NCGNE1656_Application_20231218

FOR AGENCY USE NLY Revised 10/6/2023
NCGNE1_� 5 L
Assigned to: Q . ' 0 v—
ARO FRO MRO RRO WARO WIRO R i�GFilvEC
DEC 8 W3
Division of Energy, Mineral, and Land Resoyr� StotmwatetPco9ra
National Pollutant Discharge Elimination System
No Exposure Certification for Exclusion
NCGNE0000
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, • tanks, and
• barrels, • 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 Until you are issued a No Exposure Certification and your NPDES permit is rescinded, your facility must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,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).
NC DEQ Stormwater Program requires a one-time $250 application fee via check made payable to NC DEQ. There
is no annual fee once covered under a No Exposure Certification. If approved, your conditional No Exposure
Certification has no expiration date but must be self-recertified at least annually. Please look for information about
recertification under the No Exposure section on this page: https://deg.nc.gov/about/divisions/energy-mineral-
land-resources/npdes-no-exposure.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 1612 MSC, Raleigh, NC 27699-1612. The submission of this form does not guarantee
exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a site
inspection will be conducted.
Page 1 of 5

1. 'OWner/Opetator.(to whom all,permit correspondence vvili be mailed):,
- -
_Name of_legal organizatiorialenbty`: Legallyresponsr6le person(as signed in ltem.1_below):•
Larson Manufacturing Companylnc: Mike Van L•ente,
Mailing address:, - City, - State Zip Code
171 Enterprise Way , - Mocksviile_ NC' 27028
Telephone,numbec' Email address:; -
-. ,
:336r753-8930 _ . -. . mvanlentediarsondoors com
Type of Ownership; - -
Go4errimeri_t
County, ❑ Fetlerat, ',O Municipal .0 State
:Non-government;
N'Business(If ownership is,busmessia:copy of NCSOS report must be.included with;this application);
❑Individual:
2'. 'Industriaj_Facility(facility requesting.exclusion):,
Facility name:, - 'Facility eriv_iranmental contacti
Larson<Manufacturing Company' :Lynne Syeip
'Streetaddressi, Telephone;number
171 Enterj ruse -Miy, 2fi0 330 4 -f
Email address;
Isyk0liermatru gom
. _ "
City County :State= - . -- Zip Code -
Mocksville Davie NC 27028:
Latifude of entrance ,35.9357 ;
Longitude cf entrance 80.60222,
- -
Parcel Identification Numtier(PIN)- 5729488211
bate pperation_b'egan `'317/19 - r -[Standard Industrial Classification(SIC)Code.4225
p types of industrial activities and rodu
Brief descri lion of the p cFs produced atthis`facllity:. -
Distribution warehouse shipping screen doorand storrri doors
35. .Consultant (ifapplicatile): - - '
'Name of consultant: - + -'Consulting firm'•
Street address; State and zip coc[6
Telephone number:: Email:addressf
A.• Exposure eheckiists:
Are any of the following materials or activities exposed to precipitatioh;'now or in the'foreseeable'future?if`you
answ'er"Yes'`.to°any ofthad Berns;yyou are:notsliifible for the no ekposure,exclusiom
Using,storing,.or cleaning industriafrrSachmery,orequi*gnt,' and areas where residuals from:`
using,storing,or cleaning industrial machinery or'equipmentremam and:are exposed to D YesDONo❑ N/A•
stormweter
Materials or residuals on the ground or in stormwa`ter inlets from spills/leaks ❑yes' No O.N/A.
Materials or,prodopts from -industrial activity ❑Yes&1 No;O.N/A.
_ .
Material Handling equipment(except adequately maintained vehicles) ❑yes X No❑ NIA
Page 2 of 5

Materials orprodocts during loading/unloading ortransporting activities, ,O Yes X No El
Materials of—products—stored outdoors(exceptfinalproducts-intendedfor outsideuse(e:.j new ❑Yes•X No❑ N%A
cars)'whereszposure'to stonnwater does,not resultin the discharge of pollutants)
Materials contained 16 open,;deteriorated,non-sealed',orloaking stoi age-drums iiarrels-tanks,, El Yes�I-No❑,N/A
and similar containers
NlaterialsoF;products handled/stored on-roads or railwaysowned or maintained'by'the discharger. ❑YestLNo❑ N/A.
Final productsthat would be mobilizedin'stormwaterdischwges(e.g.,�rock salt) El Yes W No:❑ N/A
Waste material(except waste in covered;non-leaking containers je g,,dumpsters)) ❑Yes,�J No❑N/A•.
'Application or disposal of process wastewater(unless othervuise permitte'd)`_ O yes R No❑N/A.
Particulate matieror visible deposits of residuals from roof stacks and/or vents not otherwise' Yes No N%A.
regulated(i.e:uhder an air guality,controlpermit)and edident in the stormwater outflow . -
Empty containers that previously contained materials that are hot properly stored(i e:,not,closed
and stored up3ide down to preven4 precipitation accumulation) — ❑YesB] No El N/A,
For any exterior ASTs as well as drums,barrels,tanks and similar containeis'stored outside,ihas /
the facility had any releases in thepastthree{3)years7 _
❑;Yes K7 No❑'N A
_ --
'Sealed means.banded or otherwise secured and with locked or non operational taps or,valves:
Above.dir d Storage.Tanks'(ASTs)and Secondary Containment,
If you ahswer',`No;'to any of the following items,you are'nofeligible for the.no exposure exclusloh. '
Afe&fienO&A orpiping,free of rust,damaged,or weathered coating,pits,or d wn,eteriorat or
evidenceof.leaks?,
- I - ., - ❑Yes E No Z N/A r
r _
Is secondary coritainmentprovided fcmall,exierior ASTs?If so,is it free of any:ciacks,holes,or
evidence of leaks,and are drain valves maintained locked shut? , ❑Yes,❑ No P,N[A '
Is secondary coritainmentprowded forsingle above ground storage containers(including drums,
❑Yes O No lSl_N/A'
barrels;etc:).with.a capacity of more than;660-gallons?'
Is secondary containment provided foe above ground 'storage containers stored in close proximity.
to each other•wi'th a combined capacity of more than 1,3k gallons?= _ ❑Yes❑,No D.6 N/A
Issecondary containment provided forTitle 111 Section 313 Superfund Amendments and p Yes O NoA(1 N/A,
Reauthorization Act(SARA)water priorityc'hem calsT
Is secondiry'containment provided forhaiardous substances designated In40 CFR 5116?' ❑Yes.[]No M,N%A' '
Are release valves on'all secondary' containment structures locked? ❑Yes O No® N/A
i -
04her informations
If you answer"Ye?.to_any of the following Items;you might not be elig blefor Lhe'no'ezposure exclusion Amore
In-depth evaluat onof the s'ite dircumstances:rtiay;be required:
Are 4ehlcles used in material handling in disrepair and/or leaking fluid? ❑ No❑'N/A
Does;this facility.store.used;.recyded,oroiherwise reclaimed`pallets outside? q ❑Yes 0 No ❑ N/A
Does this facll'tt ave coal piles bh'site? ❑'Yesjo No.❑ N/A
Does,ti isfacility store.other fuel sources ouiside'in piles,such as wood'chips,sawdust,etc.?' 0 Yes'IX'No ❑ N/A
';Page 3-of 5

Daesahis facdiry;have air.`emissions assocreted with industrial activity(e g',:degreasingioperation"s, ❑-Yes_',4 No❑ N/A
plating,painting;or-metal fhishmg)7 --
If yes:
Describe th&indu'strial:activity:
Are those emissions permitted by an Ainguality Permit? i 7 yes.O No
Pleases eci '
S. Other Facility Conditions (check.oll that apply and gzplairi accordingly);
El
This facility has other NFDES permits:
if checked li—thepefmitnumbersforAllcurrentNPDES:permits:.
❑This facility has Non Discharge permits(e g recycle perrnit)
If checked;listthe permit iiumbeO§''fdf all curieni Non-Discharge permits:?
4:1;This facility stores hazardous wastefin the 100;year floodplain.,
If checked;describe bbW the area is protected.from''flooding:.
O,This facility s`a(mark;all.thafapplp);� ,
I❑ Hazardous Waste,Generaiion Facility,
❑ Haiardous WasteTreatmChtFacility,
• ";❑ Haiardous Waste Storage Facility __ _ _ - - _ _ _
i❑ Hazardous Waste.Disposal,Facility—
'if checked,mdicate _ r
.- Kil4am"sofwastegenerated,each,monthr
• T e s of.waste:'
I' YP O,: _
•: How material is stored: _
• `Wher'emat'eriafis-stored:-
R; Number-of wastesWi iiints:peryear:
!; iName ofaransport%disposal;vehdon _
J- Transport/dispo$aLvendorEPA Ili::, J
V6fido�.address:
_ — __.
'Q This faclhtyis ocated on a Brownfield or.UPERfUNDSite. -
If checked;briefly describe,the site corfditioht:!
:OThis facile -tyislocated:onNative American'Lands:
j6 !Required Items(Application will be returned unless all of the following items have been included):
Check for'$250 made payable to NCDEQ.
A Copy of mos6kent AA ival Reportto,the NC-Secretary of State(if applicable);
This completed application and any supporting&umentatioh,
2-Copy of county map or USG.quad-sheet with the location of the facility clearly marked
Page-4 of 5:

1— iAppl'ica fit Certificatfoq,
,North Carolina�General Statute143.215.6Bti)provides that:-Any person:who knowingly makes-;any�alsestatement,
representatlon,'or certification m ariyapphcation record;,report,plan,.'of other documentfiled or required to,beriiafntaihed
un%der•this Article'or a rule'implementing this Article".,.'stiell be guilty of a class'i misdemeanor which may indude.a fine not
to exceed ten'th'ousand dollars($10,000), Thereby requestexdusion'from NPDES stormweter permitting.
Untler pehalty of.law,I certify than
I am the person responsible for tM ifidustriat activity;for satisfying'the regiigernents,of this exclusion,and.for any civil
or cnmmal penalties incuired due to violations of this;ezduswn:
d twater perm ttegguirements forclaiming 6condition of noexposure and obtaining an
exclusion from NPDES to m '
H' There are r o discharges ofstormwater contaminated by exposure to indusfrial:atiivrtiesyor:materials:from the'indusiriaC
J `facildy or site identified m this document(ekcept asallowed under 40 CFR 122.26(g)(3));
M i understand thei l am obligated to mamiain no_exposure,conditionsand complete a$eif;RecertificatiDn form at least
,once each year and;if requested;provideahis certificationto the operator of the.local municipal separate siormsewer,
system,(M54)mto which the facility dacfiarges(wFeie applicable).I understand that I must allow-the North Carolina;
IDwision of Energy Mineral;and,Land Resources,or IV operaiorwhere applicable to'perfoPm inspections toion_fiim,
the condition of no?xvosure and to make such mspection reports publicly available upon_request 1 understand 1 must
`keep i copy-of annuatrecertifications onfile at.the fad ility:
=/
C Iunderstand that m,the event 6-at the site no Longer qualifies.for a Ndtxposuie,Exclusion that I musto_btam cove_rage,.
under an NPDES permit prior to any pant source discharge of stormwater from the facility,
/ i-
C The information submitted m this IJ01 is,to the best of iny,knowledgeand belief true accurate and complete based.or,
my mgmry'of the person orpersons.wba_ manage the system or those"persons directly iesponsible for gathering the
information: I
Printed Name of Person Sgning Lit,
Signature of Appli- bate'Sign_,d
IVlail the entire package to ;DEMLR-Stiirniwater Program
Department of Enygonmental Quality
1612'Ma it Servicb;Center-
Ra leig h ,_NC'2Z699 1612'
Page 5 of 5

Al
All
P y Dr
,, i
IP
IF
Ll
i w
�`•- si - - c` r Fa'
0 -