NCGNE0835_COMPLETE FILE - HISTORICAL_20150121

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO. /V C�
DOC TYPE R/HISTORICALFILE
❑ MONITORING REPORTS
DOC DATE ❑
YYYYMMDD

w
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
January 21, 2015
Ms. Lynn Hyatt
HAECO Cabin Solutions
5568 Gumtree Road
Winston-Salem, NC 27107
Subject: Name/Ownership Change Request
No Exposure Certification NCGNE0835
HAECO Americas
Formerly TIMCO Aviation Services
Davidson County
Dear Ms. Hyatt:
The Division has reviewed your submittal of the permit name/ownership change form for the
subject No-Exposure Certification, which we received on December 19, 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:11portal.ncdenr.orglweb1l
An Equal Opportunity 1 Affirmative Action Employer—50%Recycled 110% Post Consumer Paper

1
If you have any questions or need further information, please contact the Stormwater Permitting
Program at [phone].
Sincerely,
ORIGINAL SIGNED®1
KEN PICKLE
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land Resources
cc: Winston-Salem Regional Office
Stormwater Petting Program Files

%ZHAECO
Cabin Solutions
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, NC 27699-1617
Certified Return Receipt Requested
To Whom It May Concern:
I am enclosing for your information a completed copy of the Permit Name/Ownership
Change Form with updated information at our facility located at 5568 Gumtree Road,
Winston Salem, NC.
Enclosed with the forth is a Certificate of Assumed Name for Corporation and a Notary
Acknowledgement for the "Certificate of Assumed Name for Corporation" for your
records.
Should you require any further information, please feel free to contact me.
Regards,
L nn�A =yatt
EHS Manager
HAECO Cabin Solutions
5568 Gumtree Road
Winston Salem, NC 27107
(0) 336-464-0122 ext. 22012
(C) 336-870-5430
RECEIVED RECEIVED
DEC 19 2014
1 9 2014 DENR-LAND QUALITY
DENR-LAND QUALITY STORMWATER PERM-1TING
STORMWATER PERMITTING

r �
Division of Water Quality / Surface Water Protection FOR AGENCY USE ONLY +
Date Received
Year Month Day
NCDENRNational Pollutant Discharge Elimination System
NZ_.� oN--rM"� PERMIT NAME/OWNERSHIP CHANGE FORM
EkL1R°NME�+T WD N4LRPL RESW RCE�
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C $S 1 ,61N C G N I E 10 1 8 1 3 1 5
II. Permit status prior to requested change.
a. Permit issued to (company name): TIMCO Aviation Services
b. Person legally responsible for permit: Glendon G Ross
First Ml Last
Corporate EMS Manager
'title
623 Radar Road
Permit Holder,Mailing Address
Greensboro NC 27410
Cite State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge): T1MC0_Aerosystems
d. Facility address: 5568 Gumtree Road
Address
Winston Salem NC 27107
Ciry state Zip
e. Facility contact person: Lvnn A. Fiyatt 336 464-0122
First /MI / Last Phone
III. Please Provide the following for the requested change (revised permit).
a. Request for change is a result of: x Change in ownership of the facility
r Name change of the facility or owner
If other please explain: Name change and owner name change
b. Permit issued to(company name): HAECO Americas
c. Person legally responsible for permit: Christopher M. Lunsford
First M] Last
General Manager
Title
5568 Gumtree Road
RECEIVED Permit Elolder Mailing Address
DEC g Winston Salem NC 27107
2014 city k State Zip
DENR-LAND QUALITY [phone] Mark.lunsford a,F1AECO.aero
STORMWATER PERMI lIG Phone E-mail Address
d. Facility name tscharge): HAECO Cabin Solutions
e. Facility address: 5568 Gumtree Road
Address
Winston Salem NC 27107
City State Zip
f. Facility contact person: Lynn A Hyatt
First Nil Last
[phone] Lvnn.hvatt uHAECO.aero
Phone E-mail Address
Revised 2012Ap23

NPDES 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: Lynn A Hvatt
First h11 Last
EFI&S Manager
Title
5568 Gumtree Road
Mailing Address
Winston-Salem NC 27107
City State Zip
[phone] Lvnn.hvattnl-1AEC0.aero
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change:'
X 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, Glendon G. Ross, 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.
De ,5Jej 20./4-
Signature Date
APPLICANT CERTIFICATION
1, Christopher M. Lunsford, 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.
PC
Signat e 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 712008

Notary Aciumviedgibent foi-the"Certificate of Assumed Name for Col-ponI6611"
County of
e—')
allotar for County,
.yPtiblir —2
State of. , Certify that
personally appeared Wore me this(lay and acknowledge(ftlint hialsh't is
.(Titl6 of Official)
of �Ae�&rporaflon,and that hip/she as
(Name of Corporation) Critle.of Official)
being authorized to-do w,exec'11ted the.foregoing insfromewoll behalf or(Ile said corporation.
Witness my hand and official seal, this(lie���— ay of.SSP
(ki, HQMPVlLIC Notary Public
KALREPN'BURKe
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1:�j JITI 11::11 Quiltopo ouply,tic
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RECORDED.. PC FEE$20.00 I
09-29.2014 GUILFORD COUNTY,NC I
10:53:03 AM JEFF L.THIGPEN i
8Y. PACEtLE Ffti-rR REMIER OF OEEUS
DEPUTY-oft
GT:RTITICATr,,Or ASSUMED NAME FOUR CORI'ORATiON
The undorsigned corporation,proiiosing to crigage in iittsiness in Guilford Cotuity,No111t
Carolina, under ar} assumed name other thmt its corporate name; hereby certifies that:
1. 'Cite assonied naine under which tite business is to be conducted is:
HAECO-Americas Cabin Solutions
� 2. Tile names and address of the owners)of the business is(are):
TIMCO Aeros sternst LLC
Y
815 Radar Road
Greensboro, NC 27410
In witness %thereof, this certificate is signed in the name of the corporation by its Secretary
.(Title)
this 7:7-A° day.of Septem ber ,2014
TIMCO.Aerosystems, LLC
(Name of Corporation)
By: NAkQ,-)A5F"S�
(Si ❑attire and Title)
j%/!Jr'l..J ..,//r . -`-ilk✓'� l!d.i.��ir,':.�•.J'
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t Rovised 6/8/2007

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NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
February 13, 2012
TIMCO Aviation Services
Attn: Mr. Glen Ross, Corporate Mgr. EH&S
623 Radar Road
Greensboro,ITC 27410-6221
Subject: No-Exposure Certifications NCGNE0835
Rescission of Permit NCGNE0261
TIMCO Aerosystems
Davidson County
Dear Mr. Ross:
The Division has reviewed your submittal of the application for No-Exposure Certification for exclusion from 1�TPDES
stormwater permitting. Based on your submittal and signed certifications of no exposure at the above referenced
facility, the Division is granting your conditional exclusion from permitting as provided for under 40 CFR 122.26(g),
which is incorporated by reference in North Carolina regulations. We are also hereby rescinding the prior o%vner's
Certificate of Coverage,NCGNE0261.
Please note that by our acceptance of your no-exposure certification, you are obligated to maintain no-exposure
conditions at the facility. If conditions change such that the facility can no longer qualify for no-exposure exclusion,
you are obligated to immediately obtain NPDES permit coverage for any stormwater discharge(s). Otherwise, the
discharge(s)becomes subject to enforcement as an un-permitted discharge. You must self re-certify annually using the
included form, or obtain NTDES permit coverage for any stormwater discharges. The annual self re-certification
statement does not need to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does not affect the 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 Jenifer Carter at (336) 7714957, or at
[e-mail]
f`Sincerely,
kN
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: WSRO files
SWP Central Files
Stormwater-Permitting Unit. No- Exposure File
Fran McPherson—Budget Office
Mr. Jordan Geras (TIMCO Aerosystems; 5568 Gumtree Rd, Winston-Salem, NC 27107)
North Carolina Division of Water Qualify,Winston-Salem Regional Office One
Location:585 Waugntown St Winston-Salem,North Carolina 27167 NorthCarolina
Phone:[phone] F k 336-771-46301 Customer Service:1-877-623-6748
Internet:L"%m,.ncwaterquallty.org Naturally
An Equal Oppnaunil�lAf{irmaiive.kka Employer

No-Exposure Self Re-Certification Information:
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. State statute provides for fines of up to$25,000 per day for
un-permitted discharges.
Your conditional no-exposure exclusion must be self re-certified at least annually as follows:
- Complete the re-certification at a minimum of once per year using the included Self Re-
Certification Form.
(additional copies can be downloaded from http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-5)
- Maintain a record of re-certifications on file at the facility. Do not submit the re-certification to
DWQ unless requested. If requested, submit a copy of the re-certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or local government, provide the re-certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes, or if
the facility can no longer maintain no-exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
""No exposure" means that 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. (40 CFR 122.26(g))
Information and forms related No-Exposure Certifications can be accessed on the website at:
http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-5
Rev.30Aug2010

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
February 13, 2012
TfMCO Aviation Services
Attn: Mr. Glen Ross, Corporate Mgr. EH&S
623 Radar Road
Greensboro,NC 27410-6221
Subject: No-Exposure Certifications NCGNE0835
Rescission of Permit NCGNE0261
TIMCO Aerosystems
Davidson County
Dear Mr. Ross:
The Division has reviewed your submittal of the application for No-Exposure Certification for exclusion from NPDES
stormwater permitting. Based on your submittal and signed certifications of no exposure at the above referenced
facility, the Division is granting your conditional exclusion from permitting as provided for under 40 CFR 122.26(g),
which is incorporated by reference in North Carolina regulations. We are also hereby rescinding the prior owner's
Certificate of Coverage,NCGNE0261.
Please note that by our acceptance of your no-exposure certification, you are obligated to maintain no-exposure
conditions at the facility. If conditions change such that the facility can no longer qualify for no-exposure exclusion,
you are obligated to immediately obtain NPDES permit coverage for any stormwater discharge(s), Otherwise, the
discharge(s) becomes subject to enforcement as an un-permitted discharge. You must self re-certify annually using the
included form, or obtain NPDES permit coverage for any stormwater discharges. The annual self re-certification
statement does not need to be submitted to DWQ, unless requested.
Your conditional exclusion from permitting does'not affect the 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 Jenifer Carter at [phone], or at
[e-mail]
Sincerely,
W. Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office
Division of Water Quality
cc: WSRO files
SLAT Central Files
Stormwater Permitting Unit: No- Exposure File
Fran McPherson—Budget Office
Mr. Jordan Geras(TIMCO Aeros}>stems; 5568 Gumtree Rd, Winston-Salem, NC 27107)
North Carolina Division of Water Quaiity,Winston-Salem Regional Office One
!option:585 Waughtown S1 Winston-Salem,North Carolina 271D7 NorthCaroIina
Rhcme:335.771.560 4;AX:335-771-46301 Customer Service:1-577-623-6748
lnternet,"%,A,.nc,vaterqualicy.org Aaturally
An Equak Opportunity�,Affirmative Acfion Employer �/

No-Exposure Self Re-Certification Information:
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. State statute provides for fines of up to $25,000 per day for
un-permitted discharges.
Your conditional no-exposure exclusion must be self re-certified at least annually as follows:
- Complete the re-certification at a minimum of once per year using the included Self Re-
Certification Form.
(additional copies can be downloaded from http://portal.ncdenr,org/web/wq/ws/su/npdossw#tab-5)
- Maintain a record of re-certifications on file at the facility. Do not submit the re-certification to
DWQ unless requested. If requested, submit a copy of the re-certification to the Division and/or
the municipality in which the facility is located.
-During an inspection by DWQ or local government, provide the re-certifications immediately
upon request.
- Notify the Division of any changes in ownership, significant facility and/or activity changes, or if
the facility can no longer maintain no-exposure.
-Allow the NPDES permitting authority or, if discharging into a municipal separate storm sewer
system, the operator of the system, to: (1) inspect the facility; and (2) make such inspection reports
publicly available upon request.
*"No exposure" means that 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. (40 CFR 122.26(g))
Information and forms related No-Exposure Certifications can be accessed on the website at:
http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-5
Rev.30Aug2010

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Compliance Inspection Report 6£9t,lLL-9F£:XVJ\0009-4LL-9££:8u0yd
LULZ 0N'waleS-u01su1M 30anS unwtyOneM 999
Permit: NCGNE0835 Effective: Expiration: Owner: Triad International
Timco
SOC: Effective: Expiration: Facility: TIMCO Aerosystems
County: Davidson 5568 Gumtree Rd
Region: Winston-Salem
Winston Salem NC 27107
Contact Person: Jordan Geras Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Reprosentative(s):
Related Permits:
Inspection pate: 02/1012012 Entry Time: 01:00 PM Exit Time: 01:15 PM
Primary Inspector: Jenifer Carter Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ■ Compliant ❑ Not Compliant
Question Areas:
Miscellaneous Questions 0 Misc
(See attachment summary)
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Page: 1
VAEUV

Permit: NCGNE0835 Owner-Facility: Triad International Maintenance Corporation Timco
Inspection Date: 02I1012012 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
This facility(formerly TYCO)was bought by TIMCO, which applied for new NCGNE, as opposed to keeping this current
certification. This inspection was to confirm that the facility still met the qualifications for NE. They do.
MISc Yes No NA NE
Is the facility compliant? ■ Q Q Q
Comment:
Page: 2

FOR AGENCY USE ONLY
• Division of Water Quality/Surface Wafer Protection �atc Received
Y Year \l_5 Dav
+w 1
National Pollutant Discharge Elimination System
NCDENR CcniticatcofCoecage
NO EXPOSURE CERTIFICATION for Exclusion C
Fx✓mnvert,., r+.�.,y. �..�� 1420ept.rt Of ENR -
NCGNE0000
JAN 2 6 2012
NO EXPOSURE CERTIFICATION Winston-Salem
Re Iona!office
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permi
on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notification that your facility does not require a
permit for 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.
For permitted facilities in North Carolina, DWO must approve your application for No
Exposure Certification before this exclusion is effective. Until you are issued a No
Exposure Certification and your NPDES permit is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
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 products that would be mobilized in
stormwater 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,you
certify that a condition of no exposure exists at this facility or site and are obligated to comply with the
terms and conditions of 40 CFR 122.26(g).
.You are required to self re-certify your No Exposure Exclusion annually.
For questions,please contact the DWQ Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing address of owner/operator(address to which all certification corresl2ondence will be mailed):
Name TIMCG
Contact TlwrCy Zr,-62 vslt s e- :5cfsya- A M.ri�Y
Street Address -5,568
City State AlC- ZIP Code ,-71o7
Telephone No. o/,;.Z Fax:
Email
Do
Pagel of 7 JAN 1 9 2012
DENR•WATER QUALITY
SWU-NE-12Aug2010 Vern E)SANDSTORMWATERWMCH
3 36 - 570-S`{3�

r '
NCGNE0000 No Exposure Certification
2) Location of facility producing discharge:
Facility Name _77r-Mef D S
Facility Contact rc_S
Facility Street Address 5 6 8 r
City L✓rr s-lJo� sc.I-e State tiG ZIP Code 2 7/U -7
C
County 0"v; .S0 w
Telephone No. 33G %, - o/a Fax:
Email 1orC{1vs 1 c.5_e +1 McA - C.
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). - +c.kY In rnMO1 SvIII-e IiE!a�
-{urrt /VP er40 4'—V'Vd rr e2
(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 -56 '0/ 'a'� Longitude oao'09 'SS (deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
KExisting Date operation began
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit?XYes D No
If yes, what is the NPDES Permit Number? Ve_-6r'/✓ 6
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 9
10) Provide a brief description of the types of industrial activities and products produced at this facility:
��/nGO GSS�mh/t3 6"-C cAl _Srs.-lJJ.v and a77g-Lerior ►_621v--f5 . I-Aj5 1,,k e,;Is,,
COrl�v<� /�svr.ri�- an� !-<✓rlyd�+HT, dvi� /c�f7orc,.:>'rJi'1/ '7'+Sf'lv.4 �urr�i�n�r -ram. /�.i' YI.T� SYw�S-
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
_KNo
0 Yes
If yes, list the permit numbers for all current Non-Discharge permits for this facility:
D
Page 2 of 7
SWU-NE-12Aug2010

NCGNE0000 No Exposure Certification
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 lko
c. Materials or products from past industrial activity ❑ Yes -1 (No
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes VNo
e. Materials or products during loading/unloading or transporting activities ❑ Yes )�No
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes *No
use [e.g., new cars]where exposure to stormwater does not result in the discharge
of pollutants)
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 )(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 Ao
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes _XNo
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 �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 )<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.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, or X'es ❑ No ❑ NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No VNIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
�h� ovrlY lts7'� /vCh.T-iC �vfs�clr Geri *'ter /�yr/•c� /"r�,-�,�rw hh� c�a y,.. �-
r Y y v r t r CcGO n 41.-ti/ GIrH-�s�1 ft e"rYs 4.
Page 3 of 7
5W U-NE-12Aug2010

NCGNE0000 No Exposure Certification
14) Secondary Containment: If you answer "No"to any of the following items, you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for all single above ground storage ❑ Yes ❑ No X N/A
containers (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 N/A
in close proximity to each other with a combined capacity of more than 1,320-
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund ❑ Yes ❑ No N/A
Amendments and Reauthorization Act (SARA) water priority chemicals'?
d. Is secondary containment provided for hazardous substances" designated in 40 ❑ Yes ❑ No 9N/A
CFR §116?
e. Are release valves on all secondary containment structures locked? ElYes ❑ No WN/A
T/ir �alcr�r j �pr5 1?ovG (i!(�xarGaUS Sch5r(us?c�3 �U TG /4 d-e 7f1�/
$-e4Ir! SS �.:a.//vr� Cr✓vvr,s ��Ck'{Y� !u 7(i�rnr+a�l[ /GG/ li�j. AlD
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes XNo
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes 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/disposal vendor:
Vendor address:
Footnotes to Questions 14) c. &d.
`Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFR
§372.38.
"'Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR §117.3.
Page 4 of 7
SW U-NE-12Aug2010

NCGNE0000 No Exposure Certification
16) Other information: If you answer"Yes"to any of the following items,you might not be eligible for the
no exposure exclusion. A more in-depth evaluation of the site circumstances may be required.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes XNo
b. Does your facility have coal piles on site? ❑ Yes VNo
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes XNo
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity(e.g., kes ❑ No
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity: A -e M%Ssiow5 crRorl-
e. If you answered yes to d., are those emissions permitted by an Air Quality Permit? ❑ Yes )No ❑ NIA
Pleasespecify: 6Jr cc.:_ rh. -thr Q�'&r'c55 of r�crr✓ivy c._ ZY-e p
��oc` -Trb m_ MG f},r Qvc.li
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
5WU-NE-12Aug2010

NCGNE0000 No Exposure Certification
17) 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 annually self re-certify No Exposure and, if requested, submit the re-certification to
DWQ or 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.
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:
l 2Dl�
ignature of Applicant) 67 (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 anytime in the future for compliance with the No Exposure Exclusion.
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.
Page 6 of 7
SWU-NE-12Aug2010

6568 Gumtree Road, Winston-Salem, NC - Google Maps Page 1 of 1
To see all the details that are visible on the
Gooste. screen,use the"Print"link next to the map.
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NCGNEOOQQ No Exposure Certification
Final Checklist
This application should include the following items:
.ems This completed application and all supporting documentation.
-e— A map with the location of the facility clearly marked.
.sue If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
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 Re Tonal Office Contact Information:
Asheville Office ...... [phone] wnsron•sata
Fayetteville Office ... [phone] of gh
Mooresville Office ... [phone]
Raleigh Office ........ [phone] 1 S 'tie to
,
Washington Office ...[phone] oa.
Wilmington Office ... [phone] .►
Winston-Salem ...... [phone] p vitloj
Central Office .........[phone] .' f
jI ngton
Page 7 of 7
5W U-NE-12Aug2010

e•
O� Michael F.Ensrey,Covemor
1O� �QQG William 0.Ross Jr.,Secr<Iary
North Carollna Dcpatiment of Vnvironment nad Natural Rescurces
0) ram' Alan IV.Klimck.P.EL Olrector
>• y Division of Water Quality,
0 Coleen H.Sullins,Deputy Director
Division of Water Quality
February 24,2006
Mr. [fenny Yarboro
Tyco Electronics
PO Box 3608
Harrisburg,PA 17105
Subject: No Exposure Certification NCGNE0261
Tyco Electronics
5568 Gumtree Road,Winston-Salem,NC
Davidson County
Dear Mr. Yarboro:
The Dlvlslon has revlewed your submittal of the No-Exposure Certification for Exclusion from NPDES
Stormwater PermIlting form, which we received on November 2,2005, Based on your submittal and signed
certification of no exposure at the above referenced facility, the Division is granting your certification as
provided for under 40 CFR 126.22(g),which Is Incorporated by reference in North Carolina regulations.
i .
Please note that by our acceptance of your no exposure certHioatlon,you are obligated to maintain no
exposure conditions at your facility. If conditlons 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 stormwator
discharge. Otherwlse, the discharge becomes subject to enforcement as an un-parmitted discharge. Your
condlllonal no-exposure exclusion expires in We years(February 1,2011). At that lime you must recertify
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, exi.
502, or at sarah.young®nemall.net.
Sincerely, 0 g OWE
JAN x 9 2012
for Alan W.Klimek, P.E. DEAR-WATER QUALITY
WETLANDS AND STORF,%ATER BRANCH
co: Winston-Salem Regional Office Central Files—w/altachments
Stormwater Permil(ing Unit Files
tlL!?Ef1R
N.C.Division of IYater Quality 1617 Mail Service Center Raleigh,North Carolina 27699-1617 [phone] Customerservico
1-877.623-6749

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Form Approved
United States Environmental ProiectionAgency D1AB.4o.2040-0211
NPRES Washlnpton,DC 20460
FORM ®'+�® Nq EXPOSURE CERTIFICATION for Exclusion from
3510-11
NPDES Storm Water Aermftting
Submission of this No Exposure Cordficalion constitutes rolice that the entity Identified In Section A does not require permit authodlallan far Its storm watar
discharges associatedwllh Industrial activity In the Slate Identified In Section B under EPA's Storm Water Multi-$ector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists al an Industrial facllily vrhen all industrial materials and ectivltlas are protected by a storm resislant shaper to prevent
exposure to rafn,snow,snovrmott,and/or runoff. Industrial materlafs or activities Include,but are not limited to,material handling equipment or activities,
Industrial machinery,raw materials,Intermadlale products,by-products,final products,orwaste products. Material handlingac(Nitiss include the storage,
loading and unloading,transportation,or conveyance of any raw material,intermediate product,final product or wasta product. A storm resistant shelter is
nol required for the fallowinglndustrlalmaterials and activities:
— drums,barrels,lanka,and similar containers that are tightly sealed,provfdad these containers are not deledorated and do not teak. 'Seated'
meens banded or othenvlse secured and%,Alhout operaltonal laps or valves;
— adequately maintained vehicles used In material handling;and
— final products,other than products that would be mobilized In stwm water discharges(o,g.,rock salt),
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addlrfon,tho exclusion Pram NPDES permitting Is
available on a facllily-wide basis only,not for Individual outfalfs. If any Industrial activities or materials Oro or will be exposed to precipitation,The faclllly is
not eliglbte for the no exposure exclusion.
By signing and submitting this No Exposure CortlQcatIoN form,the enlity In Section A Is certifying that a condition of no exposure exists at fla facility or slta,
and Is obllgated to comply with the terms and conditions of 40 CFR 122.20(g).
ALL INFORMATfON MUST BE PROVIDED ON THIS FORM.
Detailed Instructions for completing this form and obtaining the no exposure exclusion aro provided on pages 3 and 4.
A. Facflltyoporattorfnforniatlon f
1.Name: M I�IOI f0f/ikiCfr)RtdilJl�LCt•<t_ _t_ I_I I l I A I I-- I I I 12.Phone: 17t1-1��1 1$�LS1�IylllLil
3.Melling Address: a.Street 0 g
bxv.. INt/Q_PRALSVse rIL6i I I I I I I I _I I I I I o.s(ato: 1f)161 d.Zip Code: Ilf7I/l15i—I, f 1 I 1
B. FacllltylSlte Locatlon lnformattan
t.Facility Nance: frlYit 1011 FILE le-I Loa01N1-Llr-ESl_L I I I I t_1__1 1`1 t I I
2.a.street Address: I��.Si¢Idf _i I I I I 1 l._.1_L_L I I l i I
b.City; '1511114 191011 1 1 1 1 1 1 1 1 1 1 a.County: Ua lA INl�ri)t S to lNr I I
d.State: �� a.Zip Codo: E21-2I J IO 171—I, I 1 f I
3.Is the fad9ty located on Indian Lands? Yes❑ No
4.Is this a Federal facilty? Yes❑ No
5,a.LaWdda; 0,6 j*n•J 'rjr•J, b.Longilude: "Lf
6.a.Was the radlily or site prevfcusly covered underan NPDES storm seater permit? Yes ❑ No
b.If yes,enter NPD€S permil number:
7.SICIAcllvlty Codes: Primary: 1.16 ., Secondary
(If applicable):
8.Total size of slto associated vdth Industrial activity: cep,? acres
9,a.Have you paved at roofed over a foretsfly exposed•pervious area In order to qualify for the no exposure exclusion? Yes No 01
b. If yes,please Indicate approximately how much area was paved or rcofed over. Completing this question does not disqualify you for the no exposure
exclusion. However,your permitting authority may use this informaLten In considering whelher storm wafer disoharges from your silo are likely to have
an adverse Impact on water quallty,in whfch arse you could be required to obtain permit coverage.
Less than one acre ® Oita to five acres ❑ More Ihan five acres ❑
EPA Form 3510-11(10.99) Pago t of 4
f
i
I

P
pbEs t, NO EXPOSURE CERTI>=ICATION for Exclusion from Form Approved
FORM w6i0-A Of+iB No.20A0 02t1
s1o•11NPDES Storm Wafer Permitting
Exposure Checklist
Are any of the following materials or activities exposed to preclpflation,now or in the(are seeable future?
(Please check elther'Yes'or'No'In the appropriate box.) If you answer"Yes"to any of those questions
(1)Through(11),you are not,eilgibio(ortite no exposure exclusion,
Yes No
1. Using,storing or cleaning industrial machinary or equipment,and areas where residuals from using,storing
or cloanln9 industrial machinery or equipment remold and are exposed to storm water
2. Materials or roskluels on the ground or In storm water inlets from spidsfieaks O
3. Materials or products from past Industrial activity ❑ 19
4. Material hend2ng equipment(except adequately maintained vehfclas)
6. Materials or products during loadinglun!oading or transporting activities d 0
0. Materials or products stared outdoors(except final products intended far euWde use(e.g.,new cars)where
exposure to storm water does not result In the discharge of pollutants)
7. Materials contained In open,delerforated or leaking storage drums,barrels,tanks,and similar containers ❑
8; Materlals or products handled/stored on roads or ralWays owned or matnlalned by the discharger El El
9. Waste matodat(except%vasto In covered,non-ieakfng containers(e.g.,dumpsters)). �]
t0. Application or disposal of process wastsvraier(unless otherwise permitted) ❑ Ej
11, Parilculate matter or visible deposits of residuals from roof slacts andlor vents not otherwise regulated ❑ 0
(I.o.,under an air quality control permit)and evident in the storm water outflow
D. Certification Statement
I certify under penalty of late that I have read and understand the eliglbiiity requirements for claiming a condition of'no exposure'and oblaining an
exclusion from NPDES storm water permitting. j
I certify under penalty of law that there are no discharges of storm water conlaminated by exposure to industrial acNAUes or materials from the IndustrlaI
facility or site Identified in this document(except as alloyed under 40 CFR 122.20(g)(2)).
I understand that I am obligated to submit a no exposure carilifoalfon form once ovary 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
alloy the NPDES permitting authority,or MS4 operatorwhare the discharge is info the focal MS4,to perform Inspections to cenffrm 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 vrater from the facility.
Additionally,I certify under penally of Isvr that this document and aft attachments Ylero prepared under my direction or supervision In accordance with a
system designed to assura that qualified personnel property gathered and evafuatod 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. l am aware that there are sfgntffcant pena;lles for submitting false Informallon,lnetuding the possibility
of fine and Imprisonment for
I1r knowing violations.
Print Name;1811CiNiPlJr� idle.19 1oIRt0Fl,1 I I I I ..I I t I I I 1 i ..I..II ,1 I i f I
PrintTitle: 101AIFI1'rIA17-1-TOIA-.:l 14111`V'1OI&I-CIRI I i i i I I I I I I t 1 1 .1
5fgnalure:
U
Data:
i
EPA Form 3510.11(10-99) Page 2 of 4
I
i

NIDESFORM Instructions for the NO EXPOSURE CERTIFICATION for Form Approved
36�0 i1 EPA 0618 No.2Q40.0211
Excluslon from NPDES Storm Water Permitting
Who May File a No Exposure Certification Seellon B, FacllitylSlto Loeatlan Information
Federal We at 40 CFR Pail 122.26 prohibits point source dischargos or 1.Enter the ofNlal or legal name of the facility or site.
storm water associaled with industrial scilvity to waters of the U.S.withoul
a National Podulant Dischargs E6minalion System(NPDES)perrKL Ho6vever, 2, Enter the oomp!oto street address(if no street address exists,provide
NPDES permit coverage Is riot required for discharges of storm water a geographlc dasarfpuon(e.g.,intersection of Routes 9 end 551),city,
Modeled with industrial activities Identified at 40 CFR 122.26(b)(14)(1)• county,state,and zip code. Do not use a P.O.Box number.
(ix)and(xI)If the dlschargor can certify Iliat a condition o('no exposure'
exists a[the tndustrlel facility or site. 3. Indicate whether the facility Is located on Indian Lands.
Storm water d1scharga3 from conslrucllon acilvfllas Identified in 40 CFR 4. Indicate whether the industrial facUlly is operated by a department or
122.26(b)(14)(x)and(b)(16)are not eligible for the no exposure exclusion, agency of the Federal Government(see also Seellon 313 of the Clean
1M1aterAct),
Obtaining and Maintaining the No Exposure Exclusion 6. Enter the fatliuds and longltudo of tho approximate comer of rho facility
This form Is used to car Illy that a concillionof no exposure exists at the or site In degreesfminutoslseconds. Latitude and longitude can
Industrial fact4ty or site described hereln.Thls cerU6cagan Is only applicable be obtained from United Slates Goofogtcaf Survey(USGS)quadrangle
in)urisdtclfons where EPA Is the NPDES perm[tUng 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 hltp./Mmv.epa.govlawrnlsvr/fndustrvAndox.htm and
selecting Latitude and Longliuda Finders under the SosaurceslParmll
Thu industrial facility operator must maintain a condfllon of no exposure at ssctien.
Its faGrilyorsile In order for the no exposure exclusion to remain applicable. Llfld
If conciXons change resulirn aue and longitude far a facility In decimal lam must be converted
g In the exposure of materials and activiies to
storm water,the fadlity operator must obtain coverage under an NPDES to degrees ('), minutes('),and seconds(")for proper entry on
storm water permil Immedtetely. the certification form. To convert decimal IaMude or longitude to-
degreealminuleslseconds,follow the steps In the following example.
Where to File the No Exposure Certification Form Example: Convert decimal tadlude 45,1234567 to degrees('),minutes
Moil the completed no exposure certiftwtton form to.' (`),and seconds
a) The numbers to the Ieft of the dedmat point are the degrees: 4V.
Storm Water No Exposure CerUgestlon(4203)
USEPA b)To obtain minutes,multiply the first four numbers to the right of the
401 M Street,SW dedmal point by 0.008: 1234 x 0,008 u 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: 71.
Completing the Form
d)To obtain seconds,multiply the remaining three numbers to the
You must type or print,using uppercase loiters,In appropriate areas only. right of the decimal from the resull obtained in (b)by 0.06:
Enter-only one character par space(Le.,boNmen the marks).Abbreviate 404 x 0.06-24.24. Since the numbers to the right of the decimal
it necessary to slay Wthln the number of characters allowed for each from. point are not used,the result Is 24.
Use one space for breaks batwoen words. One form must be completed for each facility or site for whkh you are seeking to terrify a condition of no a)The conversion for 45.1234507.45s 7' 24'.
exposure. Additional guidance on completing this form can be accessed through EPA's wab site at iWepa.govfotvmisw. Please make sure you 8. Indicate whether the fa was previously covered under an NPDES
er
have addressed all apptic&e questions and have mods a photocopy for storm orator her t cl8ty If so,Include the permit number,
your records before sending the completed form to the above address, 7. Enter the 4-digi1 SIC coda which Identifies the facility's primary activity,
and second 4-41gll SIC code identifying the faculty's secondary activity,
Section A. Facility Operator Information ll applicable, SIC codes can be obtained from the Standard industrial
1. Provide the legal Hants of the parson,firm,pubtia aganlzallon,or any Classlftcatlon Manual,1987,
other entity that operales the fadrity or silo described to this cortlftcallan. a. Enter the total size of the site associated with industrial achMty 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 43,660,as
the facility. 'rho aparotor Is the legal ondly[hat controls the facility s demonstrated in the following exompla.
operation,rather than the plant or site manager.
� rL1a
2. Pfov[de the telephone numberof the facility operator. Exam : Convert 54,450 A2 to acres
Divide 54,450 ft2 by 43.660 square toot per acre:
3. Provide the mailing address of the operator(P.O.Box numbers may be 64,450 ft2.43,560 1l2facre-1.26 saes.
used). Include the city,state,and zip coda. All correspondence will
be sent to this address. 0.Chad('Yes'or'Ne as appropriate to Indicata whether you have paved
or roofed over a formerly exposed,pervious area(L4.,lawn,meadow,
did or gravel roadlpo rktng lot)In order to qualify for no exposure. If yas,
also indicate approximately how much area was paved or roofed over
and is now Imperv[ous area.
EPA Form 35 10-11(10-99) Page 3 of 4
. i
s
- i

NPDESFORM �, inMructlons for the NO EXPOSURE CERTIFICATION for Form Approved
3540.1 ���EPA OMB No,2040-0211
Exclusion from NPCES Storm Water Permitting
Socllon C. Exposure Checkllst outhorlty to sign documents has been assigned or delegated to
the manager in accordance with corporate procedures;
Check'Yee or'No'as appropriate to describe the exposure conditions at
your fad:ily, if you answer'You'la ANY of the quostions(1)through(11) For a partnership or solo proprietorship: by a genarei partner ar the
In this sactlon,a potential for exposure exists at your site and you cannot proprlatag or
certify to a condition of no exposure. You must obtain(or already have)
coverage under an NPDES alorm water permit. After oblalning permit For a muntdpal,Stale,Federal,or other public fadlity: by ellhor a
coverage,you can Institute modlacatlons to eliminate the potential for a principal executive ei ranking elected official.
discharge of storm water exposed to Industrfel activity,and then certify to
a condition of no exposure. Paperwork Reduction Act Notice -
Section D, Certification Statement Public reporting burden for this cerfff eallon Is estimated to average 1.0 hour
per certificaOon.including time,far rsvrawing instructions,searching existing
Federal statutes provldo for severe penaldas for submllling false Information data sources,gathering and malntainrng the data needed,and completing
on this applIc2tton form. Federal regulations requlre this application to be and revla%Vng the collection of information. Burden means the total Ifine,
signed as fellrvs; effort,at financial resources expanded by persons to generate.maintain,
retain,or disclose to provide Information to or for a Federal agency. This
For a corporarlon: by a responsible corporate officer,which means: Includes the time needed to review lnstrucifens;develop,acqulro,Install,.
and uOrize technology and systems for the purposes of coflactlrg,vaWating,
(I) president,secretary,treasurer,orvlce-presfdentof the m9miallon and verifying Information,processing and maintainingfnformallon,and
In charge or a principal business runction,or any other person disclosing end provfdIng informa0on;adjust the existIng ways to comptywith
who performs slmltar policy or deck?on making functions for the any previously applicable Instrutllons and requirements;Iraln personnel to
corparallon,or be able to respond to a collection of Information;search data sources;
complete and review,the collection of information:and transmit or otherwise
(0) the manager of one or more manufacturing,produclion,ar disclose the Information.An agency may not conduct or sponsor.and a
operating facliltios,provided the manager Is authorized to make parson is not required to respond to,a collecllon of informatlon unfess It
management dectsrons which govern the operation of the displays a curronliy valid OMB control number,Send comments regarding
regulated facility Including having the explicit or Implicit duty of the burdon estimate,any other aspect of the collection of information,or
malting ma)orcaphar Inveslmant recommendations,and Initiallng suggestions for improving this form.Including any suggestions which may i
and drracgng other comprehansivo measures to assure long Increase or reduce this burden to: 01raclor,OPPE Reguiatory rnfarmallon f
term environmental compliance vrith environmental laws and Division(2137).UUPA,401 M Street,SW,Washington,D.C.20460.
reguraWns:the manager can ensuro that the necessary systems include the OMB control number of this form an any correspondence. Do,
are esleb7shedoracirons taken to gather complete and accurate not send the completed Ho Exposure CsrtiRcallcn form to this address.
information for permit application requlrements;and where
EPA Form 3510.11(10.99) Page 4 of 4
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