NCGNE0290_COMPLETE FILE - HISTORICAL_20140417

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V Q
DOC TYPE L}'HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ ��y O�-{
YYYYMMDD

RECEIVED
NIFWA N.C.Dept.of ENR
k;
APR 2 9 2014
NODE R WINSTON-SALEM
North Carolina Department of Environment and Natural ResourceSREGIDNALOFFIcE
Pat McCrory John E. Skvaria, III
Governor Secretary
April 17, 2014
Ms. Sharon Ruppel
Ecolab Inc.
8300 Capital Dr
Greensboro, NC 27409
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0290
Ecolab Inc.
Formerly Kay Chemical Company
Guilford County
Dear Ms. Ruppel:
The Division has reviewed your submittal of the permit name/ownership change form
for the subject No-Exposure Certification, which we received on March 24, 2014. Division
personnel have reviewed and approved your request to transfer the exclusion from NPDES
stormwater permitting requirements.
Please note that by our original acceptance of the No-Exposure Certification and by our
approval of your request to transfer it, you are obligated to maintain no-exposure conditions at
your facility. If conditions change such that your facility can no longer qualify for the 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.
Annual re-certification is required, and we have enclosed one blank Annual No
Exposure Exclusion Self Re-Certification form for your use. 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.
Division of Energy, Mineral, and Land Resources
Energy Section •Geological Survey Section - Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX:[phone]
512 North Salisbury Street, Raleigh, North Carolina 27604•Internet:http:/IpoNal.ncdenr.org/web/Irt
An Equal opportunity 1 Affirmative Action Employer—50% Recycled l 10%Post Consumer Paper

If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
ORIGINAL SIGNED R!
KEN PICKLF
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office, M. Gantt
Stormwater Permitting Program Files
Central Files

A74
r+�r wr.►.
NC®ENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor Secretary
April 17, 2014
Ms. Sharon Ruppel
Ecolab Inc.
8300 Capital Dr
Greensboro, NC 27409
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0290
Ecolab Inc.
Formerly Kay Chemical Company
Guilford County
Dear Ms. Ruppel:
The Division has reviewed your submittal of the permit name/ownership change form
for the subject No-Exposure Certification, which we received on March 24, 2014. Division
personnel have reviewed and approved your request to transfer the exclusion from NPDES
stormwater permitting requirements.
Please note that by our original acceptance of the No-Exposure Certification and by our
approval of your request to transfer it, you are obligated to maintain no-exposure conditions at
your facility. If conditions change such that your facility can no longer qualify for the no-
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your
storrnwater discharge. Otherwise, the discharge becomes subject to enforcement as an un-
permitted discharge.
Annual re-certification is required, and we have enclosed one blank Annual No
Exposure Exclusion Self Re-Certification form for your use. 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.
Division of Energy, Mineral, and Land Resources
Energy Section -Geological Survey Section- Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604- Internet: http://portal.nc_d_enr.org/web/lrl
An Equal Opportunity I Affirmative Action Employer—50%Recycled 110%Post Consumer Paper

s
If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office, M. Gantt
Stormwatef Permitting Program Files
�s

Division of Water Quality 1 Surface Water Protection FOR AGENCY USE ONLY
r A
.j �• Date Received
� Year Month Day
National Pollutant Discharge Elimination System
NCDENR
Nam, °�� DEBT.E�OF PERMIT NAME/OWNERSHIP CHANGE FORM
E�mr. ._wo N_RE.^W"CE3
1. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
1V C S Q N G 16, N E 10 12 19 10
II. Permit status prior to requested change.
a. Permit issued to(company name): Kay Chemical Company, An Ecolab Company
b. Person legally responsible for permit: John Pelehach
First M I Last
General Counsel
— O Title
MAR 2 4 2014 8300 Capital Dr
Permit Holder Mailing Address
Greensboro NC 27409
DE - WA QU Iry
POINT OURCE aRAir1CH City State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge): Kay Chemical Com an , An Ecolab Com an
d. Facility address: 8300 Ca ital Dr
Address
Greensboro NC 27409
City State Zip
e. Facility contact person: Kimberly D. Plaster [phone]
First /MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to(company name): Ecolab Inc.
c. Person legally responsible for permit: Sharon Ruppel
First M I Last
Director of Operations
Title
8300 Capital Dr
Permit Holder Mailing Address
Greensboro NC 27409
City State Zip
(336y931-2117 [e-mail]
Phone E-mail Address
d. Facility name (discharge): Ecolab Inc.
e. Facility address: 8300 Capital Dr
Address
Greensboro NC 27409
City State Zip
f. Facility contact person: Kimberly D Plaster
First MI Last
[phone] [e-mail]
Phone E-mail Address
Revised 2012Apr23

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
r Page 2 of 2
1V. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: Kimberly D Plaster
First M1 Last
Safety, Health & Environmental Manager
Title
8300 Capital Dr
Mailing Address
Greensboro NC 27409
City State Zip
[phone] Kim.plasteroeco lab.corn
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
.....................................................................................................................
'rhe certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request,the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, Kimberly Plaster, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information is not included,this application
package will be returned as incomplete.
d !°1,7OI
Signature bate
....................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Revised 712008

0( W A r�, - Michael F.Easley,Governor
William G.Ross Jr.,Secretary
,Q RFCEIVFC North Carolina De artment of Environment and Natural Resources
`O G L VBc� nvCMR p
Alan W.Klimek,P.E.Director
J'IL 5 ' Division of Water Quality
�+ Coleen 14,Sullins,Deputy Director
Division of Water Quality
Regional ice
July 19, 2006
Mr. John A. Pelehach
Kay Chemical Company
8300 Capital Drive
Greensboro, NC 27409-9790
Subject: No Exposure Certification NCGNE0290
Kay Chemical Company
8300 Capital Drive, Greensboro, NC
Guilford County
Dear Mr. Pelehach:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES•
Stormwater Permitting form, which we received on June 22, 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, and
hereby rescinding your former Certificate of Coverage, NCG060067.
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 (June 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 SIGNED BY
lrchl DICKLE
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files
M
NMENR
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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Copyright(C)1998,Maptech,Inc.

A T� Michael F.Easley,Governor
O qQG William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.E.Director
Division of Water Quality
Coleen H.Sullins,Deputy Director
Division of Water Quality
July 19, 2006
Mr. John A. Pelehach
Kay Chemical Company
8300 Capital Drive
Greensboro, NC 27409-9790
Subject: No Exposure Certification NCGNE0290
Kay Chemical Company
8300 Capital Drive, Greensboro, NC
Guilford County
Dear Mr. Pelehach:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on June 22, 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, and
hereby rescinding your former Certificate of Coverage, NCG060067,
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 (June 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
P724
NZMEN
NR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customer Service
1-877-623-6749

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Copyright(C)1998,Maptech,Inc.

N.C.Clnpt.Of cfVA
MCC
JuN 9 o zoos
' Winston-5alem
Regional Office
United States Environmental Protection Agency Form Approved
g y OMB No.2040-0211
NPDES A Washington, DC 20460
FORM
3510-11 `"I EPA 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. If any industrial activities or materials are or will be exposed to precipitation,the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form,the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information
1. Name: JKl �1-ICAK
-1�/� 1 /� l` ,� 2.Phone: J J f
3. Mailing Address: a.Street: s( 3ld0_ IL�It"i_1_ 1_I!`il ✓f _I +Cl r 1 VILE I I I I - I__l , I I_. I I ��I// 4
b.City: A 9UjW6l 01 eo I I I I I I I I I I I c.State: d.Zip Code: [�1 `r- 1 IIC?I b
B. Facility/Site Locations Information f n �,, S /
1.Facility Name: 1K f��,I,I e m i I L&I ICI��}U'-'��Irl VTAi qi I I I I I I I I �
2.a.Street Address: I%fl, IO,10 iPl_�I_Il,�l� i I_3�1.1 yl_a 1 I I I I _l _.I_ I I I 1 1 �
b. City: `" +=dt1�'G•y 1�[1 1 + II I II I I I I c.County: Q*IiA (4_115/Qko_ .I y
d.State: b e.Zip Cade: M ITI I_1'l 17 I`l l D
3.Is the facility located on Indian Lands? Yes❑ No z� C
4.is this a Federal facility? r Yes❑ No
5.a.Latitude: L�� b. Longitude:] m
6.a.Was the facility or site previously covered under an NPDES storm wafer permit? YesEll"
No ❑
p �1 a C
b. If yes,enter NPDES permit number; f V L{Jy� Q�/ y�� �� CDc'� I
7.SIC/Activity Codes: Primary: Secondary(it applicable): �. =
8.Total size of site associated with industrial activity: Z 3. 0 acres
9.a.Have you paved or roofed over a formerly exposed,pervious area in order to qualify for the no exposure exclusion? Yes ❑ No
b. If yes,please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you 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

f

+ Sl
NPDES h NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM CA 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 spillstleaks
3. Materials or products from past industrial activity [�
4. Material handling equipment(except adequately maintained vehicles)
5. Materials or products during loadinglunloading 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
B. 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
(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: M1�1 D 1jk16 Ai iT i f i Li f_i Ai f Q A i I I 1 I I I I I I I I I I I I I I
Print Title: h R e_ S t EArn in lGicigieRiAtiQ iuoiuiAisif_iQ
Signature: -
Date: �Aplo
7�v
EPA Farm 3510 11 (14-99) VI T
1 Page 2 of 4
V �

�l
NPDES �, EPA Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
FORM �-, 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 551),city,
associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)- county,state,and zip code. Do not use a P.O.Box number.
(ix)and(xi)if the discharger 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 degreestminuteslseconds. 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 http:Jlwww.epa.gov/owm/swlindustrylindex,hlm 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 (°), minutes ('), and seconds (") for proper entry on
storm water permit immediately, the certification farm. To convert decimal latitude or longitude to
degreeslminuieslseconds,follow the steps in the following example.
Where to File the No Exposure Certification Form Example: Convert decimal latitude 45,1234567 to degrees(°),minutes
Mail the completed no exposure certification form to ('),and seconds(").
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=451 7' 24".
exposure. Additional guidance on completing this form can be accessed
through EPA's web site at www.epa.govtowmisw. 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 SIC code which identifies the facility's primary activity, .
and second 4-digit SIC code identifying the facility's secondary activity,
Section A. Facility Operator Information if applicable. SIC codes can be obtained from the Standard industrial
Classification Manual,1987.
1. Provide the legal name of the person,firm, public organization,or any
other entity that operates the facility or site described in this certification. 8. Enter the total size of the site associated with industrial activity in acres.
The name of the operator may or may not be the same as the name of Acreage may be determined by dividing square footage by 43,560,as
the facility. The operator is the legal entity that controls the facility's demonstrated in the following example,
operation,rather than the plant or site manager.
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 r 43,560 ft2/acre=1.25 acres.
used). Include the city, state,and zip code. All correspondence will
be sent to this address. 9. Check"Yes"or"No"as appropriate to indicate whether you have paved
or roofed over a formerly exposed,pervious area(i.e.,lawn,meadow,
dirt or gravel 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

FORM Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
FORM „EPA 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, State, Federal,or other public facility: by either a
coverage, you can institute modifications to eliminate the potential for a principal executive or ranking elected official.
discharge of storm water exposed to industrial activity,and then certify to
a condition of no exposure. Paperwork Reduction Act Notice
Section D. 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 far 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
(ii) the manager of one or more manufacturing, production, or disclose the information. An agency may not conduct or sponsor,and a
operating facilities,provided the manager is authorized to make person is not required to respond to,a collection of information unless it
management decisions which govern the operation of the displays a currently valid OMB control number. Send comments regarding
regulated facility including having the explicit or implicit duty of the burden estimate,any other aspect of the collection of information,or
making major capital investment recommendations,and initiating suggestions for improving this 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 taws 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 farm 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