NCGNE0291_COMPLETE FILE - HISTORICAL_20120125

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. IV CiC� NCU��
DOC TYPE 13 HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ aola�UI
YYYYMMDD

fir. S
FwArF /
Q 9pG Beverly Eaves Perdue,Governor
Dee Freeman,Secretary
> North Carolina Department of Environment and Natural Resources
O 'c
Coleen It.Sullins,Director
Division of Water Quality
SURFACE WATER PROTECTION SECTION
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
No Exposure Certification (or) Certificate of Coverage
N I G I G I N I E 10 1 1 N I G G
II. Permit status prior to requested change.
a. Permit issued to (company name): Novamelt-Jowat, LLC
b. Person legally responsible for permit: Gerhard Haas
First M l Last
Director of Manufacturing
Title
P.O. Box 948
Pennit Holder Mailing Address
High Point NC 27261
- City State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge): Novamelt-Jowat
d. Facility address: 5608 Uwharrie Rd.
Address
Archdale NC 27263
City State Zip
c. Facility contact person: Gerhard Haas [phone]
First 1 Ml/ 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 explaiW
b. Permit issued to(company name): Novamelt Americas LLC
c. Person legally responsible for permit: James Auber
First M I Last
President
Title
5608 Uwharrie Rd.
Pennit Holder Mailing Address
Archdale NC 27263
City State Zip
336�1 { ) 434-9500jauber c,novamelt.com
5 �dj2 Phone E-mail Address
d. FAillityname(discharg ): Novamelt Americas LLC
e. ¢�aciliona-did' s 5608 Uwharrie Rd a��ic�. cac�►
t1K-
PpINT S0 Address
Archdale NC 27263
City State Zip
f. Facility contact person: Ulrike Lambert
First M I Last
[phone] [e-mail]
Phone E-mail Address
Revised 812008

1
PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First M I Last
Title
Mailing Address
City State Zip
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: TIIIS 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.
.....................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I,�• PAA 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 tha i�ail r uired supporting information is not included, this application package will be
returned as incot p te.
Signature Date
APPLICANT CERTIFICATION
I, James Auber, 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.
u 1/13/12
Signature Date
....................................
PLEASE SEND TIIE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008

`O�(F warF RpG Beverly Eaves Perdue,Governor
Vj r Dee Freeman,Secretary
North Carolina Department of Environment and Natural Resources
0 C
Coleen H.Sullins,Director
Division of water Quality
SURFACE WATER PROTECTION SECTION
PERMIT NAMEIOWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
No Exposure Certification (or) Certificate of Coverage
N I C 10 1 N I E 10 1 2 T9 1 N .G G
II. Permit status Arior to requested change.
a. Permit issued to(company name): Novamelt-Jowat, LLC
b. Person legally responsible for permit: Gerhard I-laas
First M I Last
Director of Manufacturing
Title
P.O. Box 948
Permit [[older Mailing Address
Huh Point NC 27261
City State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge): Novamelt-Jowat, LLC
d. Facility address: 5608 Uwharrie Road
Address
Archdale NC 27263
City State Zip
e. Facility contact person: Gerhard l4aas [phone]
First I 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. Pen-nit issued to(company name): Nova melt Americas, LLC
c. Person legally responsible for pernut: Jim Auber
First Ml Last
President
Q v Title
5608 Uwharrie Road
APR 1 6 2012 Permit Holder Mailing Address
Archdale NC 27263
DENR _ ► ATER DUALJTY City State Zip
wounds 3 2nogLw Branch [phone] jauber ct novamelt.com
Phone E-mail Address
d. Facility name (discharge): Novamelt Americas, LLC
e. Facility address: 5608 Uwharrie Road
Address
Archdale NC 27263
City State Zip
f. Facility contact person: Terry Fortner
First M I Last
[phone] [e-mail]
novamelt.com
Phone E-mail Address
Revised 812008

1PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the pennit)
Pennit contact: Terry Fortner
First M t Last
_ Production Manager _
Title
5608 Uwharrie Road
Mailing Address
Archdale NC 27263
City State Zip
[phone] tfortner rt,novamelt.com
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.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, Gerhard Haas, 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 i Il required supporting information is not included, this application package will be
returned as incom e.
GQ �Z/?//z
Signature Date
APPLICANT CERTIFICATION
I, Jim Auber, 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 incompletEr
DWI
Y �z
�i
Signature Date
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 V2008

Transfer of Membership Interest Contract between Novarnelt GmbH,
-Jo, 0 Novam3ll wat LLC. Jowat AG. Jowat Corporation and J wat Holding
Benelux
Transfer of Membership Interest
This Contract is made on Nov. 21't 2011 between the following Parties:
1. Jowat AG, Emst-Hilker-Strasse 10-14,32758 Detmold, Germany
hereinafter referred to as "Jowat' or"Seller ,
2. Jowat Corporafion, 5608 Uwharrie,Archdale, North Carolina, 27263-
1236 USA, hereinafter referred to as'Jowat Corporation'or"Seller",
3. Jowat Holding Benelux B.V., Ootmarsumseweg 283, 7666 Fleringen,
Netherlands, hereinafter referred to as "Jowat Benelux",
4. Novamelt GmbH, Oflinger Str. 120, 79664 Wehr, Germany
hereinafter referred to as "Novarneir or"Buyer" and
5. Novamelt-Jowat LLC, 5608 Uwharrie Road
Archdale, NC 27263, U.SA hereinafter referred to as the Company"
or.Novamelt-Jowat'
Whereas the Buyer and the Sellers are investors and own membership
interests in Novamelt-Jowat LLC, a company duly organized and existing
under the laws of Delaware,with its legal address at 5608 Uwharrie Road,
Archdale, NC 27263-1236, USA
Whereas Jowat Benelux,a group related company of the Sellers, has
granted certain loans to the Company-,
Whereas Novamelt-Jowat intends to change and/or continue several
contractual relationships with the Jowat-Group as laid down in Art. 3 sec.
7 of this agreement;
Whereas the paid-in capital of the Company is 1,500,000 USD which is
fully paid in;
Whereas the Seller Jowat AG intends to sell its membership interest of
345,000 USD which is equal to 23% of the paid-in capital to the Buyer and
the Buyer intends to acquire the entire equity interest;
KV 10000038 Page 1 r)f 14

r
i ransfer of Mernbership Interest Contract between Novarnelt GmbH,
Natamelt-Ja vai l.LC. .Jowat AG, Jowat Corporation and Jowat Holding
Sen�lux
Whereas the Seller Jowat Corporation intends to sell its membership
interest of 390,000 USD which is equal to 26% of the paid-in capital to the
Buyer and the Buyer intends to acquire the entire equity interest;
Whereas the Managing Director of the Buyer has been the Chairman of
the Board of the Company since its establishment and has acquired
extensive knowledge and experience with regard to the Company
the Parties hereby agree as follows:
Art. 1 Transfer of Membership Interests i
Subject to the terms and conditions set forth in this Contract, the Sellers
hereby transfer their membership interests in the Company to the Buyer
effective on Dec. 30t', 2011 CEffective Date"). After the transfer of the
membership interests the Company's equity shall be as follows:
Novamelt GmbH 1 00%
::v Pace of tO c

� f
Transfer of Membership Interest Contract between Novamelt GmbH,
' Novamalt-Jowat LLC. Jowat AG. Jowat Corporation and Jowat Holding
C..,o nF, u.f ,
.
i
Art. 14 Language
This Contract has been executed by the Parties in the English language.
y Art. 15 Notices '
All notices or other communications under this Contract shall be in writing {
in English and shall be either delivered by hand or sent by mail, e-mail, i
telex, telefax or cable to the Parties at their respective address set out
above or at such other addresses as either Party may designate by notice !
y' to the other Parties. '
This contract is made in six sets of which one is kept by each party.
7
Wehr, ...�3............. i
l
,... Novamelt GmbH
f
Harald Braun l
Geschattsffihrender
Geselischafter
� � f
�v
Archdale, .�
Novamelt4owat LLC
VVvw'
Harald Braun Rainh rd Kramme
Chairman of the Board President and CEO
IT
€ Detmold,
3
r Jowat AG t
l ' Raff Nitschke Klaus Kullmann
€, ' Managing Director Managing Director
a'
I
t
�• 3
1
} ' KV 1000003C Page 9 of 14

. �
§ Transfer of Membership mlreeslContract l Ueen §ovammlGmbH,
NQammpuo at LLG, Jowat#G jowat Corporation and JowatHoUng
Ben@uX ! |
d \
\ Detmod. AAA \
Jowat Homing Benelux B.V.
� | j
\ | Klaus Ku|�mann kif N beke
\' Managing Director Managing Director
§. g
\ \
^ High Rdnt .���\�41 .
) JoW ova |on \
R¥nh Kramme
{
President
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\\ KV 10000038 A to of G
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C201201300353
SOSID: 0831094
Date Filed: 1/13/2012 1:05:00 P\l
Effective: 1/17/2012
Elaine F. ,Marshall
North Carolina Secretary of State
State of North Carolina C201201300353
Department of the Secretary of State
APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY
FOR LIMITED LIABILITY COMPANY
Pursuant to§57C-7-05 of the General Statutes of North Carolina,the undersigned limited liability company hereby applies for an
Amended Certificate of Authority to transact business in the State of North Carolina,and for that purpose submits the following
statement.
I. The name of the limited liability company is: NUVAMELT-JOWAT LLC
2, The name the limited liability company is currently using in the State of North Carolina is:
NOVAMELT-JOWAT LLC
3. The state or country of formation is: Delaware
4. The date the limited liability company was authorized to transact business in the State of North Carolina is:
Februa 28. 2006
5, The changes being made are as follows:
Chan a of the limited IiabiU com an 's name to"NUVAMELT AMERICAS LLC°
6. Attached is a certificate of existence(or document of similar import),duly authenticated by the Secretary of State or other official
having custody of limited liability company records in the state or country of formation. The certificate of existence must be less
than six months old. A photocopy of the certification cannot be accepted.
7. This application will be effective upon filing,unless a date and/or time is specified:
This the 3rd day of January ,20 12
NUVAMELT-JOWAT LLC
N e of Limited:ZLility Company
Signature
James Auber, President
Type or Print Name and Title
Notes:
1. Filing Fee is SSo, This application must be filed with the Secretary of State.
CORPORATIONS DIVISION P_O.BOX 29622 RALEIGH,NC 27626-0622
(Revised Ja—y7002) (Form L-10)

C201201300353
Defaware PAGE 1
q e First State
I, JEFFREY W. BULLOCK, SECRETARY OF STATE OF THE STATE OF
DELAWARE, DO HEREBY CERTIFY THE ATTACHED IS A TRUE AND CORRECT
COPY OF THE CERTIFICATE OF AMENDMENT OF "NOVAMELT-JOWAT LLC",
CHANGING ITS NAME FROM "NOVAMELT-JOWAT LLC" TO "NOVAMELT
AMERICAS LLC", FILED IN THIS OFFICE ON THE NINETEENTH DAY OF
DECEMBER, A.D. 2011, AT 4:39 O'CLOCK P.M.
AND I DO HEREBY FURTHER CERTIFY THAT THE EFFECTIVE DATE OF
THE AFORESAID CERTIFICATE OF AMENDMENT IS THE THIRTY-FIRST DAY
OF DECEMBER, A.D. 2011.
y
Jeffrey W.Bullock.Secretary of State
4005731 8100 '�� AUTHEN C TTOM: 9240782
`.
111310740 °c1w��```~ DATE: 12-19-11
You may verify this certificate online
at corp.delaware.gov/authver.aheml

NOVAMELT
Novamelt Americas LLC
5608 Uwharrie Road
Archdale, NC 27263
Phone: [phone]
Fax: [phone]
E-mail: [e-mail]
www.novamelt.corApril 12, 2012
NCDENR—Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-t617
Subject: Ownership/Name Change — No Exposure Certification
Novamelt-Jowat, LLC
Archdale, North Carolina
Air Permit No. 05861Ro5
No Exposure Certification No. NCGNE029:1
To Whom It May Concern:
Novamelt-Jowat, LLC has recently undergone an ownership/name change. The new company
name and owner is Novamelt Americas, LLC. The facility will continue to conduct the same
industrial activities conducted prior to this ownership/name change and the No Exposure
Certification remains valid.
I am the new responsible official replacing Gerhard Haas and have enclosed a completed Permit
Name/Ownership Change Form with a copy of legal documentation of the transfer of ownership.
If you have any questions or require additional information, please contact our Production
Manager Terry Fortner or me at [phone]•
Sincerely,
- 9 0 19
imAuber APR 1 6 2012
President
Novamelt Americas, LLC W R
Branch
Enclosures

F VV�A TF C Michael F.Easley,Governor
William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
7 Alan W,Klimek,P.E.Director
`l Division of Water Quality
Coleen H.Sullins,Deputy Director
Division of Water Quality
1:�CCiVr'1
June 23, 2006
JUN.2 8 2006
Mr. Gerhard Haas
Novamelt-Jowat, LLC Regional office
PO Box 948
High Point, NC 27261
Subject: No Exposure Certification NCGNE0291
Novamelt-Jowat, LLC
5638 Uwharrie Road, Trinity, NC
Guilford County
Dear Mr. Haas:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on June 13, 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 SIGNED BY
!<EN, PICKLE
for Alan W. Klimek, P.E.
cc: Winston-Salem Regional Office Central Files—wlattachments
Stormwater Permitting Unit Files
V*A
NCDENR
N.C.Division of Water Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1 61 7 [phone] Customer Service
1-877-623-6748

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W A TF Michael F.Easley,Governor
William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
Alan W.Klimek,P.E.Director
Division of Water Quality
p Coleen H.Sullins,Deputy Director
Division of Water Quality
June 23, 2006
Mr. Gerhard Haas
Novamelt-Jowat, LLC
PO Box 948
High Point, NC 27261
Subject: No Exposure Certification NCGNE0291
Novamelt-Jowat, LLC
5638 Uwharrie Road, Trinity, NC
Guilford County
Dear Mr. Haas:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on June 13, 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 under40 CER 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
N ENR
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` \1

United States Environmental Protection A Form Approved
Agency
NPDES Washington,
Washington, DC 20460 g y OMB No.2040-0211
FORM E PA 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
1. Name: E L L1 it1 2. Phone: 13131h14.3141a 1510101
3. Mailing Address: a.Street: If 11 01 I13I00xl 1a141g1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 _1 1 I 1
b.City. jRI f I6jI HI I P1()1 l It�IT1 I I I I I I I 11_ 1 11 c.State: &LU d.Zip Code: I2111216A I—1 I I I 1
B. Facility/Site Location information
1.FacilityName: 1tyi0iVIAIM1EVri -IJiQWAir1 ii—iLiC.l I i I I I I I I I I 1 1
2.a.Street Address: 1 51 6 a lS i _IU IWI HIAI{Z1 lit I I& ROA DI I I I I I I I I I I I I l 1
b. City: rrIR1 Tly I
I I I I I I I I j I I 1 1 1 1 1 c.County: aVit L O
d.State: I�G4 e.Zip Code: 1 AI q I ZI 6131—I I I I I 2
Im
3. Is the facility located on Indian Lands? Yes ❑ No ® M Ir1LL1
4. Is this a Federal facility? Yes ❑ No © pe. Z
5.a. Latitude: b. Longitude: 1 18 IC> [C& La
qJ
nn Ca�7
6.a.Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No Z m p v
�c o
b. If yes,enter NPDES permit number:
7.SIC/Activity Codes: Primary: IZIsICt, I Secondary(if applicable): I I I 1 ' ------------
S.Total size of site associated with industrial activity: 0, [2✓ _ 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

L
NPDES �EPA NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
FORM wr 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 ❑ 1Z
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 spillsAeaks ❑
3. Materials or products from past industrial activity D I�
4. Material handling equipment(except adequately maintained vehicles)
5, Materials or products during loadinglunloading or transporting activities
S. 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]) d
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
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,l 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: 6 / S
Print Title: LVJ .G E 4�fi&iSilY I N
Signature:
Date:
EPA Form 3510-11 (10-99) �; Page 2 of 4