NCGNE0287_COMPLETE FILE - HISTORICAL_20060628

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /v o'
DOC TYPE Q' HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑
YYYYMMDD

Nf A 7 E Michael F.Easley,Governor
`o=O RPG William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
rAlan W,Klimek,R E.Director
Division of Water Quality
Coleen H.Sullins,Deputy Director
Division of water Quality
June 23, 2006
- Ii'=0EI:IZ0
Mr. Randy Sell N.G.nerk of FNR
Gold Toe Brands, Inc. ,uN 2 8 2006
661 Plaid Street
Burlington, NC 27215 eglona Of c-0
Subject: No Exposure Certification NCGNE0287
Gold Toe Brands, Inc.
661 Plaid Street, Burlington, NC
Alamance County
Dear Mr. sell:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 17, 2006. 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 (May 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(919) 733-5083, ext.
502, or at [e-mail].
Sincerely,
ORIGINAL SIGNER BY
KEN PICKLE
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files
WAY
NDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

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APPROXIMATE SITE LOCATION LAW
ENGINEERING AND ENVIRONMENTAL SERVICES,INC.
�& GREENSBORO,NORTH CAROLINA
APPROXIMATE SCALE
2000 1000 0 2000 xrn =ter« SITE LOCATION MAP
9 GREAT AWRICAN KNITTING MILLS
( IN FEET ) ANNEI EEN HOSIERY PLANT
REF.:U.s.G.S.TOPOGRAPHIC MAP, BURLINGTON,NORTH CAROLINA
BURLINGTON.N.C,QUADRANGLE,
DATED 1969.PHOTOREVISED 1981. PROJECT NO. 30459-B-1032 FIGURE 1

F W ArF Michael F.Easley,Governor
� 9QG William G.Ross Jr„Secretary
]North Carolina Department of Environment and Natural Resources
`J Alan W.Klimek,P.E.Director
> � Division of Water Quality
Coleen H.Sullins,Deputy Director
Division of Water Quality
June 23, 2006
Mr. Randy Sell
Gold Toe Brands, Inc.
661 Plaid Street
Burlington, NC 27215
Subject: No Exposure Certification NCGNE0287
Gold Toe Brands, Inc.
661 Plaid Street, Burlington, NC
Alamance County
Dear Mr. sell:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on March 17, 2006. 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 (May 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(919) 733-5083, 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
ZENit
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6748

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APPROXIMATE SITE LOCATION LAW
ENGINEERING AND ENVIRONMENTAL SERVICES,INC.
GREENSBORO,NORTH CAROLINA
APPROXIMATE SCALE
2000 1000 0 2000 n cuwwn SITE LOCATION MAP
mi GREAT AMERICAN KNITTING MILLS
( IN FEET } ANNEDEEN HOSIERY PLANT
REF.:U.S.G.S.TOPOGRAPHIC MAP, BURLINGTON,NORTH CAROLINA
BURLINGTON,N.C.QUADRANGLE,
DATED 19B9,PHOTOREMSED 1981. PROJECT NO. 30459-8-1032 FIGURE 1

Re: Lookinc for approval for issuance of a COC for NCG030547 (ano...
Subject: Re: Looking for approval for issuance of a COC for NCG030547 (another Tyco Electronics
facility in Greensboro), and a No exposure certification for a previously approved NOI, NCG 170404
From: Corey Basinger<[e-mail]>
Date: Mon, 17 Apr 2006 08:20:40 -0400
To: Aisha Lau <[e-mail]>
Good Monday morning to you, Aisha!
OK to proceed with issuance of the NCGNE for Gold Toe Brands, Inc. and NCG030507 for Tyco
Electronics.
Take care!
Corey
Corey Basinger
Corey_Basinger@NCmail .net
NC DENR Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
(336) 771-5000
Fax (336) 771-4630
On 4/10/2006 11:40 AM, Aisha Lau wrote.
Howdy Corey,
I hope that all is well with you.
When you get the chance would you please either review this information yourself or pass it to the
appropriate person for approval. In addition to the table below I've also attached a scanned copy of
the NOI and No Exposure Certification forms for review.
If I don't hear back from you or one of the other WSRO staff regarding this application before
Friday, May 12 both will be issued with your assumed approval.
COC # :Facility ;Location City
NCG170404 request for No Exposure 'Gold Toe Brands, 661 Plaid St. Burlington 1,
Certification Inc.
NCG030547 Tyco Electronics 719 Pegg Greensboro:
Road
Thank you for your help.
Happy Monday,
Aisha
Aisha Lau
N.C_ Division of Water Quality
1 of 2 6/9/2006 2:55 PM

Re:-Loohin- for approval for issuance of a COC for NCG030547 (ano...
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Phone: (919) 733-5083 ext. 578
Fax: (919) 733-9612
email: aisha .lau@ncmail .net
Website: http://h2o.enr.state.nc.us/stl/srorm.,Facer.html
Never doubt that a small group of thoughtful, committed citizens can
change the world; indeed, it's the only thing that ever has.
Margaret Mead
Corey Basinger<Core .Basin-,[e-mail]>
WSRO
NC DENR
2 of 2 6/9/2006

Fan Approved
United States Environmental Protection Agency OM�NoT204M211
NPp]Es ,r EPA Washington, DC 20460ORM
35110 NO EXPOSURE CERTIFICATION for Exclusion fro'e_
NPDES Storm Water Permitting 1�yp ��s V,,r
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit auth6 n form sto`m�ew\r
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi-Sector General Peh53t�y ue toe e)asten
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 resisail e o pre '
exposure to rain,snow,snowmelt,and/or runoff. Industrial materials or activities include,but are not limited to,material handling equipment or a es,
industrial machinery,raw materials,intermediate products,by-products,final products,or waste products. Material handling activities Adude.t 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 campty 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: IG10LI A IT101EI_1$IRIAIN1D1Rif IIINiQ. I I I I I__ I I I 1 1 2.Phone: [phone]A1 --117.1()1n
3. Mailing Address: a.Street: 1 El 61 11 1 P1 L I AlI I DI I S1 TI RI El E I T 1 I I I I I I I I I_I I I I I I
b.W. I BI U I R I L I I I Ni Gi TI OI N I I I I I I I I I I I I c.State: (mod d.Zip Code: 1217 12 i 1 1 SI- 1 1 1 1 1
B. Facility/Site Location Information
1.Facility Name: I G10 Ll 1) LTI Ol El 1131 RI Al Nl D1 SI, 1 II Nil. I._ I i I I__l I I I I�
2.a. Street Address: 161601 01LIAII]DIS T R E E T
b.City: 1BlUIRII.1IINLGLTi01N I I 1 I 1 1 _1_ 1 l__1__1 LJj c.County: 1AILIAIM1AINiCIELI
d.Sate: L l 1 e.Zip Code: I?1 71 21 151-1 L L 1
3. Is the faci]4 located on Indian Lands? Yes No
4.Is this a Federal facility? Yes No
5.a.Latitude: 13161 o VJ 1015 " b. Longitude: 101719 ' L?L6� 14141 "
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.SICIActivity Codes: Primary: 12121512 Secondary(if applicable): 1 I I I
8.Total size of site associated with industrial activity: 8• 2 4 5 acres
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to qualify for the no exposure exclusion? Yes :j 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 five acres More than five acres
EPA Form 3510-11 (10-99) Page 1 of 4

NPDES NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM `..r'Epq 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 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
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger
9. Waste material(except waste in covered,non-Leaking containers[e.g,,dumpsters])
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 Q
(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)).
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 knowing violations.
Print Name: IMAINlDi YI iSIF.iT,I7,1 I I i I I I I I I I I I_ 1 _I I I I I I I i I j
PrintTtle: L1.5ISIrtSITIAINITI I�GIE/INIEtRfAILI IMIAINIA]GiE]RI I I I l_ L-j 1_1
Signature �' t�,c�j .�6C.C.C�f
Date: 100 1 )1 SD 6
EPA Form 3510-11 (10-99) Page 2 of 4

FOR AGENCY USE ONLY
Date Received
Division of Water Quality/Water Year Month Da
Q y Quality Section z a
Certificate of Coverage
NCDENRNational Pollutant Discharge Elimination System G Amount
.0 -w�
e.tiww�c+r.wo Har,.�acsounccs Permit Assigned to
NCG170000 a�
NOTICE OF INTENT
m
� z
National Pollutant Discharge Elimination System application for coverage under General Perm a 7° M
NCG170000: Re tD
a w
STORMWATER DISCHARGES associated with activities classified as:
SIC*22 Textile Mill Products
'Standard Industrial Classification Code �� LJIJLJ
(Please print or type)
1) Mailing address of oownerloperator:
Name &01- J -roeF 8 R AA.) DC-
Street Address 6(o ( PCA r b 5 T.
City Gt R L,.v6rZb State N C ZIP Code
Telephone No. Fax: [phone]
"Address to which all permit correspondence will be mailed
2) Location of facility producing discharge:
Facility Name &0&6 Ta E_ 3 AA) 6 S ; T--,c ,
Facility Contact ' 1Z AAj'O V S ALL - 'P&.4,,,T rna.UP�C-crZ
Street Address s!o6,1 P1,A 10 S 7
City JA ZL lit!6--o-3 State AJ•C, ZIP Code o;2 7a/S
County
Telephone No. 3 3 Q a s 9 - 3 700 Fax: 33 6 a a 9- 9 7/0
3) Physical Location Information:
Please provide a narrative description of how to get to the facility(use street names, state road numbers, and
distance and direction from a roadway intersection). XA.) -R UtRL�A.3&Tbn2 , A 7- A.; g Sce-T.a.c7 4 ;7
WcRA AUC d #GtRe✓f[ S7, 60 k)O2-T7{ o,y tj&A3 A 0 cF 11F fig Or- y-1 rh,LZ PZ.A.VT0.,-> LcFT,
(A copy of a county map or USGS quad sheet with facility clearly located on the map is required to be submitted with this application)
4) This NPDES Permit Application applies to which of the following :
❑ New or Proposed Facility Date operation is to begin
G?Existing
5) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code)that describes the primary industrial
activity at this facility
SIC Code: ,? vC S .'.�
6) Provide a brief narrative description of the types of industrial activities and products manufactured'at
this facility: rn P4lJi r-7-Gr'G�Z D r m i2y's _ WnMF&A •r CHI L6'Q E.yS NOSIE y
S -S cS AI�tJ �► N.Nc�
Pau
ge i of 3
SWU-232-101701

NCG170000 N.O.I.
7) Discharge points I Receiving waters:
How many discharge points (ditches, pipes, channels, etc.)convey stormwater from the property? 7
What is the name of the body or bodies of water(creek, stream, river, lake_ etr..1 that the facility stormwater
discharges end up in? A LAM AuCE 0 ke K , Lc31L[y[-RRooK: CQECk
If the site stormwater discharges to a separate storm sewer system, name the operator of the separate storm
sewer system (e.g. City of Raleigh municipal storm sewer). MIA
8) Does this facility have any other NPDES permits?
❑ No
L9'Yes
If yes, list the permit numbers for all current NPDES permits for this facility: A C O Pee 3 Sr6
9) Does this facility have any Non-Discharge permits (ex: recycle permits)?
VN 0
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
10) Does this facility employ any best management practices for stormwater control?
❑ No
K?Yes
If yes, please briefly describe: Ain O[wT_� r N 5 t'o Lr�_�,-` e)F fit?o Gc 5S Ch6 M 1<_4 L_S
MA-i-P_,ALS eATEi!> 41r77Y/10 7HE PLAAjr Ash �cCEru��6-�Da�-K5
11) Does this facility have a Stormwater Pollution Prevention Plan?
❑ No
P-'�'es
If yes, when was it implemented? _ (OC.Ta j�&P 191 $ T
12) Are vehicle maintenance activities occurring at this facility?
L?I o ❑ Yes
13) Hazardous Waste:
a) Is
this facility a Hazardous Waste Treatment, Storage, or Disposal Facility?
9d'No ❑ Yes
b) Is this facility a Small Quantity Generator(less than 1000 kg. of hazardous waste generated per month)of
hazardous waste?
Li'N0 ❑ Yes
c) Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste generated per month)of
hazardous waste?
P/N o ❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:
Type(s)of waste: A-)l /4
How is material stored: Aj ZA
Where is material stored: A
Page 2 of 3
SWU-232-101701

NCC170000 N.O.I.
How many disposal shipments per year:
Name of transport 1 disposal vendor:
Vendor address:
14) Certification:
North Carolina General Statute 143-215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record,
report, plan or other document filed or required to be maintained under Article 21 or regulations of the Environmental
Management Commission implementing that Article, or who falsifies, tampers with or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under Article 21 or regulations of
the Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a Tine not to exceed $10,000, or by imprisonment not to exceed six months, or by both" (18 U.S.C. Section 1001
provides a punishment by a fine of not more than$10,000 or imprisonment not more than 5 years,or both,for a similar
offense.)
I hereby request coverage under the referenced General Permit. I understand that coverage under this permit
will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge
and belief such information is true, complete, and accurate.
Printq.d Name of Person Signing: _RA tiu-D Y S r S 64 L"
Title: �L A i m A. A 6-c—j-
(Signature of pplicant) (Date Signed)
Notice of Intent must be accompanied by a check or money order for$80.00 made payable to-
NCDENR
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
P Check for$80 made payable to NCDENR
This completed application and all supporting documents
WCopy of county map or USGS quad street with location of facility clearly marked on map
Mail the entire package to:
Stormwater and General Permits Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of an NPDES permit.
Page 3 of 3
S W U-232-101701

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APPROXIMATE SITE LOCATION LAW
ENGINEERING AND ENVIRONMENTAL SERVICES,INC.
GREENSBORO,NORTH CAROLINA
APPROXIMATE SCALE
2DOO loon o 2WO R,k SITE LOCATION MAP
1 GREAT AMERICAN KNITTING MILLS
( IN FEET ) ANNEBEEN HOSIERY PLANT
REF.:U.S.G.S.TOPOGRAPHIC MAP, BURLINGTON,NORTH CAROLINA
BURLINGTON,N.C.QUADRANGLE, K
DATED 1969,PHOTOREVISED 1981. PROJECT NO. 30459-8-1032 TGURE 1

proved
United States Environmental Protection Agency ' Ap'2040-0211
NPDES SWE
Washington,DC 20460 ,:._
FORM r� NO EXPOSURE CERTIFICATION for Exclusion fra
3510-11
NPDES Storm Water Permitting
m .
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authd� n form sto vvat�ri
discharges associated with industrial activity in the State Identified in Section B under EPA's Storm Water Mulll-Sector General Pe us to e ` 691
t
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 res€st e o pry t'
exposure to rain,snow,snowmelt,and/or runoff. Industrial materials or activities include,but are not limited to,material handling eq nt or a es.
Industrial machinery,raw materials,intermediate products,by-products,final products,or waste products. Material handling activitles[r4ciud 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 sgning and submltUng 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: 1GIGIL113, ITIQIEI IBIRIAINiniR., IT[ NiC1. I I I I I I I I 1 1 2.Phone: [phone].191117[{1()I
3.Mailing Address: a.street 1 6 61 1 1 I P1L I Al II DI I Si Tf RI EI m Ti I I I I I I I I I I I I I I I j
b.W. I Bi U i R i L I I I Ni GI n g N i I I 1_,L I I I I I I i c.state: J d.Zip Code: 1217 1 21 1J_5l—I I I I _1
B. Fac[litylSlte Location Information
1.Facility Name: I Gi 01 L TI 01 El I B1 RI Al NI JDI SI, iliNiCi.
2.a.Street Address: 1616111 1PlLIA1I1D1 _I StTIRiEiEiTL I I I I [ 1_1 1 1 1 1 1_ I I I
b.City: I$I UIRI L II Ni GiT-1_0 N I I _1_j 1 I I I _I i i I 1 c.County: IAILI_A_IMf AINIC[E[ f__ I
d.State: q e.Zip Code: II?171211 [ 51-1 1 1 1
3,Is the facility located on Indian Lands? Yes] No
4.Is this a Federal facility? Yes] No
5.a Latitude; l6j `L6J ' 0 5 ' b.Longitude: 101719 ° L?L LjL4j
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes ] No
b. if yes,enter NPDES permit number:
7.SIC/Activity Codes: Primary: 2( [21 51 21 Secondary(if applicable):
B.Total size of site associated with industrial activity: 8 . 245 acres
9.a.Have you paved or roofed over a formerty exposed,pervious area in order to qualify for the no exposure exclusion? Yes ] No J
b, if yes,please indicate approximately how much area was paved or roofed over. Completing this question does rot 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 qual€ty,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
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;A f-� J

IF�
NPDES Form Approved
FORM �-/EPA NO EXPOSURE CERTIFICATION for Exclusion from OMB No.2040-0211
3510.11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activates exposed to precipitation,now or in the foreseeeb€e 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. Us€ng,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 act€vity
4. Material handling equipment(except adequately maintained vehicles) :J
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
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger
9. Waste material(except waste In covered,non-leaking containers(e.g..dumpsters))
10. Application or disposal of process wastewater(unless otherwise permitted)
11. Particulate matter or visible deposits of residuals from roof stacks andlor vents not otherwise regulated Lai
(l.e.,under an air quality control permit)and evident in the storm water outflow
D. Certification Statement
I certify under penalty of taw 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 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
knowiedge and belief true,axurate and complete. i am aware that there are significant penalties for submitting false Information,including the possibility
of one and imprisonment for knowing violatlons.
Print Name; I1aAiNIDi Yi iSIF IT.IJ,1 I I I L i I t I I I I i i I t I i I I I I I
PrintTltle: IAISISiT€SITIAINITI 1GIEINLEIEIAfLi MiAiNIAiGiEiR l t _i I_ i I_ I I
Signature �4t,a�� el
Date: I Q631 i I SI 01 bl
EPA Form 3510.11 (10-99) Page 2 of 4