NCGNE0135_COMPLETE FILE - HISTORICAL_20141009

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V GCo NEV
DOC TYPE O-/HISTORICALFILE
❑ MONITORING REPORTS
DOC DATE ❑ aOlq I I) U�
YYYYMMDD

Ai
C O
MC®EN R
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor Secretary
October 9, 2014
Sean Bir
Essentra Filter Products, Inc.
303 Gallimore Dairy Road
Greensboro, NC 27409
Subject: Compliance Evaluation Inspection
No Exposure Certification NCGNE00458
Essentra Filter Products, Inc.
Guilford County
Dear Mr. Bir:
On October 8, 2014, Aana Taylor-Smith of the Winston-Salem Regional Office of the Division of Energy, Mineral, and
Land Resources (DEMLR) inspected the Essentra Filter Products, Inc. site in Greensboro, Guilford County to determine
compliance with No Exposure Certification NCGNE0135 issued on May 1, 2005. DEMLR file review and site inspection
revealed that the site is compliant with the terms and conditions of this certification. Please find a copy of the completed
form entitled "Stormwater Inspection Report" attached to this letter.
Please note that as per your No Exposure Certification, Essentra Filter Products, Inc. is obligated to maintain no exposure
conditions at this facility. If conditions change such that the facility no longer qualifies for no exposure exclusion, you are
obligated to immediately obtain NPDES permit coverage for any stormwater discharge. Otherwise, the discharge
becomes subject to enforcement as unpermitted discharge.
As a reminder., Essentra Filter Products, Inc. must recertify the no exposure status annually using the attached NCDENR
self-recertification form. Any "yes" answer would require that you obtain NPDES permit coverage for stormwater discharge
from the facility. The annual self-recertification form does not need to be submitted to DEMLR, unless requested.
For extra copies of the form, please visit our website at http://[e-mail]/web/irinpdes-stormwaterg-tab-5. Please
note that this conditional exclusion from permitting 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 Aana Taylor-Smith or me at(336) 771-5000.
Sincerely,
Matthew E. Gantt, PE
Regional Engineer
Land Quality Section
Enclosures:
1. Stormwater inspection Report
2. Annual No Exposure Exclusion Self-Recertification Form
CC: Debbie Shoffner(City of Greensboro Stormwater Management Division,via email! [e-mail])
Central Files - DWR
WSRO Files—Land Quality
Division of Energy, Mineral, and Land Resources
Land Quality Section •Winston-Salem Regional Office
585 Waughtown Street,Winston-Salem, NC 27107 • Phone: [phone] FAX: [phone]

Compliance-Inspection Report
Permit: NCGNE0135 Effective: 05101/05 Expiration: Owner: Essentra Filter Products Inc
SOC: Effective: Expiration: Facility: Essentra Filter Products,Inc-
County: Guilford 303 Gallimore Dairy Rd
Region: Winston-Salem
Greensboro NC 27409
Contact Person: Sean Bir Title: Phone: 336A78-3114
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
Related Permits:
Inspection Date: 10/0812014 Entry Time: 02:45PM Exit Time: 02:55PM
Primary Inspector: Aana Taylor-Smith Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwate€Discharge,No Exposure Certificate
Facility Status: ® Compliant Not Compliant j
i
Question Areas:
IM Miscellaneous Questions ® Misc
(See attachment summary)
Page: 1

I ti
Permit: NCGNE0135 owner-Facility:Essenlra Filter Products Inc
Inspection date: 10 OM01d Inspection Type:Compliance Evaluation Reason for Visit: Routine
Inspection Summary;
Please refer to attached inspection letter.
Page: 2

Permit: NCGNE0135 Owner-Facility:Essentra Filter Products Inc
Inspection Date: 1 CIO812014 Inspection Type:Compliance Evaluation Reason for Visit: Routine
MISC
Yes No NA NE
Is the facility compliant? ® ❑ ❑ ❑
Comment: Facility is in com liance with No Exposure Certification.
Page: 3

J
ESSENTRA
303 Gallimore Dairy Road
Greensboro, NC 27409
August 21, 2014
RECEIVED
Bethany Georgoulias
Division of Energy, Mineral and Land Resources AUG 2 5 2014
Stormwater Permitting Program DENR-LAND QUALITY
1612 Mail Service Center STORMWATER PERMITTING
Raleigh, NC 27699-1612
Dear Ms. Georgoulias:
Our facility currently has a "No Exposure"status in NPDES permitting under the name "Filtrona
Greensboro, Inc." However, we have had a name change and are submitting this form for NCDENR to
process this information. There has been no ownership change,and the facility is not undergoing any
physical changes subject to NPDES permitting.
If you have further questions, please feel free to contact me.
Regards,
Sean Bir
Engineering Manager

1
•i Ao
Division of Energy,Mineral& Land Resources FOR AGENCY USE ONLY
Date Received
'�L Land Quality Section/Stormwater Permitting Year Month Da
NCDENR National Pollutant Discharge Elimination System
D�-
rr.,,,,•.orr vw n�rk�n �PERMIT NAME/OWNERSHIP CHANGE FORM _O
1-35-
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
INIOLS; 101 I I I I I I N 10 10
II. Permit status prior to requested change.
a. Permit issued to(company name): F'}( phQ2PMsz� nG,
b. Person legally responsible for permit: b.p y-t sr)rn
First MI Lase
RECEIVED Gekle xc % ah er-
Title
AI IG 25 2014 __ 13e 3 GnAuty-t e
Permit Holder Mailing Address
OENR-LAND QUALITY NC 4174oq
STORMWATER PERMITTING City State Zip
(ice )�0OS-oag3 (53(p)Coos -GRqS_
Phone Fax
c. Facility name(discharge): 4v� VNa G�VysSb r-0 fin..
d. Facility address: 903 Gz.11i
Address
Ck_rm,s6►o Nc_ a74c)q
City State Zip
e. Facility contact person: Sean fir (33 31 t
Vie..?..�7$,=.�.
First /Ml /Last Phone
Ill. Please provide the following for the requested change(revised permit).
a. Request for change is a result of ❑ Change in ownership of the facility
K Name change of the facility or owner
If other please explain:
b. Permit issued to(company name): essevrwo_ �1+ r 1�'r��t S Ivic.
c. Person legally responsible for permit: V-pSoert- t,,Mes3 i
First MI Last
G'2 v-r� rczhoras GLvt �Y
Title
_ 303 GO tLWror2—IA511try �d
Permit Holder Mailing Address
Gyre e nsbvra !� a 71
City State Zip
33W a•C0M
Phone E-mail Address
d. Facility name(discharge): _� 2h`}YQ _rtWjZ.Ar rim-roG(1.A_c'f5 , k"C,
e. Facility address: A Yc- 7Da t r,4 r1�d
Address
l.3YiGErvk��oOh� �� d
City State Zip
f. Facility contact person: 5 f2IYr
First MI Last
Phone E-mail Address
IV. Permit contact information(if different from the person legally responsible for the permit)
Revised Jan.27,2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
` Page 2 of 2
Permit contact: P w�
Firs�tt MI Last
Title
i GccLl VYt ciY� k�k
Mailing Address
City State Zip
3 n-3 i 4: B it C--)e.'S Se4-_j+YQ.c.�.
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.
•.......................... .............................................................................0.............
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.
PkRMITTEE 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. I 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 complete.
Z/ 2C)/
Signature 0 Date
APPLICANT CERTIFICATION
I, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I 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
return incomplete.
— — A ,,� z 1 zd1 c
ignature a Date
.....................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh,North Carolina 27699-1612
Revised Jan.27,2014

�0F W A TF9Q Michael F.Easley,Governor
William G.Ross Jr.,Secretary
co North Carolina Department of Environment and Naturai Resources
J �
Alan W.Klimek,P.E. Director
Division of Water Quality
Filtrona-Greensboro
303 Gallimore Dairy Road
Greensboro,NC 27409
Subject: General Stormwater Permit Inspections
Filtrona-Greensboro
Permit Nq NCGNEO-5�f
Guilford 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: htl :llh2o.enr•.slale.nc.trslsulFornrs Dociiirients.htm#Slormtii,alerGP.
If you have any questions, please contact Corey Basinger in the Winston-Salem Regional Office
at [phone].
Sincerely,
Corey Basinger
cc: NPS Compliance & Assistance Oversight Unit
SWP-Central Files DEC 3 ®�
WSRO Files
.,�. No`
rthCarolina
` -• r LI � Miturally
North Carolina Division of Water Quality 585 Waughtown Street Winston-Salem,NC 27107 Phone[phone] Fax[phone]
Internet: h2o.enr.state.nc.us
An Equal Opportunity/Affirmative Action Employer—50%Recycled110%Post Consumer Paper

F 1NArF Michael F.Easley,Governor
`O�� RQG William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
rAlan W.Klimek,P.E.Director
Division of Water Quality
0 Coleen 11.Sullins,Deputy Director
Division of Water Quality
April 20, 2005 REGslvED^"�—
N.C.Dect of ENR
APR 2 7 2005
Christopher Franklin Winston-Salem
Filtrona-Greensboro Regional office
303 Gallimore Dairy Rd
Greensboro, NC 27409
Subject: No Exposure Certification NCGNE0135
Filtrona-Greensboro - 303 Gallimore Dairy Rd
Guilford 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 August 17, 2003. 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,
gull ,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files ,
4-
iNCD R
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-977-623-6748

Michael F. Easley,Governor
`O�C' 7QG William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural resources
C%1 Alan W.Klimek,P.E.Director
Division of Water Quality
0 Coleen H.Sullins,Deputy Director
Division of Water Quality
April 20, 2005
Christopher Franklin
Filtrona-Greensboro
303 Gallimore Dairy Rd
Greensboro, NC 27409
Subject: No Exposure Certification NCGNE0135
Filtrona-Greensboro- 303 Gallimore Dairy Rd
Guilford 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 August 17, 2003. 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 F
WC—D i'R
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

FILTRIONA
Filtrona Greensboro, Inc.
is. 'slia Lau
NCDENR - Stoi-i1111'atcr ailil{:moral Pcrllllls Unit AUG
1617 Nlail Scry iu;c Ceflt-or r �d
Plakidm- Ntorth Carolina 2 7699-16 17 s
UEf�
R _
R-oftrcilco.- No Exposure C�rtif' :itioll Form Submittal ITy
Pf};F1T SD€hr E .%j j,
&;t,
CH ' t
Filtromi Greensb wo, Inc.
j;•�L{1:lynrp� l�r3l'tll A.'itE-��1€13� "' - -.... ._^. .- ,
Dear iQ i. Lai.:
1.11°. t'i;l:i :itC1�s�Cl lllr ti {'� COrl.- of 111-- No Ccrl€fica clil .f6rol Ion il`;lllai ailLi
fbi- th,C. loc. fact' iv lccat,Cd :t 30, Cil lllim,)ri Dair"' 'Cad III G[v!_il_I,JIo.
t_.:irVltil.'I.
1+31. COI. 1ti1=11igC:l L)l`tli;: Stor111151tttr l!111( ill tllt i lllstlil- I Ofi C:'Of- Cl_l.�NR' CSC?_II":iLICL� l
situ !isit 011 r�ilglfSl t=.'_ 2004 tt� CltdCr111i(1C it the facility 1= �.\C12luf flt1lll (Or111='•Ctt=..r 13i r111itt11]�. j i:.,
d"Icl'llllih-d 113at tlli� 11;1S 110 111CItlstrlal actit-1:6--s k_-vosi:d io and 1€a� SiylliCl th tiii=:i1�`Cl
Cl:rtlflcauoil ft_li'111 {1�1CCast i'CftF (0 la i'C 2 i11 tr fa;i' Ills shill,1WIV), 111C 13Cilil�' i'i1111i1L
fi'olll Sl0ilil,'V.11cr j1,�r1tlmi1jL-
t'vtm hat v MIVC1til'StlCall_ 1:011CCrillilkl till= r CILIC--A, l]ltasi CQ11131Ct M-1- It
scolt S11 ailll
Flltrona Grtcnstloro; Inc,
1✓1lclosuivs
303 Gallinnore Dairy Road, Greensboro, North Carolina 27409 U.S.
P.O. Box 49421, Greensboro, North Carolina 27419 U.S.
Telephone:[phone] Fax:[phone]
OUNZL FIURONA GREENSSORO,INC.Registered Office 110 Park Street.London W1Y 3138.Registered in
- England No.358948.Fivona Greensboro.Inc.is a member of the Bund group of companies.

Form Approved
United States Environmental Protection Agency OMB No.2040-0211
NPDES A Washington,DC 20460
FORM `AW ��A NO EXPOSURE CERTIFICATION for Exclusion from
3510-11
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).
n,u
ALC;W! RMATION MUST BE PROVIDED ON THIS FORM.
yet. .
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: IFI IIL IT( pia[^JIRI -16,ki!Fj firvl.516(012O I I I I I I i 1_ i 1. 1 2.Phone: 3131' 1 &) 15-16I1-1`413�
3. Mailing Address: a.Street: 131o131 161AI �_"IL"-Ii 1,`'fl 41-el c-1 161*1/ I,eIy1 Iklo141dl I I I I I I I I
b.City Ili 12 IE� 51 BI V LEI G I I I J_ I I I I I, I I I c.State: I/VIC I d.Zip Code: 1 4-74 10 19 I—I I I I I
B. FacilitylSite Location Information
1.Facility Name: I FI 31, T R o N A - G A2 E E N S $ a +e o
2.a.Street Address: 1310 131 iGI A I LI LI I 1 Ja1 RI El 10 1A I I IQt Yt I L_2j41k1 01 1 1 1 1 1 1 1 I
b.City: 6192IEeIA4518.1a12141 1 1 1 1 1 1 1_ l I I I I I c.County: AL]il1l-IFICIR)81 1 1
d.State: PC I e.Zip Code:
3.Is the facility located on Indian Lands? Yes❑ No
4.Is this a Federal facility? Yes❑ No
5.a.Latitude: L J 4 114 uJ b.Longitude: 1 1719 �LJ I zf(-
6.a.Was the facility or site previously covered under an NPOES storm water permit? Yes ❑ No LJ 13 V i L O I N C, $!
b. If yes,enter NPDES permit number: q t o0O F7 2
4� SCc o '2•a9
7.SIC/Activity Codes: Primary:
919 'l Secondary(i applicable):nda qfa licable): 1 �CIZ�
1 I I 1
8.Total size of site associated with industrial activity: f 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
b. If yes,please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you far 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) Page i of 4

,ry4 •t .1
I
• � i� � ��
� r
�. ,
• �
. �
S i
s
. s .• _ - _ .. .. -. � ..
-, �! _�
.�. '

NPDES NO EXPOSURE CERTIFICATION for Exclusion from Farm Approved
S 0`�11 NO OMB No.2040-0211
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.) H 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 ❑
3. Materials or products from past industrial activity ❑ L_I
4. Material handling equipment(except adequately maintained vehicles) ❑
6. 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 ❑
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 ❑ L K
9. Waste material(except waste in covered,non-leaking containers[e.g.,dumpstersn ❑ 12/
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 I22.26(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 property 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 know{iinng�jviolations
.. n p� y
Print Name: �I"I`�, Ii T7A Al\ i } !�i` ! k?"1L1 I1� I I I I I I I I I I I i I
Print Title: k p ,
Signature:
Date: F0 I k 191�i 1
EPA Form 3510-11 (10-99) Page 2 of 4
�sdt) 2

' 1 �- i �
u
� 4
}
� . ,
. r
t-
- � 4
� ..
i - _ a � r- �
i � r �
' - � T r �. �
r _. - I
r � .j
' � ��
- j
' ' ..
, 1 1 � I = }

NPDES Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
3510`�; 1011 EPA OMB No.2040-0211
Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. FacilltylStte Location Information
Federal law at 40 CFR Part 122.26 prohibits point source discharges of 1. Enter the official or legal name of the facility or site.
storm water associated with industrial activity to waters of the U.S.without
a National Pollutant Discharge Elimination System(NPDES)permit. However, 2. Enter the complete street address(if no street address exists,provide
NPDES permit coverage is not required for discharges of storm water a geographic description[e.g., Intersection of Routes 9 and 551), city,
associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)- county,state,and zip code. Do not use a P.O.Box number.
(ix)and(xi)if the discharger ran certify that a condition of'no exposure'
exists at the industrial facility or site. 3. Indicate whether the facility is located on Indian Lands.
Storm water discharges from construction activities identified in 40 CFR 4. Indicate whether the industrial facility is operated by a department or
122.26(b)(14)(x)and(b)(15)are not eligible for the no exposure exclusion. agency of the Federal Government(see also Section 313 of the Clean
Water Act).
Obtaining and Maintaining the No Exposure Exclusion
5. Enter the latitude and longitude of the approximate center of the facility
This form is used to certify that a condition of no exposure exists at the or site in degreeslminuteslseconds. Latitude and longitude can
industrial facility or site described herein.This certification is only applicable be obtained from United States Geological Survey(USGS)quadrangle
in jurisdictions where EPA is the NPDES permitting authority and must be or topographic maps,by calling 1-(888)ASK-USGS,or by accessing
re-submitted at least once every five years. the Census Bureau at: htto:/lwww.census.aovlcai-binloazgtter.
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 Latitude and longitude for a facility in decimal form must be converted
storm water,the facility operator must obtain coverage under an NPDES to degrees (1), minutes ('), and seconds (") for proper entry on
storm water permit immediately, the certification form. To convert decimal latitude or longitude 10
degreeslminuteslseconds,follow the steps in the following example.
Where to File the No Exposure Certification Form Example: Convert decimal latitude 45.1234567 to degrees(°),minutes
('),and seconds("}.
No Exposure Fomas sent regular,mail: Forms sent ovemig express;
a) The numbers to the left of the decimal point are the degrees: 451.
SW No Exposure Certification(4203M) SW No Exposure Certification
USEPA US EPA East Building,Rm.7420 b) To obtain minutes,multiply the first four numbers to the right of the
1200 Pennsylvania Avenue,NW 1201 Constitution Avenue,NW decimal point by 0.006: 1234 x 0.006=7.404.
Washington,D.C. 20460 Washington,D.C.20004 c) The numbers to the left of the decimal point in the result obtained
[phone] in(b)are the minutes: 7.
Completing the Form
d) To obtain seconds, multiply the remaining three numbers to the
You must type or print,using uppercase letters,in appropriate areas only. right of the decimal from the result obtained in (b) by 0.06:
Enter only one character per space(i.e.,between the marks). Abbreviate 404 x 0,06=24.24. Since the numbers to the right of the decimal
if necessary to stay within the number of characters allowed for each item. point are not used,the result is 24".
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 e) The conversion for 45.1234567=450 7" 24".
exposure. Additional guidance on completing this form can be accessed
at EPA's website:tpuo&ena.goylnndeslstormwater. Please make sure you 6. Indicate whether the facility was previously covered under an NPDES
have addressed all applicable questions and have made a photocopy for storm water permit. if so,include the permit number.
your records before sending the completed form to the above address.
Please submit original document with signature In Ink-00 NOT send copies. 7. Enter the digit SIC code which identifies the facility's primary activity,
and second 4-digit SIC code identifying the facility's secondary activity,
Section A. Facility Operator Information if applicable. SIC codes can be obtained from the Standard Industrial
Classification!Manual,1987,
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. 8. Enter the total size of the site associated with industrial activity in acres.
The name of the operator may or may not be the same as the name of Acreage may be determined by dividing square footage by 43.560,as
the facility. The operator is the legal entity that controls the facility's demonstrated in the following example.
operation,rather than the plant or site manager.
Example: Convert 64,450 ft2 to acres
2. Provide the telephone number of the facility operator.
Divide 54,450 ft2 by 43,560 square feet per acre:
3. Provide the mailing address of the operator(P.O.Box numbers may be 54,450 fit-43,560 ft2/acre=1.25 acres.
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 roadlparking lot)in order to qualify 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

NPDES �, Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
3$�p M ��EPA OMB No.204D-0211
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. Certlfication Statement Public reporting burden for this certification is estimated to average 1.0 hour
per certification,including time for reviewing instructions,searching existing
Federal statutes provide for severe penalties for submitting false information data sources,gathering and maintaining the data needed,and completing
on this application form. Federal regulations require this application to be and reviewing the collection of information. Burden means the total time,
signed as follows: effort,or financial resources expended by persons to generate,maintain,
retain,or disclose to provide information to or for a Federal agency. This
For a corporation: by a responsible corporate officer,which means: includes the time needed to review instructions;develop,acquire,install,
and utilize technology and systems for the purposes of collecting,validating,
(i) president,secretary,treasurer,or vice-president of the corporation and verifying information, processing and maintaining information, and
in charge of a principal business function,or any other person disclosing and providing information;adjust the existing ways to comply with
who performs similar policy or derision making functions for the any previously applicable instructions and requirements;train personnel to
corporation,or be able to respond to a collection of information;search data sources;
complete and review the collection of information;and transmit or otherwise
(ii) the manager of one or more manufacturing, production, or disclose the information. An agency may not conduct or sponsor,and a
operating facilities,provided the manager is authorized to make person is not required to respond to,a collection of information unless it
management decisions which govern the operation of the displays a currently valid OMB control number. Send comments regarding
regulated facility including having the explicit or implicit duty of the burden estimate,any other aspect of the collection of information,or
making major capital investment recommendations,and initiating suggestions for improving this farm,including any suggestions which may
and directing other comprehensive measures to assure long increase or reduce this burden to: Director,OPPE Regulatory Information
term environmental compliance with environmental laws and Division (2137), USEPA,401 M Street, SW,Washington, D.C. 20460,
regulations; the manager can ensure that the necessary systems Include the OMB control number of this form on any correspondence. Do
are established or actions taken to gather complete and accurate not send the completed No Exposure Certification form to this address.
information for permit application requirements; and where
EPA Form 3510-11 (10-99) Page 4 of 4
v t 5�o,�l p� f t� L-'� �u A a
�7�012.t�t u1/�7 Z r e'e7JE--A+- Ti:--A iTS cl nlri
1617
/�Til1 q �Srl.rf Lev
9(9- 7-33- ",Y3
-5'7$

r
--Tiger Map Server Browser Page 1 of 3
U.S. Census Bureau0 Years-on--the We
'
6 This mapping engine uses 1998 TIGER/Line® data
�$ and 1990 Decennial Census data.
Click ON THE IMAGE to:
OZoom in, factor: 0
O Zoom out, factor: 0
*Move to new center
O Place Marker(select syml
0 Down Ioad GIF image
OR
REDRAW MAP
with any option selectee
OFF/ON Lacers OFF101\
i ❑ R1 City labels ❑ ❑ ]
❑ ❑ Ctrrid (lat/lon) ❑ ❑
❑ ❑ Cens bg points ❑ ❑
❑ ❑ Ccns bg bounds ❑ ❑ ;
f ❑ ❑ Congress dirt ❑ ❑ 1
❑ ❑ Counties ❑ ❑
❑ ❑ Indian Resx, ❑ ❑
NewEl El Highways
top, ❑ ❑ Parks and other
❑ ❑ MSA/CMSA
❑ ❑ Cities/Towns
❑ R Railroad
Scale: 1:2627(Centered at Lat: 36.0798454 Lon: -79.9395447) El ElShoreline
4r , ��• r 2�" ❑ ❑N Streets
REDRAW MAP j ❑ ❑ Census Tracts
If your browser doesn't support client-side imagemaps,
use the controls below to navigate the map.
http://tiger.census.gov/cgi-bin/m ap surfer?infact=2&outfact=2&act=move&on=CITIES&on... 7/8/2004

-Tiger Map Server Browser Page 2 of 3
NW N NE
Zoom In W Pan E Zoom Out
SW S SE
LEGEND
County Military Area
BE LakelPend/Ocean National Park
-- Street Other Park Map Census Statistics:
i Expressway School one
....H i ghway 0 City Level: (n )
Connector County Theme: I(none) Q
EM Stream
_ n ��,500t Classify Method:
Sca I e 7 : zsz7 '� "50 100 00 m Q Quintiles or ® Eq Interval
*average- true scale detzends on monitor resolution
Click on the legend to download it as a GIF file.
Place a marker on this map: Enter precise coordinates:
Latitude(deg): 3fi.077683 Latitude(deg): 36.0798454
Longitude(deg): -79.908602 Longitude(deg): -79.939544
Symbol: I Red Stickpin Ell Map Width(deg): 0.003
Label: 127409_Greensbc Map Height(deg): 0.003
Marker URL:
Choose a color palette:
sorry, but no font control yet I(default) []
REDRAW MAP
a You can also search for a U.S. city or town:
Name: State(optional): Q
or for a Zip Code: Search
e Or choose from the following preset values:
Washington, D.C. (default), The Mall, Continental United States, Entire United States, Northeast U.S.,
New York City.
This request serviced by (tiger.census.gov)
For further information, refer to the TIGER Map service web page,located at URL:
http://www.census.gov/ftp/pub/geo/Www/tiger/itigermap.htmi
FOIA I Privacy Statement I Confidentiality I Quality I Accessibility I Contact Us I Doing business with us
http://tiger.census.gov/cgi-bin/mapsurfer?infact=2&outfact=2&act=move&on=CITIES&on... 7/8/2004

—Tiger Map Server Browser Page 3 of 3
USCENSUSBUREAU
Helphw}feu Make b#bmwd DecWam
http,//tiger.census.gov/cgi-bin/mapsurfer?infact=2&outfact=2&act=move&on=CITIES&on... 7/8/2004