UNC1 NEE Self-Recertification Form.docx

Division of Energy, Mineral and Land Resources

Land Quality Section – Stormwater Permitting

National Pollutant Discharge Elimination System

ANNUAL NO EXPOSURE EXCLUSION SELF RE-CERTIFICATION

NCGNE0000

Do not submit this form to DEMLR unless requested.
For questions, please contact the DEMLR Regional Office for your area or the Central Office.
(Please print or type)
Facility’s No Exposure Exclusion No. Date Completed (MM/DD/YYYY)

N C G N E
/ /

1) Has the facility name or owner changed? Yes No
(if yes, please submit a separate Name/Ownership Change Form to DEMLR located at:
http://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-permits/npdes-
industrial-sw )
2) 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 to maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
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 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, Yes No
tanks, and similar containers
h. Materials or products handled/stored on roads or railways owned or maintained Yes No
by the discharger
i. Waste material (except waste in covered, non-leaking containers \[e.g., Yes No
dumpsters\])
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 Yes No
not otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
l. 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)
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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?
3) Above Ground Storage Tanks (ASTs): If you answer “No” to any of the following items, you are not
eligible to maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Are exterior ASTs and piping free of rust, damaged or weathered coating, pits, Yes No
or deterioration, or evidence of leaks? N/A
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 N/A
shut?
4) Secondary Containment: If you answer “No” to any of the following items, you are not eligible to
maintain your no exposure exclusion, and must immediately apply for a permit from DEMLR.
a. Is secondary containment provided for all single above ground storage Yes No
containers (including drums, barrels, etc.) with a capacity of more than 660-N/A
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-N/A
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund Yes No
Amendments and Reauthorization Act (SARA) water priority chemicals*? N/A
d. Is secondary containment provided for hazardous substances** designated in Yes No
40 CFR §116? N/A
e. Are release valves on all secondary containment structures locked? Yes No
N/A
Footnotes to Questions 4) 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.
5) Other information: If you answer “Yes” to any of the following items, and the answer if different from
how it was answered when originally applying, you might not be eligible to maintain your no exposure
exclusion. Please contact the Division if this is the case.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? Yes No
b. Does your facility have coal piles on site? Yes No
c. Does your facility store other fuel sources outside in piles, such as wood chips, Yes No
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., Yes No
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. If you answered yes to d., are those emissions permitted by an Air Quality Yes No
Permit? Please specify: N/A

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6) 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/maintaining 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 this re-certification to
DEMLR 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 provided. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information provided is to the best of my knowledge and belief true, accurate and complete. I am aware
that there are significant penalties for providing false information, including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this document and that to the best of my knowledge and belief
such information is true, complete, and accurate.

Printed Name of Person Signing:
Title:

_____________________________________________________ ___________
(Signature) (Date Signed)

Please note: The Regional Office may inspect your facility at any time 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).

This completed form must be kept on file at the facility for at least 5 years. Do not submit this
form to DEMLR unless requested.

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