NCGNE0485_COMPLETE FILE - HISTORICAL_20090313

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. IV U& f y EO H�s
DOC TYPE HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑ aW
YYYYMMDD

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
February 27, 2009
RTIVED
N.C. of ENR i
Mr. Kevin Gold
ITW Labels MAR 2009'
#1 Missouri Research Park Dr. Winston-Salem
St. Charles, MO 63304 Regional Office
Subject: No-Exposure Certification NCGNE0485
ITW Labels
780 Woody Dr., Graham, NC 272853
Alamance County .
Dear Mr. Gold: -
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES Stormwater
Permitting form. Based on your submittal and signed certification of no exposure at the above referenced facility, the
Division is granting your conditional exclusion from permitting 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 (February 26, 2014). At that time you must re-certify with the Division, or
obtain NPDES permit coverage for any stormwater discharges from your facility.
Your conditional exclusion from permitting 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 Robert Patterson at(919) 807-6375, or at
[e-mail].
Sincerely,
for Coleen H. Sullins
cc: Winston-Salem Regional OfZjcenny Gra n
Stormwater Permitting Unit re Files
Wetlands and Stormwater Branch One
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 North Caroli na
Location:512 N.Salisbury St.Ralegh,North Carolina 27604 �7 f I
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6743 ;Vat l ally
Internet:www,ncwaterquality.org
Are Equal Opportunity 1 Affirmative Action Employer

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
February 27, 2009
Mr, Kevin Gold
ITW Labels
#1 Missouri Research Park Dr.
St:Charles, MO 63304
Subject: No-Exposure Certification NCGNE0485
ITW Labels
780 Woody Dr., Graham, NC 272853
Alamance County
Dear Mr. Gold:
The Division has reviewed your submittal of the No-Exposure Certification for Exclusion from NPDES Stormwater
Permitting form. Based on your submittal and signed certification of no exposure at the above referenced facility, the
Division is granting your conditional exclusion from permitting 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 (February 26, 2014). At that time you must re-certify with.the Division, or
obtain NPDES permit coverage for any stormwater discharges from your facility.
Your conditional exclusion from permitting 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 Robert Patterson at(919) 807-6375, or at
robe [e-mail].
Sincerely,
ORIG1NA4.SIGN PICKLE BY
KEN
for Coleen H. Sullins
cc: Winston-Salem Regional Office-Jenny Graznak
Stormwater Permitting Unit No- Exposure Files
Wetlands and stormwater Branch One
1617 Mail Service Center,Raleigh,North Carolina 27699-1617 North Carolina
Location:512 7 Salisbury St.Raleigh,North Carolina r27604
Service:
;Vat a r ry
Phone:919�07-63001 FAX:919�t}7-64941 Customer Service:1-877-623-6748 `i` a/`/
Internet:www.ncwaterquality.org
An Equal Opportunity\Afrmative Action Employer

Re: IF%vd: Revised No EXposure and Rescission Lists]
Subject: Re: [Fwd: Revised No Exposure and Rescission Lists]
From: Jenny Graznak Venny.Graznak a ncmail.net>
Date: Wed, 29 Oct 2008 14:08:29 -0400
To: Sarah Young <Sarah.Young a ncmail.net>
CC: Steve,[e-mail]
NCmail.net
1-11 Sarah,
Here is the information regarding the No Exposure & Rescission requests in Alamance & Caswell
Counties from the recent list you sent out:
No Exposure Requests:
NCGNE0485 ITW Labels (Alamance)
Site visit on 10/28/2008 -- All industrial materials and activities are covered by storm-resistant shelter.
WSRO Recommendation: Issue No Exposure Certification
NCGNE0526 Ken Smith Yarn Co. (Alamance)
Site visit on 4/23/2008 -- All industrial materials and activities are covered by storm-resistant shelter.
WSRO Recommendation: ISSUe No Exposure Certification
NCGNE0500 Craftique LLC (Alamance)
Site visit on 2/7/2008 -- All industrial materials and activities are covered by storm-resistant shelter.
WSRO Recommendation: Issue No Exposure Certification.
NCGNE0479 Wicker Services (Alamance)
Site visit on 10/25/2007 -- All industrial materials and activities are covered by storm-resistant shelter.
WSRO Recommendation: Issue No Exposure Certification
Rescission Requests:
NCGO80017 Abercrombie Oil (Caswell)
Site visit on 2/1 a/2005 -- **Jonathan Diggs (DWQ) sent Abercrombie a letter dated 6/27/05, stating that
the permit was rescinded, however this information was never entered into f31MS**
WSRO Recommendation: Rescind Permit
NCG160162 S.T. Wooten Mebane Asphalt Plant (Alamance)
Site visit on 1/16/2008 -- Plant is closed.
WSRO Recommendation: Rescind Permit
Thanks Sarah!!
Jenny Graznak
NC DENR Winston-Salem Regional Office
Division of Water Quality
585 Waughtown Street
Winston-Salem, NC 27107
Voice: (336) 771--4960
FAX: (336) 771-4630
l ol'3 1/31/2009 2:48 PM

FOIL AGENCY USE ONLY
• ❑ate Rcceivcd
Division of Water Quality/Surface Water Protection Year nionF Dav
NO EXPOSURE CERTIFICATION for Exclusion
NCDENR National Pollutant Discharge Elimination System Certificate ofCovetage
NaiT+t Wouw D[r+xrNcrrt aF
NICIGI o S
Ex�anwMer wwo r�.vtww Rcu,i.xr.o
NCGNEOOOO
NO EXPOSURE CERTIFICATION
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit
based on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notice that your facility does not require permit
authorization for its stormwater discharges associated with industrial activity in the State of North
Carolina because it qualifies for a no exposure exclusion. A condition of no exposure at an industrial
facility means all industrial materials and activities are protected by a storm resistant shelter(with some
exceptions) 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 with locked or non-operational taps or valves;
adequately maintained vehicles used in material handling; and final products, other than prod s t at o
would be mobilized in stormwater discharges(e.g., rock salt). ccrn
IFUDIIII
A No Exposure Certification must be provided for each facility qualifying for the no exposure eclu
slun.
In addition, the exclusion from NPDES permitting is available on a facility-wide basis only—ntfitJ,
individual outfalls. If any industrial activities or materials are, or will be, exposed to precipita�ti I theme
facility is not eligible for the no exposure exclusion. By signing and submitting this No Exposureel
Certification form, you certify that a condition of no exposure exists at this facility or site and, r
obligated to comply with the terms and conditions of 40 CFR 122.26(g). m �lr�! ll1
You are required to reapply for the No Exposure Exclusion once every five 5 "ears
For questions, please contact the DWQ Regional Office for your area. (See page 5)
(Please print or type)
1) Mailing address of owner/operator(address to which all certification correspondence will be,mailed):
Name I'Ti.; LIABEL5 *77- I: I6e1/14 G01-0
Street Address &/ MIS-Soofe t Re5,--1RC.H P,#rel< DP. _
City ST C H.49(6-5 State MO ZIP Code _ G 330 V
Telephone No. 636 300 -2044 Fax: $U 0 _6 4 5 - Y 5 $`tf
2) Location of facility producing discharge:
Facility Name TT W LA6E R- S
Facility Contact IE S S E E fit)A 20
Street Address 790 WOO O R.
City Cr2RHA,V? State C ZIP Code 27,753
County 41-A M A A C e
Telephone No. 3 3 L A 2 7 3 Fax; 33 (. 9- 07Y8
Page 1 of 5
SWU-NE-060607 Last revised 06/06/07

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NCGNEGGGG No Exposure Certification
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). TOW E T-y%S Ty Hui Y- 5 '/ . &0 .5C
0, ( % -las 7-a20 2t CrHf dnra WoaoY 02. Cc-,> 0,1 miiir3 To Pt-r9or OA Gt%f7—
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands?❑ Yes XNo
5) Is this a Federal facility? ❑ Yes XNo
6) Latitude.N3G 3 - 0 _ Longitude k)79 22 5-5 (deg, min, sec)
7) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
AExisting Date operation began
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ❑ Yes KNo
If yes, what is the NPDES Permit Number?
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code: 2 7 5 7
10) Provide a brief description of the types of industrial activities and products produced at this facility:
2210 7-10 C.- f Ri S5 k-Ro" S c'Y1 5 r Tl v4G c RB E4S
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
;<N0
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either"Yes" or"No.") If you answer"Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes KNo
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes )<No
c. Materials or products from past industrial activity ❑ Yes ,'<No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes <, No
e. Materials or products during load inglunloading or transporting activities ❑ Yes KNo
f. Materials or products stored outdoors (except final products intended for outside El Yes )(No
use[e.g., new cars)where exposure to stormwater does not result in the discharge
of pollutants)
Page 2 of 5
SWU-NE-060607 Last revised 06/06/07

NCGNEOOOO No Exposure Certification
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, ❑ Yes No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes KNo
the discharger
i. Waste material (except waste in covered, non-leaking containers [e.g., dumpsters]) ❑ Yes No
j. Application or disposal of process wastewater (unless otherwise permitted) © Yes ;<No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes )(No
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑ Yes g No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers © Yes )J No
stored outside, has the facility had any releases in the past three (3) years?
13) Above,Ground Storage Tanks (ASTs): If you answer"No"to any of the following items, you are not eligible for the no exposure exclusion. THcaE ARE ,4
Aid 45 T 5 7- )'R1 S FRC/L-/TY
a.'Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
14) Secondary Containment: If you answer"No" to any of the following items, you are not eligible for the
no exposure exclusion. 7-14E2 E 4(2 F AO /48 0 V c CtC OA A rJ 5TP(2.4G-5:
a. Is secondary containment provided for single above ground storage containers ❑ Yes ❑ No
(including drums, barrels, etc.)with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored ❑ Yes ❑ No
in close proximity to each other with a combined capacity of more than 1,320-
gallons?.
c. Are release valves on all secondary containment structures locked? ❑ Yes El No
Page 3 of 5
5WU-NE-060607 Last revised 06/06/07

NCGNEOOOO No Exposure Certification
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes KNo
b. Is this facility a Small Quantity Generator(less than 1000 kg. of hazardous waste ❑ Yes A No
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste ❑ Yes )<�No
generated per month) of hazardous waste?
If you answered yes to questions b, or c., please provide the following information:
Type(s) of waste.-
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport i disposal vendor:
Vendor address:
16) Certification:
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 stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater 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(5)years to the North Carolina
Division of Water Quality 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 North Carolina Division of Water
Quality, 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.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater 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.
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.
Printed Name of Person Signing:
Title: ��A.et-cvl A.n►..r.. T _
(Signature of Applicant) (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at any time in the future for compliance with the No Exposure Exclusion.
Page 4 of 5
SWU-NE-060607 Last revised 06/06/07

NCGNE0000 No Exposure 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 this Article or a rule implementing this Article:or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management]Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($10,000).
There is currently no fee for a No Exposure Exclusion.
Final Checklist
This application should include the following items:
I This completed application and all supporting documentation.
A map with the location of the facility clearly marked.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
!Vote
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
Win ton Sole 1,ti
Asheville Office ...... [phone] 4r s
Fayetteville Office ... [phone] W
$
Mooresville Office ... [phone] ' `_� 'n to
Raleigh Office ......_. [phone]
Washington Office ...[phone]
Wilmington Office ... [phone] + _
Winston-Salem ...... [phone] F ye"t ille -
Central Office .........[phone]
r
Wit' ngton
r
Page 5of5
SWU-NE-060607 Last revised 06/06/07

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FOR AGENCY USE ONLY
. Date Received
�, Division of Water Quality/Surface Water Protection year Month Day
.A �� 0 I{
NCDENRNational Pollutant Discharge Elimination System Certi6eateurC verage14-1 S
Np Y- NO EXPOSURE CERTIFICATION for Exclusion
EwvirxcME.rt u.o NRIR..L Resdncc�
NCGNE0000 -
NO EXPOSURE CERTIFICATION
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit
based on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notice that your facility does not require permit
authorization for its stormwater discharges associated with industrial activity in the State of North
Carolina because it qualifies for a no exposure exclusion. A condition of no exposure at an industrial
facility means all industrial materials and activities are protected by a storm resistant shelter(with some
exceptions) to prevent exposure to rain, snow, snowmelt, andlor 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 with locked or non-operational taps or valves;
adequately maintained vehicles used in material handling; and final products, other than produeff_iKa_F_0�—E,,j 1,
would be mobilized in stormwater discharges(e.g., rock salt). mfzI
-
A No Exposure Certification must be provided for each facility qualifying for the no exposure uslon. i
In addition, the exclusion from NPDES permitting is available on a facility-wide basis only—nart r
individual outfalls. If any industrial activities or materials are, or will be, exposed to precipita�i ; the ��-U
facility is not eligible for the no exposure exclusion. By signing and submitting this No ExposureI
Certification form,you certify that a condition of no exposure exists at this facility or site and: } ,
obligated to comply with the terms and conditions of 40 CFR 122.26(g). _, ;
13 ., _
You are required to reapply for the No Exposure Exclusion once every five (5) years. 'r
For questions, please contact the DWQ Regional Office for your area. (See page 5)
(Please print or type)
1) Mailing address of owner/operator(address to which all certification correspondence will be mailed):
Name ITw LABEL *77-fl. 1(c—vtrT COL40
Street Address &/ Al i S s o a I RcSc-flRGH PAre1< D P.
City ST_. CHA/1tE5 State In ZIP Code 633oI/
Telephone No. 636 3W -20` (, Fax: 60 A G 4 5 -�Y 5 T y
2) Location of facility producing discharge: M '/_ -+
Facility Name l T W L RBE L- S ! I l FP- M I" }el I
Facility Contact 10SSE ElUa20 (0 trvv) _ _ (R13�a0$—
Street Address 790 9000,0Z 0 T' cp9p 1
City cr2,4HAA State A/ C- ZIP Code 27.753
County AL-A rh/4A Ce-
Telephone No. 33 L 2.27 3 Fax: 33 G .2 07YA
Page 1 of 5
SWU-NE-060607 Last revised 06/06/07

,Y
r
NCGNEOOOO No Exposure Certification
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). TAkE t-NOzrS ro Hul y. 5 `� , tiro SE
I M. y TaRrl 2i &wr o1rn WoDVy 02. 6_o, o,i ,4rrzr3 7- F&/Mr On Lt'fT
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands?❑ Yes XNo
5) Is this a Federal facility? ❑ Yes XNo
6) Latitude tJ3G 3 y 0 Longitude w*79 22 SS (deg, min, sec)
7) This NPDES Permit Application applies to which of the following:
❑ New or Proposed Facility Date operation is to�begin
KExisting Date operation began
8) Was this facility or site ever covered under an NPDES Stormwater Permit? p Yes XNo
If yes, what is the NPDES Permit Number?
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code)that describes the primary industrial
activity at this facility
SIC Code:2 7 5 i
10) Provide a brief description of the types of industrial activities and products produced at this facility:
A21j9 r P2C55k-Rcr Sc-M Sr7—t0E_4_R9E45*
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
f<N0
❑ Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
Exposure Checklists(12, - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either"Yes" or"No.") If you answer"Yes" to any of these items,you are not
eligible for the no exposure exclusion.
a. Using, storing, or cleaning industrial machinery or equipment, and areas where ❑ Yes )<No
residuals from using, storing or cleaning industrial machinery or equipment remain
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes )<No
c. Materials or products from past industrial activity ❑Yes )<No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes <No
e. Materials or products during loading/unloading or transporting activities ❑ Yes XNo
f. Materials or products stored outdoors (except final products intended for outside a Yes ffNo
use [e.g., new cars]where exposure to stormwater does not result in the discharge
of pollutants)
Page 2 of 5
SWU-NE-060607 Last revised 06/06/07

r
NCGNE0000 No Exposure Certification
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, ❑ Yes K No
and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes )'No
the discharger
i. Waste material (except waste in covered, non-leaking containers [e.g., dumpsters]) ❑ Yes No
j. Application or disposal of process wastewater(unless otherwise permitted) ❑ Yes )<No
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not' ❑ Yes )(No
otherwise regulated (i.e_ under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑ Yes `o No
(i.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers ❑ Yes ` 6 No
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage ranks (ASTs): If you answer"No" to any of the following items,you are not
eligible for the no exposure exclusion. THErzE A2F Al J R S T S 47- 7WI5 F4C/[.I Ty
a, Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes ❑ No
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
14) Secondary Containment: If you answer"No" to any of the following items,you are not eligible for the
no exposure exclusion. 7-14tg E 4R e- Al,�7 AB 0 V F a2 aA A O 57v(2A6.,*
a. Is secondary containment provided for single above ground storage containers ❑ Yes ❑ No
(including drums, barrels, etc.)with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored ❑ Yes ❑ No
in close proximity to each other with a combined capacity of more than 1,320-
gallons? .
c. Are release valves on all secondary containment structures locked? ❑ Yes ❑ No
Page 3of5
SVVU-NE-060607' Last revised 06/06107

NCGNE0000 No Exposure Certification
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? D Yes KNo
b. is this facility a Small Quantity Generator(less than 1000 kg. of hazardous waste 0 Yes A No
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator(1000 kg. or more of hazardous waste 0 Yes N0
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport i disposal vendor:
Vendor address:
16) Certification:
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 stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater 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(5)years to the North Carolina
Division of Water Quality 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 North Carolina Division of Water
Quality, 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.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater 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.
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.
Printed !Name of Person Signing:� V_+?+1+`i X L-'O .R
Title:
Q
(Signature of Applicant) (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to that approval. The Regional Office may also
inspect your facility at any time in the future for compliance with the No Exposure Exclusion.
Page 4 of 5
SWU-NE-060607 Last revised 06/06/07

NCGNEOOOO No Exposure 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 this Article or a rule implementing this Article;or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management]Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($10,000).
There is currently no fee for a No Exposure Exclusion.
Final Checklist
This application should include the following items:
This completed application and all supporting documentation.
A map with the location of the facility clearly marked.
Mail the entire package to:
Stormwater Permitting 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 a No Exposure Exclusion.
For questions,please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
1hl►n
Asheville Office ...... (828) 2964500
Fayetteville Office ... [phone]
Mooresville Office ... [phone] 11
Raleigh Office ........ (919) 7914200
ocr to
Washington Office ...[phone]
Wilmington Office ... [phone]
Winston-Salem ...... [phone] r .9
Central Office .........[phone] -
Will' ngton
Page 5 of 5
SWU-NE-060607 fast revised 06/06/07

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