NCGNE0150_COMPLETE FILE - HISTORICAL_20050427

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V CiC�NE�ISU
DOC TYPE H'HISTORICAL FILE
0 MONITORING REPORTS
DOC DATE ❑ �OI)� �)�I O�'�
YYYVMMDD

W Michael F.Easley,Governor
o�0 9pG William G.Ross Jr,,Secretary
North Carolina Department of Environment and Natural Resources
f!1 Alan W.Klimek,P. E.Director
Division of Water Quality
Q Coteen H.Sullins,Deputy Director
Division of Water Quality
April 20, 2005 RECEIVED
-'oot,of ERR
C Darrell stout APR 2 l 2M
ft.. s—m—satem
Patrician Furniture Co Regional Office
1107 W Market Ctr
High Point, NC 27260
Subject: No Exposure Certification NCGNE0150
Patrician Furniture Co - 1107 W Market Ctr
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 October 8, 2004. 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. In addition, your coverage under general permit NCG180139 is also
hereby rescinded. This rescission is based upon your certification of no exposure conditions at this facility.
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 Fran McPherson - DWQ Budget
NCDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

WA]"�,t Michael F.Fasley,Governor
Ot0 TQ� William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.F.Director
Division of Water Quality
Q -C Coleen H.Sullins,Deputy Director
Division of Water Quality
April 20, 2005
C Darrell Stout
Patrician Furniture Co
1107 W Market Ctr
High Point, NC 27260
Subject: No Exposure Certification NCGNE0150
Patrician Furniture Co - 1107 W Market Ctr
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 October 8, 2004. 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. In addition, your coverage under general permit NCG180139 is also
hereby rescinded. This rescission is based upon your certification of no exposure conditions at this facility.
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 Fran McPherson - DWQ Budget '
NCDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

f
PATRICIAN FURNITURE CO., INC.
P.O. Box 2353
High Point, NC 27261
��.�.Oa'l-n.fliMaYWwYVti�•~'�11i2.Yyy�iW'.:/I.1.�..
October $, 2004 +
Mr. Bradley Bennett OCT 8 2004
NCDENR
Department of Water Quality ENR -
WATER 4Up«1Y =
1617 Mail Service Center _ V _POINT SOURCE SRANCH
Raleigh, NC 27699-1617 ;
RE: No Exposure Certification for Patrician Furniture Co., Inc.
Located at 1107 West Market Center, High Point
Dear Mr. Bennett:
We had received a storm water discharge permit from the state, and we believe that it was
sent to us in error since we had submitted our original exclusion form in 2002. Please find
enclosed a copy of this "No Exposure Certification for Exclusion from NPDES Storm Water
Permitting" form for our facility.
Although this facility is categorized with an SIC code of 25, there are no material handling
equipment, raw materials, intermediate products, final products, waste materials, by-products
or industrial machinery exposed to storm water at this facility.
If you have any questions or need anything else, please feel free to call our office at 336-889-
6186. Thank you for your help with this matter.
Regards,
Darrell Stout
President/Owner
Enclosure

United States Environmental Protection Agency Form'Approved
OMB No
NPOES Washington, DC 20460 .204M211
FORM NO EXPOSURE CERTIFICATION for Exclusion from
3510-11 14 YEPA NPDES Storm Water Permitting
Submission of this No Exposure Ceffcatlon 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 8 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 otheAvise secured and without operational taps or valves;
adequately maintained vehicles used in material handling;and
final products,otherthan 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 oulf0s. 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 an pages 3 and 4.
A- Facility Operator Information
1. Name: 12iAiTiRil ic-ill 04011 IFIMIN11 ILIAlairl IC101 IiNICI 1 1 l 2-Phone:.1313IWhU14J4'Ik1
3. Mailing Address: -a.Street 19161 1 61b N I III 91CI31 I I I I I I I I I I I f I I I I I I I I I
b.CiV loll Ili ipl Ifinj I 16T1 I I I I I I I I I I I I c.State: IN I d.Zip Code: 111-7 12 1 6 1 1—I I I I
B. Facility/Site Location Information
1.Fac:14Narne: IC161, 111A)IL I I I
2.a.Str"Address: I III All iWiEIS III AAAKEL iCjE-iKJjT-iEiKi IDA ) NiE; I I
b.City: 191JIG141 IPIOIJIMITI I I I I I I I I I I I I I c.county: [glUIjILjrlQIKIbI _t__j
d.State: 1A I(-I -a.Zip Code. 1), 12,611 1-1 1 1 1
3.Is the facility located on Indian Lands? Yes No
4.Is this a Federal facility? Yes No
5.a.Latitude: b,L--gitd.: 16IRID I %�J� • LQJ_3 J'
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: I 51 Secondary(if applicable):
S.Total size of site associated with Industrial activity. L-7 acres
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to qualify for the no exposure exclusion? Yes E] No D,
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 an 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 I of 4

i.di:i,..=.::._::a:..:_,..:__:=::is.S:e:::::_:.:7.-_�s.c.w._.-.-=,,..._.- ......._i.r..i_.,._...._..,.a,.<::f:.:::....... _�._ �.................a. _.-.._a.. ... _.r.•.t:u=..._.:i.:
NORM � e NO EXPOSURE CERTIFICATION for Exclusion from Fore Approved
FORK ,��E�� 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 elther'Yes'or`No'th the appropriate box.) H you answor"Yos"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 splilsAaaks ❑
1 Materials or products from past industrial activity [�
4. MateriM 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 far outside use[e.g.,new cars]where Q
ff-
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,non4eaking containers[e.g.,dumpsters)} El 191,
10..Application or disposal of process wastewater(unless otherwise permitted) 0
lij-
11. Particulate matter or visible deposits of residuals from roof stacks andfor vents not otherwise regulated El
(€.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.
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)).
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 faci ty discharges(where applicable). I understand that I must
allow the NPDES permitting authority;or MS4 operator where the discharge is Into the focal MS4,to perform Inspections to oonf[nm 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!acidity.
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 br knowing violations_
Print Name: I D•IG],A,I_RI E l I-II-f l SITI dI IAITI I I I I I I 1 1 1 € I I I I i 1 1 1 1 1
Print Title: IP19i D Jll
Signature:
Date: 10141 115101%I
EPA Form 3510-11 (10-99) Page 2 of 4

�t:tom::.=�:.:��.u._:It...:�:..�..:...,:::::._a..... .�...:..�:._,:as:.u.:..:_G-'.. m...._.:_.-.ish..l:�r1J�v_•...u.�..�t.._s _.__.,.u�..........-._,_v_. .�._.._�_u..t�-_..t r.a....ic�t.ra�e_.i Ci.._,.LA rv_.hwls....�..v._I.is�'?Str-mL]G�I.1
NPDES n Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
FORM ��rEPA OMB No.2040-0231
3510-1+ Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section 6, Facility/Site 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)permlL 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 55]),city,
associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)- county,state,and zip code. Do not use a RO,Box number.
(Ix)and(A)If the discharger can 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 degrees/minutes/seconds. 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. EPA's web site at httpJAvww.epa.gov/owm/sw/industrylindex.htm and
selecting Latitude and Longitude Finders under the ResourcewPermit
The industrial facility operator must maintain a condition of no exposure at section.
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 (°), minutes ('), and seconds (") for proper entry on
storm water permit Immediately. the certification form. To convert decimal latitude or longitude to
degreeslminutesdseconds,follow the steps in the following example.
Where to Fels the No Exposure Certification Form Example: Convert decimal latitude 45.1234567 to degrees("),minutes
Malik the completed no exposure certification form to: (7,and seconds(").
a) The numbers to the left of the decimal point are the degrees: 45°.
Storrs Water No Exposure Certification(4203)
USEPA b) To obtain minutes,multiply the first four numbers to the right of the
401 M Street,SW ti'• decimal point by 0.006: 1234 x 0.006=7.404.
Washington,D.C. 20460 c) The numbers to the left of the decimal point In the result obtained
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=451 T 24 .
exposure. Additional guidance on completing this form can be accessed
through EPA's web site at www.epa.govlowmisw. Please make sure you 6. storm wIndicate whether the facility in was previously covered under an NPDES
have addressed all applicable questions and have made a photocopy for storm water permit. ff so,include the permit number,
your records before sending the completed form to the above address. 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,
Section A Facility Operator Information If applicable. SIC codes can be obtained from the Standard Industrial
1. Provide the Legal name of the person,firm,public organization,or any Classification Manual,1987.
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.
2. Provide the telephone number of the facility operator. Example: Convert 54,450 ft2 to acres
Divide 54A50 ft2 by 43,560 square feet per acre:
3. Provide the mailing address of the operator(P.O.Box numbers may be 54,450 11:2+43,560 ft24acre=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 road/parking 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

NPCC=S Form Approved
FORN Instructions for the NO EXPOSURE CERTIFICATION for OMB No.2040-0211
3S10-111 I ,curs 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 coriditlons at
yourfacility. 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 candition 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 othBr.public facility: by either a
coverage,you can Institute modifications to eliminate the potential for a principal execudve or ranking elected official.
discharge of storm water exposed bD industrial activity,and then certify to
a condition of no exposure. Paperwork Reduction Act Notice
Section D. Certification 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 swore 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,
fl) president,secretary,treasurer,or vice-president of the corporation and verifying information,pro'oessing 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 decision 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
(i I) 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 Informaton,or
making major capital investment recommendations,and initiating suggestions for improving this form,including any suggestions which may
and directing other comprehensive measures to assure long increase ar 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

PATRICIAN FURNITURE CO., INC.
P.O. Box 2353
High Point, NC 27261
1 7
April 15, 2002 APR 2002
PDENR ware avatar
POINT S0URCE RR,4NC1,
Mr. Bradley Bennett
NCDENR
Department of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: No Exposure Certification for Patrician Furniture Co., Inc.
Located at 1107 West Market Center, High Point
Dear Mr. Bennett:
Please find enclosed the "No Exposure Certification for Exclusion from NPDES Storm Wa- •
ter Permitting" form for the facility listed above. Although this facility is categorized with an
SIC code of 25, there are no material handling equipment, raw materials, intermediate prod-
ucts, final products, waste materials, by-products or industrial machinery exposed to storm
water at this facility_
If you have any questions or need anything else, please feel free to call our office at 336-889-
6186. Thank you for your help with this matter.
Regards,
Darrell Stout
President/Owner
Enclosure

+ 7
Form Approved
United States Environmental Protection Agency OMB No.2040-021 f
NPDES ;'��� Washington, DC 20460
FORM 'fir
3570-17 NO EXPOSURE 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. it 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: 1PIA111911 IC-d 1141NI jE1119IN111 I N ICI I 1 1 2.Phone: I3 131�1 19 1
3. Mailing Address: a.Street: Ip l D l 181 Ix I I zl I S 13 I It III I [ I I I I I I I I I I I I I 1
b.city I. I I I liA 1 P t(jl I I M[I T I I I I, I I I I I I I I c.State: N-L-U d.Zip Code: 1)-1-7 11 1 61
B. Facility/Site Location information
1.Facility Name: lfiAiTiRil il!-i I Aiki LRIKIM11N
2.a.Street Address: I I ! All W " S M A C ` k) T E b V
b.City: 14111G11�� IF1(),I 1T1 .1.,_ 1 1 l I I, I I 1 11 c.County: IG1u111LIF7101►Z1�1 I I
d,State: IN e.Zip Cade: 1�1-7 121611 1—,I I 1 1 I
3.Is the facility located on Indian Lands? Yes❑ No
4.Is this a Federal facility? Yes❑ No 0
5.a.Latitude: I. t�� �rJ + I��+ b,Longitude: 4LL 10 o 1 i v i' ! �3J
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No 0—
b.If yes,enter NPDES permit number:
7.SIC/Activity Codes: Primary: 11 S 12.4 Secondary(if applicable): I I I I
8.Total size of site associated with industrial activity: , L7 0 G 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 ©r
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 ❑ More than five acres ❑
EPA Form 3510-11(10-99) Page 1 of 4

J
NPOESFORM A NO EXPOSURE CERTIFICATION for Exclusion from Farr"Approved
FORM r�,EPA OMB No.2040.0214
3510-11 NPDES Storm Water Permitting
C_ Exposure Checklist
Are any of the fallowing 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 those 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
El 21-
3. Materials or products from past industrial activity Cl R_
4. Material handling equipment(except adequately maintained vehicles)
S. 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 IT
8. Materials or products handledistored on roads or railways owned or maintained by the discharger 0 Ei-
9. Waste material(except waste in covered,non-leaking containers[e.g.,dumpsters]) EJ Ig
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
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.
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)).
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 directty 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: IDAKAR iLIL I ISIYIDIttITI I I I I I I I I I I I I I I I I I I I I
Print Title: P !; ) .l� ,JT/f O l� t
Signature:
Date: I ell 41 e I ei
EPA Form 3510-11 (10-99) Page 2 of 4

NPDES A p� Form Approved
FORM ��SEPA Instructions for the NO EXPOSURE CERTIFICATION for OMB No.2040-0211
3510-11 Exclusion from NPDES Storm Water Permitting
Who May File a No Exposure Certification Section B. Facility/Site 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 55]),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 can 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. EPA's web site at httpJ/www.epa.gov/owm/sw/industrytindex.htm_and
selecting Latitude and Longitude Finders under the Resources/Permit
The industrial facility operator must maintain a condition of no exposure at section.
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 to
degreeslminuteslseconds,follow the steps in the fallowing example.
Where to File the No Exposure Certification Form Example: Convert decimal latitude 45.1234567 to degrees('),minutes
Mail the completed no ex ('),and seconds(").
pl exposure certification form to:
a) The numbers to the left of the decimal point are the degrees: 45
Storm Water No Exposure Certification(4203)
USEPA b) To obtain minutes,multiply the first four numbers to the right of the
401 M Street,SW decimal point by 0.006: 1234 x 0.006=7.404.
Washington,D-C. 20460 c) The numbers to the left of the decimal point in the result obtained
in(b)are the minutes: T.
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=45" 7' 24".
exposure. Additional guidance on completing this form can be accessed
through EPA's web site at www.epa.govlowmisw. 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.
7. Enter the 4-digit 51C 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.
2. Provide the telephone number of the facility operator. Example: Convert 54,450 ft2 to acres
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 ft2+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'Ncr 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
and is now impervious area.
EPA Form 3510-11 (10-99) Page 3 of 4

NPDES A Form Approved
FORM i",EPA Instructions for the NO EXPOSURE CERTIFICATION for OMB No.2040-0211
3510-11 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, Slate,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 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 decision 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
(4) 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 form,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