federal ❑ Municipal ❑ State
Non -government
06usiness (If ownership is business, a copy of NCSOS report must be included with this application)
❑ Individual
2. Industrial Facility (facility requesting exclusion):
Facilityf name:
Facility environmental contact:
`�
0.Fe- A-r\ow- IL'• s ••w
ACLM /V 45 Ii
Street address:
Telephone number:
I/SZ 2&
7o4 SZ8 337,61'
Email address:
Q Na}s 1: br � $L,•+e�r:was � C,O ✓'�-'-- � ---_" -- -_----'_--- .-_- ---__ -_'-- _
City
Tr•o..i-n•�a+.
County' -
.Trd�ie II '.
State
f✓
Zip Cade
Z $1 i0Co �••.
Latitude of entrance: 'g S °•y 0 Ol . 3 "N `
_
Longitude of entrance* • ! 90° y-3' 38.3 "w i ..:
Parcel Identification Number (PIN): _------- - '
4-1730,17-.113 Lt. coo
Date operation began:" -- ' _ -:::Standard
Industrial Classification (SIC) Code:
�„k I,3 -1020
Li493 - , -
Brief description. of the types of industrial activities and products produced at this facility.. - '"
3. Consultant (if applicable):
Name of consultant:
Consulting firm:
Street address:
City:
State and zip code:
Telephone number:
Email address:
4. Exposure Checklists
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future? If you
answer "Yes" to any of these items, you are not eligible for the no exposure exclusion.
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
❑ Yes GKO ❑ N/A
stormwater
Materials or residuals on the ground or in stormwater inlets from spills/leaks
❑ Yes VNo ❑ N/A
Materials or products from past industrial activity
❑Yes No ❑ N/A
Material handling equipment (except adequately maintained vehicles)
❑ Yes RNo ❑ N/A
Page 3 of 6

Materials or products during loading/unloading or transporting activities
❑ Yes P<o ❑ N/A
Materials or products stored outdoors (except final products intended for outside use [e.g., new
cars] where exposure to stormwater does not result in the discharge of pollutants)
❑ Yes I No ❑ N/A
Materials contained in open, deteriorated, non -sealed', or leaking storage drums barrels, tanks,
and similar containers
�/
El�7 Yes No ❑ N/A
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑ Yes 2"No ❑ N/A
Final products that would be mobilized in stormwater discharges (e.g., rock salt)
❑ Yes R�o ❑ N/A
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
❑ Yes [KNo ❑ N/A
Application or disposal of process wastewater (unless otherwise permitted)
❑ Yes GKNo ❑ N/A
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 stormwater outflow
❑ Yes & No ❑ N/A
Empty containers that previously contained materials that are not properly stored (i.e., not closed
and stored upside down to prevent precipitation accumulation)
❑ Yes 2" o ❑ N/A
For any exterior ASTs, as well as drums, barrels, tanks and similar containers stored outside, has
the facility had any releases in the past three (3) years?
❑ Yes RrNo ❑ N/A
'Sealed means banded or otherwise secured and with locked or non -operational taps or valves.
Above Ground Storage Tanks (ASTs) and Secondary Containment
If you answer "No" to any of the following -items, you are not eligible for the no exposure exclusion.
Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or deterioration, or
-
�
Prles ❑No El
- -
evidence of leaks? _ -"
N/A
Is secondary containment provided for all exterior ASTs? If so is it free of any cracks, holes, or
Q'Yes ❑ No ❑ N/A
evidence of leaks, and are drain valves maintained locked shut?
Is secondary -containment provided for single above ground storage containers (including drums,
_ --
'
Ce's ❑ No ❑ N/A
barrels, etc.) with a capacity of more than660-gallons?
'�,es
Is secondary containment provided,for above ground storage containers stored in close proximity
-
El No ❑ N/A
to each other with a combined capacity of more than 1,320 gallons?
Is secondary containment provided for Title III Section 313 Superfund Amendments and
❑ Yes ❑ No CAN/A
Reauthorization Act (SARA) water priority chemicals?
Is secondary containment provided for hazardous substances designated in 40 CFR §116?
21es ❑ No ❑ N/A
Are release valves on all secondary containment structures locked?
❑ Yes ❑ No lm' /A
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.
Are vehicles used in material handling in disrepair and/or leaking fluid?
❑ Yes
No ❑ N/A
Does this facility store used, recycled, or otherwise reclaimed pallets outside?
❑ Yes
WNo ❑ N/A
Does this facility have coal piles on site?
❑Yes
No ❑ N/A
Does this facility store other fuel sources outside in piles, such as wood chips, sawdust, etc.?
❑Yes
No ❑ N/A
Page 4 of 6

Does this facility have air emissions associated with industrial activity (e.g., degreasing operations, ❑ Yes Q No ❑ N/A
plating, painting, or metal finishing)?
If yes:
Describe the industrial activity:
Are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No
Please specify:
5. Other Facility Conditions (check all that apply and explain accordingly):
❑ This facility has other NPDES permits.
If checked, list the permit numbers for all current NPDES permits:
❑ This facility has Non -Discharge permits (e.g. recycle permit).
If checked, list the permit numbers for all current Non -Discharge permits:
❑ This facility stores hazardous waste in the 100-year floodplain.
If checked, describe how the area is protected from flooding:
❑ This facility is a (mark all that apply)
❑ Hazardous Waste Generation Facility
❑ Hazardous Waste Treatment Facility
❑ Hazardous Waste Storage Facility
❑ Hazardous Waste Disposal Facility- - — ---- - - - ---- - " ''
If checked, indicate: _
• Kilograms of waste generated each month:
• Type(s) of waste:
• How material is stored: _
• Where material is stored:
• Number of waste shipments per year: 'ao
• Name of transport/disposal vendor:
• Transport/disposal vendor EPA ID:
• Vendor address:
❑ This facility is located on a Brownfield or SUPERFUND site.
If checked, briefly describe the site conditions:
❑ This facility is located on Native American Lands.
6. Required Items (Application will be returned unless all of the following items have been included):
❑ Copy of most recent Annual Report to the NC Secretary of State (if applicable)
❑ This completed application and any supporting documentation
❑ copy of county map or USGS quad sheet with the location of the facility clearly marked
Page 5 of 6

7. Applicant Certification
North Carolina General Statute 143-215.613 (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
I am the person responsible for the industrial activity, for satisfying the requirements of this exclusion, and for any civil
or criminal penalties incurred due to violations of this exclusion.
I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES stormwater permitting.
EIr 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)).
9'� I understand that I am obligated to maintain no exposure conditions and complete a Self -Recertification form at least
once each year and, if requested, provide this certification 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 Energy, Mineral, and Land Resources, or MS4 operator where applicable, to perform inspections to confirm
the condition of no exposure and to make such inspection reports publicly available upon request. I understand I must
keep a copy of annual recertifications on file at the facility.
I understand that in the event that the site _no longer qualifies for a No Exposure Exclusion.that.l must obtain coverage
/under an NPDES permit prior to any point source discharge ofstormwater from the facility.
2 The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and complete.based on
my inquiry of the person.or persons who manage the system, or those persons directly responsible for gathering the
information.
Printed Name of Person Signing:
Title:
Signature of Applicant
Mail the entire package to:
Date Signed
DEMLR —Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 6 of 6

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Tax Map Information
•PIN
4730721894.000
• Address
1152 PERTH RD
• Account k
Acct 80073444
• Tax Owner
SHM SKIPPERS LANDING LLC
• Mailing Address
PO BOX 800729
DALIA.S, TX 75380
• GIS Owner
SHIM SKIPPERS LANDING LLC
• Deed into
271512099. NW - 20200717
• Tax Acres
7.5098 AC
Lot 4
• Description
PERTH RD SKIPPERS MARINA
Zoning
RR
• Old Parcel a
150N(A)OOOA109
• Bldg Value
$2.659,020
• OBXF Value
$121,450
•Land Value
$1,926.320
•Total Value
E4,7OQ790
• Defer Value
$0
• Tax Districts
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MAP FOR REFERENCE ONLY
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Geometry updated 0313112023
Data updated 03/31/2023
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Tax Map Information
-"-
Print map scale is approximate.
•PIN
4730721894.000
Critical layout or measurement
•Address
Account.
1152 PERTH RD
Acm60073444
activities should not be done using
• Tax Owner
SHIM SKIPPERS LANDING
LLC
this resource.
• Mailing Address
PO BOX 800729
DALLAS, Tx 75380
MAP FOR REFERENCE ONLY
• GIS Owner
SHM SKIPPERS LANDING LLC
NOT A LEGAL DOCUMENT
• Deed Into
2715/2099 - NW - 20200717
• Tax Acres
7,5098 AC
Iredell County, North Carolina makes no claims and n0
• Lot a
warranties, expressed or impfed, concerning the val or
• Description
PERTH RD SKIPPERS MARINA
accuracy of the GIS data presented on this map.
• Zoning
RR
Geometry updated ON31/2023
• Old Parcel d
1503F0000OA109
Data Updated 03131/2023
• Bldg Value
$2,659,020
• OB%F Value
$121.450
• Land Value
$1,926,320
•Total Value
S4,706790
• Defer Value
$0
• Tax Districts
-ALLCNTY FIRE-