NCGNE0115_COMPLETE FILE - HISTORICAL_20180329

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
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DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
YYYYMMDD

�'� • Division of Energy, Mineral & Land Resources
nand Quality Section/Stormwater Permitting Program
NCDENRNational Pollutant Discharge Elimination System
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Eem Nntw u b NOU RESP C�
RESCISSION REQUEST FORM
A'aPfi) �/ LF'111
7L�d
FORA ENCY USE ONLY
Date Received
Year I Month Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. P, 0, Boy ! �0
1) Enter the permit number to which this request applies: LQ rj rn�
Individual Permit (or) Certificate of Coverage
N I C I 5 I I I I I I N C G E r
2) Owner/Facility Informa
Owner/Facility Na
Facility Contact
* Final correspondence will be mailed to the address noted below
e.Y-h kv" f FZCMI 711k e 3 en466
Street Address
City Le r-"D ; f State
County L E-mail Address
Telephone No. 2 Fax:
ZIP
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on f __� . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to on . If the facility will continue operations under the new owner it
may be more ap
J4 Other:
4) Certification:
to request ap ownership change to reissue to permit to the new owner.
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accu e.
P
Signature 66
Date
Af> t7' o VVI
Print or type name of person signing above Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
RECEIVED
Raleigh, North Carolina 27699-1612
FEB 08 2013
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
DENR LAND QUALITY
Phone: [phone] FAX: [phone]
S,ToRMWATER PERMITTING
An Equal Opportunity 1 Affirmative Action Employer

O�OF W Ar�9p�i Michael Ross
Jy, Governor
William G., Ross r., Secretary
North Carolina Department of Environment and Natural Resources
� q
r Nan W. Klimek, P. F. Director
Division or Watcr Quality
Q ^� Culecn IL Sullins, Deputy Director
Division or Water Quality
April 20, 2005
Joseph Riddle
Joseph Riddle
PO Box 740
Lenoir, NC 28645
Subject: No Exposure Certification NCGNE0115
Bernhardt Furniture Company - 904 Virginia St
Caldwell County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on November 13, 2001. We apologize for the extended
period it has taken us to get back to you on this request and we appreciate your patience as we have worked
through this process. Based on your submittal and signed certification of no exposure at the above referenced
facility the Division is granting your certification as provided for under 40 CFR 126.22(g) which is incorporated
by reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (April 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Asheville Regional Office Central Files — wlattachments
Stormwater Permitting Unit Files V
NCDENR
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone] Customer Service
1-977-623-6748

NPDES
AEPA
FORM
3510-11
,8#
United States Environmental Protection Agency
Washington, DC 20460
NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
Form Approved
OMB No, 2040-0211
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
f
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activi ios,
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
nit required for the following industrial materials and activities:
- drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational laps or valves;
- adequately maintained vehicles used in material handling; and
- final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual oulfalls. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed Instructions for completing this farm and obtaining the no exposure exclusion are provided on pages 3 and 4.
Facility Operator Information
1. Name: JJ )C�L - Il ! 1 1(�LLFJ I I I I I i i I I I I I I I I I l i 12• Phone: 1810. fa!Z i SI�1I `i31 S I
3, Mailing Address: a. Street: JQ Q I I[1 OI I Ii 10 11 1 1 1 1 1 1 1 1 1 1 1 1 1, 1 1 1 1# _I I f
b. City: [LL El_Wl Q1 I I E 1 1 1 1 1 1 1 1 1 1 1 1 1- I I I c. State: I N j C� d. Zip Code, I A lRa 14 to- I, I I I I
a Facility/Slte Location Information
1. Facility Name: IEI.RJ�IKli�1Q,�QLTi lFl oiA lwi I ITIU 12JE1 IC101M A erlNI `4 1 I I
2. a. Street Address: E?IOIAI IVIII-0,401111INILIALISIT-1
b, city: IL I �i W o i l I Rl I I I I, „I_�1_._i—L-.I—_1 I I I I I I c. County, IC_I A-1 L IOI WIl
f
t-l-1
d. State: IN fZ- I e. Zip Code: 1AjR61415-1- I I I I
3, Is the facility located on Indian Lands? Yes ❑ No 2
+ `
,I
" 4. is this a Federal facility? Yes ❑ No
m F
15. a. Latitude: ff�j5J ICI I b. Longitude: I 19,
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No
l b. If yes, enter NPDES permit number:
7. SICIAclivily Codes: Primary: , Secondary (if applicable): t ' � 1
� t i 8. Total size of site associated with industrial act it�y crest W�
cam
J
9. a, Have you paved or roofed over a formerly exposed, pervious area in order to quality for the no exposure exclusion?
Yes ❑ . No Ll
' b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre • ❑ One to five acres ❑ More than five acres ❑
EPA' Form 3510-11 (10-99) Page 1 of 4

NPDES
FORM
351D-11
A NO NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
Form Approved
QMB No. 2040-0211
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
❑
d
or cleaning industrial machinery or equipment remain and are exposed to storm water
2. Materials or residuals on the ground or in storm water inlets from spills/leaks
3. Materials or products from past industrial activity
❑
d
4. Material handling equipment (except adequately maintained vehicles)
d
5. Materials or products during loading/unloading or transporting activities
o
d
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
exposure to storm water does not result in the discharge of pollutants)
7, Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
EJ
B. Materials or products handled/stored on roads or railways owned or maintained by the discharger
D
9. Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
F1[�
10. Application or disposal of process wastewater (unless otherwise permitted)
El
11, Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(i.e., under an air quality control permit) and evident in the storm water outflow
I
i
D. Certification Statement
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES storm water permitting.
I certify under penalty of law that there are no discharges of storm water contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, if requested, to
the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I understand that I must
allow the NPDES permitting authority, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water from the facility.
Additionally, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted, Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my
knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name: PQ`NU V i i I I I I I I I I I I I I _I 11 _1� I I I I J
I
j PrintTile: 10 1 1 V I 1 1 SI k 101 f) IPA *-IN I N coo- 7 I I I I I I I I I I I I 1 I I I
Signature:
Date: l _ l l _I 101610A I
EPA Form 3510-11 (10-99) Page 2 of 4