NCGNE0241_COMPLETE FILE - HISTORICAL_20060515

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE . l7 HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ (/NJV V�
YYYYMMDD

RECEIVED 6 Q
F W A TF N.C.De❑t.of z`1R Michael F.Easley,Governor
William G. Ross Jr..Secretary
North Carolina Department of Envi
20� ronment and Natural Resources
CIOL lW Alin W. Klimek,P. E.Director
Winston;5airm Division of Water Quality
Q Regional offcce Coleco H.Sullins,Deputy Director
Division of Water Quality
May 8, 2006
Ms. Linda Simmons Mansfield
Hickory Springs Mfg. Co.
PO Box 128
Hickory, NC 28603-0128
Subject: No Exposure Certification NCGNE0241
Ultra-Flex
1905 Alleghany Street, High Point, NC
Guilford County
Dear Ms. Mansfield:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on August 25, 2005. 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, 2011). 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], ext.
502, or at [e-mail].
Sincerely,
ORIGINAL-SIGNED BY
KEN PICKLE
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—w/attachments
Stormwater Permitting Unit Files
INCDENR
N.C.Division of Water Quality 1017 Mail Service Center Raleigh,North Carolina 27699-1 6 1 7 [phone] Customer Service
1-877-623-6748

i !
{� '\NA]�C Michael F.Easley.Governor
0 RpG William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
C? Alan W.Klimek.P.E.Director
Division of Water Quality
Colcen H.Sullins,Deputy Director
Division of Water Quality
May 8, 2006
Ms. Linda Simmons Mansfield
Hickory Springs Mfg. Co.
PO Box 128
Hickory, NC 28603-0128
Subject: No Exposure Certification NCGNE0241
Ultra-Flex
1905 Alleghany Street, High Point, NC
Guilford County
Dear Ms. Mansfield:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on August 25, 2005. 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, 2011). 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], ext.
502, or at sarah.young @ ncmail.net.
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—w/attachments
Stormwater Permitting Unit Files
"CDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

United States Environmental Protection Agency Form Approved
9 Y OMB No.2040-0211
NPDES E PA Washington, DC 20460
FORM `�' 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).
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 ny� nn M ((''��nn
1. Name: Ailcixtelrll'I I((S,PIrinni1!19I`-tSl Imf 1�l •I 1`-1`-'I • I I I I 1 1 2.Phone: 1812,813,21812,21011�
3. Mailing Address: bra.Street: trig I�` _,' 11,218, 11 1 1 1 1 ,I 1 1 1 I I I I L I I I I I I I
b.City: µ 1lilci RIoIrIYI I I I I I I I I I I I I I I j c.State: NO d.Zip Code: 1 21 81 61 01 31—1 01 11 M
B. Facility/Site Location Information 1. Facility Name: jUlllttrlc-� lF
I1lelXl I I I 11 -1 1 1 1 1 1 1 1 1 1 1 1 t 1 I
2.a. Street Address: 19 O 5 Ile S
dr t .
b. City: fL'i�-IgI 1�10111y�itl I I I I 11 ,.1 . I, _I_J 1 I 1 c.County: f`- U,i,11f,0,r1d 11
d. State: NLJ e.Zip Code: J2171216131—I I I I 1
3.Is the facility located on Indian Lands? Yes❑ No R] C111{
4. Is this a Federal facility? Yes No 2 14J�+
CC � �
5.a.Latitude: 31--?1 L(� 051„ b. Longitude: L,7 9 �7J
00
fi. a.Was the facility or site previously covered under an NPDES storm water permit? Yes No Qy
tO
b. If yes,enter NPDES permit number:
-�
m CD7.SICIActivity Codes: Primary: �l Secondary(if applicable):
8.Total size of site associated with industrial activity: -__4_, 1___acres -
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to qualify for the no exposure exclusion? 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,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 El One to five acres ❑ More than five acres
EPA Form 3510-11 (10-99) G eA Pagel of 4

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NPDESFORM NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM ��,EPA OMB No.2040.021t
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.) If 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 ❑ ✓❑
4. Material 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 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 ❑ Q
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger ❑ 0
9. Waste material(except waste in covered,non-leaking containers(e.g.,dumpsters)) ❑ 0
10. Application or disposal of process wastewater(unless otherwise permitted) ❑ Q
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.
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 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). 1 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. 1 understand that t 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 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 knowing violations.
Print Name: Z
Print Title: IV,t 1 S rEliP r V
Signature: _
Date: is 17 /
EPA Form 3510-11 (10-99) Page 2 of 4

r
HicKoRYSPRiNGs
MANUFACTURING COMPANY
August 23, 2005
Ms. Aisha Lau
NC Division of Water Quality
Water Quality Section
Storm Water & General Permit Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Ms. Lau:
Enclosed is a USEPA NPDES Form 3510-11, 'No Exposure Certification" for The
Hickory Springs Manufacturing Company's Ultra-Flex facility located in High Point,
NC.
If you require any further information, please contact me at [phone], ext. 4669 or
email [e-mail]
Sincerely,
avid F. McNeil
Corporate Manager--Foam Research
� Cn
V%
Q
A � �
Hickory Springs Manufacturing Company
235 2nd Avenue,N.W. P.O. Box 128 • Hickory, North Carolina 28603-0128 • Telephone: [phone]

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V D
DOC TYPE L7 HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ �v 1, V4J I�
YYYYMMDD

i�i�Q
F W ACEIVED rF N.C.Nnt.of F4R Michael F.Easley,Governor
. .
`O�C' 9QG William G.Ross Jr.,Secretary
C ���C North Carolina Deparlm4nt of Elivironment and Natural Resources
MAY J U Alan W. Klimek,P.E.Director
Winasa, 5aie.n Division of Water Quality
Reglonil b1fca Coleen H.Sullins,Deputy Director
Division of Water Quality
May 8, 2006
Ms. Linda Simmons Mansfield
Hickory Springs Mfg. Co.
PO Box 128
Hickory, NC 28603-0128
Subject: No Exposure Certification NCGNE0241
Ultra-Flex
1905 Alleghany Street, High Point, NC
Guilford County
Dear Ms. Mansfield:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on August 25, 2005. 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. It 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, 2011). 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], ext.
502, or at [e-mail].
Sincerely,
ORIGINAL SIGNED BY
KEN PICKLE
tor Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files
VA
NCDENR
N.C.Division of Water Quality 1017 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-977-023-6748

r
s
WA7'F Michael F.Easley,Governor
ew� 6,
William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.E.Director
Division ol"Water Quality
pColeen H.Sullins,Deputy Director
Division of Water Quality
May 8, 2006
Ms. Linda Simmons Mansfield
Hickory Springs Mfg. Co.
PO Box 128
Hickory, NC 28603-0128
Subject: No Exposure Certification NCGNE0241
Ultra-Flex
1905 Alleghany Street, High Point, NC
Guilford County
Dear Ms. Mansfield:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on August 25, 2005. 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, 2011), 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], ext.
502, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files
AM
NO) MR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh.North Carolina 27699-1617 [phone] Customer Service
1-877-023-6748

r
United States States Environmental Protection Agency Form Approved
9 Y OMB No.2040-0211
NPDES �E PA Washington, DC 20460
FORM `�` 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 13 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. ff 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: Ailciork irll S,P,rli,ppGS, Im f lsjl •I l q • I I I I i I 2.Phone: [phone],2,81212 011i
3. Mailing Address: Ira.Street: �PIQ IAg� 11,218, 1 1 1 1 1 1 1 1 1_ 1 1 1 1 1 I 1 1 1 1 1 1 1
b.City. µ Ililgk1e1r1Yl t l I _I 1 I I I I I I 1 I I I c.State: NIQ d.Zip Code: 121 8 61 01 31-i 01 ll28
B. FacllltylSite Location Information
l y
1. Facility Name: 1ULtIrI� Z1,ep1 Ihh ill 1 .1��++1 1 1 I 1^1 f I 1 11 Ill
2. a. Street Address: 1h1191Tn0,5, tp"L�i�lel�ly�1� Y1 1` ,t, •I I I I _ I_ I I II I I I I I 11
b. city: 1191i'1 Irl0l�-LKjtl 1 1 1 1 1 t I I I I I I I c.County: QUlil1,f,01r,a I I
d.State: NIC, e.Zip Code: 2 7ZEI-I I I l
3.IS the facility located on Indian Lands? Yes❑ No ❑✓
CP
4. Is this a Federal facility? Yes❑ No
5.a. Latitude: 351 1�6J 3.t5� b. Longitude: 101719 5,7 �,9
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No ❑✓ !}
CT,r t©
b. If yes,enter NPDES permit number: _—______________ N
?: C=)
7.SIC/Activity Codes: Primary: L22 4 1 I Secondary(if applicable):
8,Total size of site associated with industrial activity: :_ _—acres
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to qualify for the no exposure exclusion? 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,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 rive acres More than five acres ❑
EPA Form 3510-11 (10-99) "T G t�( Page 1 of 4

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NPDES A NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
3500 1A1 ��•EPA 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.) if 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 spillslleaks �✓
3. Materials or products from past industrial activity �✓
4. Material handling equipment(except adequately maintained vehicles) R
5. Materials or products during loading/unloading or transporting activities 0
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
B. Materials or products handled/stored on roads or railways owned or maintained by the discharger
9. Waste material(except waste in coveted,non-leaking containers[e.g.,dumpsters]) Q
10. Application or disposal of process wastewater(unless otherwise permitted) Q
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated 0
(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 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 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 knowing violations.
Print Name: 1 f ,
Print Title: IV,r I 1 S r , P r v
rh
Signature:
' t, �- - -- -- ------ --------------
Date: ri
EPA Form 3510-11 (10-99) Page 2 of 4

HicKoRYSPRiNGs
MANUFACTURING COMPANY
August 23, 2005
Ms. Aisha Lau
NC Division of Water Quality
Water Quality Section
Storm Water& General Permit Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Dear Ms. Lau:
Enclosed is a USEPA NPDES Form 3510-11, "No Exposure Certification" for The
Hickory Springs Manufacturing Company's Ultra-Flex facility located in High Point,
NC.
If you require any further information, please contact me at [phone], ext. 4669 or
email [e-mail]
Sincerely, �7
;avid F. McNeil
Corporate Manager—Foam Research
A CP
4
Hickory Springs Manufacturing Company
235 2nd Avenue,N.W. P.O. Box 128 • Hickory, North Carolina 28603-0128 Telephone: [phone]

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