NCGNE0029_COMPLETE FILE - HISTORICAL_20090324

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE L7 HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
YYYYMMDD

Sim
HC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
FN;AcR�2
IVED
of E4R
March 18, 2009 4 2009
Mr. Robert E. Paxton Winston-Salem
Regional OfficeSuiza Dairy Group, LLC (dba Dairy Fresh, LLC)
2221 Patterson Avenue
Winston-Salem, NC 27105
Subject: Name Change
No Exposure Certification NCGNE0029
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
Fonmerly Dairy Fresh, LLC
2221 Patterson Avenue, Winston-Salem,NC
Forsyth County
Dear Mr. Paxton:
The Division has reviewed your submittal of the permit name/ownership change form for your No-Exposure Certification,
which we received on February 9, 2009. Division personnel have reviewed and approved your request to change your name
under your Certificate of No-Exposure. .
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 on 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 Sarah Young at [phone], or at
[e-mail].
Sincerely
.for .Colleen H. Sullins
cc: Winston-Salem Regional Office
Stormwater Permitting Unit Files
Wetlands and Stormwater Branch
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604 One
Phone:[phone] FAX:[phone]Customer Service:1-877-623-6748 No1-t.hCal of ina
fntemet:www,ncwaterquality.org J,]��jl
An Equal QpportunitylAifirmaliveAction Employer ;V/j t L ally

MCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
March 18, 2009
Mr. Robert E. Paxton
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
222I Patterson Avenue
Winston-Salem, NC 27105
Subject: Name Change
No Exposure Certification NCGNE0029
Suiza Dairy Group, LLC (dba Dairy Fresh, LLC)
Formerly Dairy Fresh, LLC
2221 Patterson Avenue, Winston-Salem,NC
Forsyth County
Dear Mr. Paxton:
The Division has reviewed your submittal of the permit name/ownership change form for your No-Exposure Certification,
which we received on February 9, 2009. Division personnel have reviewed and approved your request to change your name
under your Certificate of No-Exposure.
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 on 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.
1f you have any questions or need further information, please contact Sarah Young at(919) 807-6303, or at
[e-mail].
Sincerely
10� r
for Coleen H. Sullins.
cc: Winston-Salem Regional Office
Stormwater Permitting Unit Files
Wetlands and Stormwater Branch
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604 One
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 NorthCa-ol ina
Internet:~rn+vw.ncwaterquality,org yr�
An Equal Opportunity ti Affirmative Action Employer �atK�rlul

OF WArFgQG Michael F.Easley,Governor
V
vj y William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
fl Y
Coleen 14.Sullins,Director
Division of Water Quality
SURFACE WATER PROTECTION SECTION
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N G 0 0 N C I l G N E 0 0 2 9
lI. Permit status prior to status change.
a. Permit issued to(company name): Dairy Fresh LLC
b. Person legally responsible for permit: Robert E Paxton
First MI last
Plant Manager
r--w .��!�/] Title
U �.�f l \JEN 2221 Patterson Avenue
j Permit Holder Mailing Address
LJAL29 001' Winston-Salem NC 27105
City State Zip
DENR - WATER Qt1ALl (336) 7149032 (336)7230353
wetlands&Stomrwater Bra"' Phone Fax
c. Facility name(discharge): Dairy Fresh, LLC
d. Facility address: 2221 Patterson Ave.
Address
Winston Salem NC 27105
city State Zip
e. Facility contact person: Roland H Goldston (336) 7149016
First /Ml/Last Phone
111. Please provide the following for the requested change(revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to(company name): Suiza Dairy Group, LLC(dba Dairy Fresh, LLC)
c. Person legally responsible for permit: Robert E Paxton
First MI Last
Plant Manager
Title
2221 Patterson Avenue
Permit Holder Mailing Address
Winston-Salem NC 27105
city State zip
_(336)7149032 [e-mail]
Phone E-mail Address
d. Facility name(discharge): Suiza Dairy Group, LLC(dba Dairy Fresh, LLC)
e. Facility address: 2221 Patterson Ave.
Address
High Point NC 27105
city State Zip
f. Facility contact person: Roland H Goldston
First MI Last
[phone] [e-mail]
Revised aP20178

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Phone E-mail Address
IV. Permit contact information(if different from the person legally responsible for the permit)
Permit contact:
First Ml Last
Title
Mailing Address —
City State Zip
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No(please explain)
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,
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 signed by both the permit holder prior to the change,and
the new applicant in the case of an ownership change request. For a name change request,the signed
Applicant's Certification is sufficient.
PERMIT'TEE CERTIFICATION(Permit holder prior to ownership change):
1, ,attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge_ 1 understand that 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 incomplete.
Signature Date
APPLICANT CERTIFICATION
1, Robert E Paxton, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. l understand that if all required parts of this
application are not completed and that if all required supporting information is not included,this application
package will n
d as in mplete.
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Revised 7CM

2009001215 00029
FORSYTH CO,NC FEE$14.00
^� PRESENTED&RECCRDED'.
- 01-14-2009 10:21 AM
C. NORMAN HOLLEMAN
f%EG5rER OF DEEDS
13Y,PATSY RUTH DAVIS
am
BK: RE 2868
PG: 3231-3231
s4- P0v S.1c, z100
Dui1Gs 7 S -Z
CERTIFICATE OF ASSUMED NAME FOR A LIMITED LIABILITY COMPANY(LLCI
The undersigned LLC,proposing to engage in business in Forsyth County,North
Carolina,under an assumed name other than its LLC name,hereby certifies that:
I. The name under which the business is to he conducted is:
Dairy Fresh,LLC
(Insert assumed name)
2. The name and address of the owner(s)of such business is(are):
Suiza Dairy Group,LLC
2515 McKinney Avenue,Suite 1200,Dallas,Texas 75201
(Insert name and address of LLC)
In witness whereof,this certificate is signed in the name of the LLC by its manager(s),this
day of January ,2009
By: SEAL
Manager Rachel A.Gonzalez.Sole Manager
By: SEAL
Manager
By: SEAL
Manager
State of TEXAS
County of DALLAS L
I, a+hi L N t>�fa� ,a Notary Public,do hereby certify that
Rachel A.Gonzalez,Sole Manager ,manager(s)of
Suiza Dairy Group ,LLC,personally
appeared before me thisr �� day of January 20 09 and that they
signed the foregoing certificate on behalf of the LLC.
�kt ness my hand and official seal,this the_ 12 day of January 20 09
otary Public ( r
My Commission Expir [Q j *� s CATHIE NOLEN R .7102
MY COMMISSION EXPIRES
January 24,2D10
NColo.05MY2DO9 C T System on fine

Delaware PAGE 1
Ire First State
I, HARRIET SMITH WINDSOR, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY THE ATTACHED IS A TRUE AND CORRECT
COPY OF THE CERTIFICATE OF MERGER, WHICH MERGES:
"DAIRY FRESH, LLC", A DELAWARE LIMITED LIABILITY COMPANY,
WITH AND INTO "SUIZA DAIRY GROUP, LLC" UNDER TEE NAME OF
"SUIZA DAIRY GROUP, LLC", A LIMITED LIABILITY COMPANY ORGANIZED
AND EXISTING UNDER THE LAWS OF THE STATE OF DELAWARE, AS
RECEIVED AND FILED IN THIS OFFICE THE TWENTY—SECOND DAY OF
DECEMBER, A.D. 2008, AT 3:52 O'CLOCK P-M.
AND I DO HEREBY FURTHER CERTIFY THAT THE EFFECTIVE DATE OF
THE AFORESAID CERTIFICATE OF MERGER IS THE THIRTY—FIRST DAY OF
DECEMBER, A.D. 2008.
6
Harriet Smith Wndsor,Secretary of State
3098889 810014 o AUTHENTICATION: 7046387
'b ti
081220241 wA DATE: 12-23-08
You may verify this certificate online
at corP.delarare.g+ov/authver.shtml

state of Dalsmmm -
secxeta.y of State
of tions
veredDa 10�2 2 12 22%00808
SR r 08I22024I - 3098889 FTW
STATE OF DELAWARE
CFJKMCATE OF MERGER OF
DAIRY FiftF IN,LLC
R f'O
SUIZA DAIRY GROUP,LLC
Pursuant to Section 18-209 of the Delawam I.amited Liability Company Ate,the undersigned limited
liability company executed ft following Certificate of Mug:
MM: The name of the surviving IbWted liability wnqmy is SUIZA DAIRY GROUP,LLC, a
Delawa,e lmmited liability c;ompany.-
SUCOND: The name of the limited liability company being merged into the surviving limited
-bability company is DAIRY FRESH,LLC,a Delaware limited liability compagy
THIRD: An agtcment of mesgur has been, approved and executed by each constituent limited
hability .y
FOURTH: The merger is to became effem&e as of December 31,2008.
FMRI - The Apeamerd and P1w of Mager is on file at 2515 McKinney Avow, Suite 1200,
Dallas,Tea as 75201,tle place ofbusinm of the swviving limited liability ao4sny.
SDM-. A copy of dw Agreement and Plan of Merget will be furnished by the surviving limited
liability compaay oa request,without to any member of either of the surviving limited liabifity
oompmy or the meaging limited liability company.
IN WP1'NF.SS ROOF,said sucrlvi ing limited liability any has cauwd this cmtficatz to be
aided by an authodzed paean,ft day of December 2008.
SU1ZA DAIRY GROUP,LLC
1 By-
Rachcl A.Gonzalez,
Vice President,Secretary and Sole Manager
I
1 L•5I�19tiq ]0��lYw2Y3KL� dWp�iry Pifrb Vp SdaE]i�GvlqJpe
I
I
i

�QF W A I Michael F.Easley,Governor
William G.Ross Jr.,Secretary
rNorth Carolina Department of Environment and Natural Resources
Q Alan W.Klimek,P.E.Director
Division of Water Quality
Roland H. Goldston
2221 Patterson Avenue
Winston Salem, NC 27115
Subject: General Stormwater Permit Inspections
Dairy Fresh LLC
Permit No. NCGNE0029
Forsyth 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: hup://h2o.enr.state.nc.us/su/Forms_Documents.htm#StormwaterGP.
If you have any questions, please contact Rose Pruitt in the Winston-Salem Regional Office at .,
[phone],
Sincerely,
Rose Pruitt
CC. NPS Compliance & Assistance Oversight Unit
SWP-Central Files
WSRO Files
Na R hcarolma
Naturally
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%RecycleV0%Post Consumer Paper

W A 7E Michael F.Easley,Governor
O �QG William G.Ross 3r.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.E.Director
Division of Water Quality
Q Coleen H.Sullins,Deputy Director
Division of Water Quality
April 20, 2005 RECEIVED
N-C,Oeot.of ENR
APR 2 l 2M
Roland H Goldston Winston-Salem
Roland H. Goldston Regional office
2221 Patterson Ave
Winston Salem, NC 27115-4009
Subject: No Exposure Certification NCGNE0029
Dairy Fresh LLC -2221 Patterson Ave
Forsyth 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 February 21, 2000. 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
NCDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 2 7699-1 6 1 7 [phone] Customer Service
1-877-623-6748

(� J A] Michael F. Easley,Governor
`OtO 9QL William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.E.Director
Division of Water Quality
p ^� Coleen H.Sullins,Deputy Director
Division of Water Quality
April 20, 2005
Roland H Goldston
Roland H. Goldston
2221 Patterson Ave
Winston Salem, NC 27115-4009
Subject: No Exposure Certification NCGNE0029
Dairy Fresh LLC - 2221 Patterson Ave
Forsyth 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 February 21, 2000. 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(919) 733-5083 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
NCDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-023-6748

United States Environmental Protection Agency Farm Approved
9 Y OMB No.2D4D-02t t
NPDES . Washington, DC 20460
FORME��
35�0-» i� NO E_ XPOSURE 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, 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: ILt '4114IEll 191 16-
11911-1DIsl Ia1/J1 1 i i I I I I I I I I 12.Phone: Vi3ib17Z 1.3 iD, i, /
3. Mailing Address: a.Street: fz 1 21 ZI 1 1 I I A 1 1 ITl El 21 S 11111, 1 jl�1 V I,�l I I I I 1 I I I I l I l Ij
b.City: IWI Al L 1 EIMI I 1 1_ 1 1 t I I I C.State: tJ I d.Zip Code: 2-4? E-1—
B. Facility/Site Location Information
1. Facility Name: A; Z 9 Y ' L I L"1
C
2.a.Street Address: Iz12-1 21 11 IFIA1TITiE1�91I S1019 1 1 Al�1 f_ t 1 I I I I I I I I I I I j!
b. City: w ! $? p S Ern c.County: 1F[0I0I S1 Yl_r1#I I - f j
d.state: ' L1J e.Zip'Code: i21 71 /1 1 1�
3.Is the facility located on.Indian Lands? Yes No
4. Is this a Federal facility? Yes No
5. a. Latitude: 1-3 1 � �J 10,31 b. Longitude: — ©I 1910
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes No
b. If yes,enter NPDES permit number:
7.SIC/Activity Codes: Primary: 2� I�I 21 J Secondary(if applicable):
8.Total size of site associated with industrial activity: 8" S acres
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to quality 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,ynt it permitting emithnMy may use thl!: nformat-en in=nsid;.ri.9 .1hather I orm water discharges frow,your slie ai a 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) Page 1 of 4
y

NPDES �, NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM ��,EPA OMB No.2a40 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.) K 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 r
2. Materials or residuals.on the ground or in storm water inlets from spills/leaks ❑ LJ
3. Materials or products from past industrial activity ❑
4. Material handling equipment(except adequately maintained vehicles) ❑ [�
5. Materials or products during loadinglunioading or transporting activities ❑ d
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 ❑ Er
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑
Fill"'
9. Waste material(except waste in covered,non-leaking containers[e.g.,dumpsters)) ❑ d
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 + ❑ 19/
(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 CFA 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 mquiry cf the person or
persons who manage the system, or those persons directly responsible for gathering the information,the information•st6mmad-is`to the best oft my
knowledge and belief true,accurate and complete. I am aware that there are significant penalties for submitting false information;including the ssibility
of fine and imprisonment for knowing violations. i � 5
j�0 L� rp4 Ca � � STD Id Q�
Print Name: 11 I 1 1 1 1 I 1 f 1 1 I 1 1 1 1 1 1 1 L I j 1_ I j _l_ L I I 1 LJI G�
Print Title: cy
Signature: \ !a U W n
�a
Date: I01'I'17I019 r �
9=1 G
EPA Form 3510-11 (10-99) Page 2 of 4