NCGNE0230_COMPLETE FILE - HISTORICAL_20140121

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

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NC®ENIR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM Pat McCrory, Govenor
Director John Skvada, III Secretary
January 21, 2014 RECEIVED
Chris Walker
Southern Graphic Systems, Inc.
P.O. Box 38069
Charlotte, NC 27278
Dear Mr. Walker:
JAN 21 2014
CENTRAL FILES
DWQIBOG
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCGNE0230
Southern Graphic Systems Inc., Charlotte Plant
Mecklenburg County
On June 20, 2013, the Division of Energy, Mineral and Land Resources received your request to rescind
Your coverage under Certificate of Coverage Number NCGNE0230. In accordance with your request,
Certificate of Coverage Number NCGNE0230 is rescinded effective immediately.
Operating a treatment facility, discharging wastewater or discharging specific types of stormwater to
waters of the State without valid coverage under an NPDES permit is against federal and state laws and
could result in fines. If something changes and your facility would again require stormwater or
wastewater discharge permit coverage, you should notify this office immediately. We will be happy to
assist you in assuring the proper permit coverage.
If the facility is in the process of being sold, you will be performing a public service if you would inform
the new or prospective owners of their potential need for NPDES permit coverage.
If you have questions about this matter, please contact Julie Ventaloro at 919-807-6370, or the
Stormwater staff in our Mooresville Regional Office at 704-663-1699.
Sincerely,
for Tracy E. Davis, P.B., CPM
cc: Mooresville Regional Office — Z. Khan
Stormwater Permitting Program
Central Files - w/attachments
Deborah Reese, DEMLR Budget Office - please waive applicable fees
Mecklenburg County DEP, Water Quality, 700 N. Tryon Street, Charlotte, NC 28202
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http:/Iportal.ncdenr.org/web/Irl
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

/Yl.o�s viu�
�' • . Division of Water Quality / Surface Water Protection
r
National Pollutant Discharge Elimination System
NCDENR
Nd7„CARD—A0EPARIMENT OF RESCISSION REQUEST FORM
t_p� MErvi — N6 UHAL RESO RCE5
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I J.. 1 1 N I C I G I N I E 1 0 2 FiE
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below,
Owner/Facility Name Southern Graphic Systems, Inc. Charlotte Plant
Facility Contact
Chris Walker
Street Address
P.0 Box 38069
City
Charlotte
County
Mecklenburg
Telephone No. 704-587-3899
a
State NC ZIP Code 27278
E-mail Address chris.walker@sgsin,tl;com
Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on August 1s', 2013** . All industrial activities have ceased such that no discharges
of stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to onary.n.r.. 1 . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other: *"Tentatively scheduled for closure on August 1 s', 2013. All is dependent on move in date
for new facility.
4) Certification:
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 accurate.
Signature Date
Print or type name of person signing above
Please return this completed rescission request form to
1617 Mail Service Center, Raleigh, North Caroilna 27699-1617
Location! 512 N. Saklsbury St. Raleigh, North Carolina 27604
Phone: [phone] i FAX: [phone] Customer Service: 1.877-623-6748
Internet: www ncwaterquality.org
An Equal Opportunilyl Affirmativ@AClior Employer
Title D .:
SW NPDES Permit Coverage Rescis ion
F
Stormwater Permitting Unit 13
1617 Mail Service Center i . I
Raleigh, North Carolina 27699-1617 •'
1NUFLIll_ U )l111it
Aatumll#

t
.t
SGS
SW NPDES Permit Coverage Rescission
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: closure status for NCGNE0230
To whom it may concern,
Southern Graphic Systems, LLC (SGS) currently operates three facilities in North Carolina and is planning
to consolidate these operations into one new location in the Greensboro/High Point, North Carolina
area. Enclosed please find paperwork for the closure of the SGS Charlotte plant which is tentatively
scheduled to close around August 1", 2013. The address for the SGS Charlotte plant is as follows:
SGS Charlotte
9201-A Forsyth Park Drive
Charlotte, NC 28273
Please let me know immediately if you have questions about the paperwork or if you need additional
information.
Sincerely,
tom'
Chris Walker
Plant Manager

���
NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
Land Quality Section
Tracy E. Davis, PE, CPM
Director
January 21, 2014
Chris Walker
Southern Graphic Systems, Inc.
11.0. Box 38069
Charlotte, NC 27278
Pat McCrory, Govenor
John Skvarla, III Secretary
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCGNE0230
Southern Graphic Systems Inc., Charlotte Plant
Mecklenburg County
Dear Mr. Walker:
On June 20, 2013, the Division of Energy, Mineral and Land Resources received your request to rescind
your coverage under Certificate of Coverage Number NCGNE0230. In accordance with your request,
Certificate of Coverage Number NCGNE0230 is rescinded effective immediately.
Operating a treatment facility, discharging wastewater or discharging specific types of stormwater to
waters of the State without valid coverage under an NPDES permit is against federal and state laws and
could result in fines. If something changes and your facility would again require stormwater or
wastewater discharge permit coverage, you should notify this office immediately. We will be happy to
assist you in assuring the proper permit coverage.
If the facility is in the process of being sold, you will be performing a public service if you would inform
the new or prospective owners of their potential need for NPDES permit coverage.
If you have questions about this matter, please contact Julie Ventaloro at 919-807-6370, or the
Stormwater staff in our Mooresville Regional Office at 704-663-1699.
Sincerely,
ORIGINAL. SIGNED B)
KEN PICKLE
for Tracy E. Davis, P.E., CPM
cc: Mooresville Regional Office—Z. Khan
Stormwater Permitting Prograrn
Central Files - w/attachments
Deborah Reese, DEMLR Budget Office - please waive applicable fees
Mecklenburg County DEP, Water Quality, 700 N. Tryon Street, Charlotte, NC 28202
1612 Mail Service Center, Raleigh, North Carolina 27699-1612.919-707-92001 FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 - Internet: htt :11 ortal.ncdenr.or /web(r!
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

Ventaloro, Julie
From:
Schweiber, Erich
.Sent:
Tuesday, January 21, 2014 8:25 AM
To:
Ventaloro, Julie
Cc:
Khan, Zahid
Subject:
Rescissons
Follow Up Flag:
Follow up
Flag Status:
Flagged
Southern Graphic Systems / NCGNE 0230 / may be rescinded, I looked at this site, It is closed for business, and no
materials or anything of that nature are on the site.
Also
Rea Contracting Sand Pit 130 / NCG020719 may be rescinded as well, I spoke with Donna Wood on this she confirmed
the duplication permit, so this one can be closed.
thanks
NCDENR
Erich Schweiber - [e-mail]
Division of Energy, Mineral, and Land Resources
North Carolina Dept. of Environment & Natural Resources
Land Resources Division
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Ph: [phone] Fax: (7C4) 663-6040
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.

Montafvo, Sheri A
From: Bou-ghazale, Samar
Sent: Thursday, July 18, 2013 3:09 PM
To: Montalvo, Sheri A
Subject: FW: Rescission request for NCGNE0230 - Southern Graphic Systems
Sheri,
Please note below the e-mail from Marcia Allocco regarding the subject site.
Thanks,
Samar
From: Allocco, Marcia
Sent: Monday, July 15, 2013 1:49 PM
To: Bou-ghazale, Samar
Subject: Rescission request for NCGNE0230 - Southern Graphic Systems
Samar,
I visited the site last Thursday (7/11) and they do qualify for No -Exposure (just 2 covered dumpsters out back).
However, the company will be manufacturing at this site until probably the end of August. I told them once they
shutdown to give you a call and then we can rescind the No -Exposure at that point.
Marcia
Marcia Allocco, MS - Environmental Chemist
NC Dept: of Env. & Natural Resources (NCDENR)
Division of Water Quality - Surface Water Protection Group
610 East Center Ave., Suite 301, Mooresville, NC 28115
Phone: [phone] Fax: [phone]
marcia.allocco(a)ncdenr.gov
www.ncwatercivality.org
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties unless the content is exempt by statute or other regulation.
y'
}'QS6'ss)n/-) o'�-h1

fit'0,7k (��
• Division of Water Quality 1 Surface Water Protection
National Pollutant Discharge Elimination System
AC®ENRN-111
ENOF
vOHMENTA10 NdUAAL RapCE] RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year Month Day
I
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C s N I C LG.J N I E 0 1 2 3 0 1
2) Owner/Facility Information: Final correspondence will be mailed to the address noted below j (!
Owner/Facility Name Southern Graphic Systems, Inc. Charlotte Plant SA9"�
r
Facility Contact Chris Walker
Street Address P.0 Box 38069
City Charlotte State NC . ZIP Code 27278
County Mecklenburg E-mail Address [e-mail]
Telephone No. 704-587-3899 Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on August ls', 2013"" . 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 appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:. "Tentatively scheduled for closure on August 1st, 2013. All is dependent on move in date
for new facility,
4) Certification:
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 accurate.
Signature ___ Date Cl
i s lit
Print or type name of person signing above
Please return this completed rescission request form to
1617 Mail Service Cenler, Raleigh, North Carolina 27699.1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] Y Customer Service: 1-877-623-6748
Inlernei: www.ncwalorquality.org
An Equal Qpporlu6ty'',• Affirmative Aclion Employe,
Title
SW NPDES Permit Coverage Re
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-
ion I 1
IAU !J 1
._i1SYJ a_11dkA�St IN®tZk �f&11CF1
1 N UI-LI1 Dial U111121
Aawralltl

SGS
SW NPDES Permit Coverage Rescission
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: closure status for NCGNE0230
To whom it may concern,
Southern Graphic Systems, LLC (SGS) currently operates three facilities in North Carolina and is planning
to consolidate these operations into one new location in the Greensboro/High Point, North Carolina
area. Enclosed please find paperwork forthe closure of the SGS Charlotte plant which is tentatively
scheduled to close around August 151, 2013. The address for the SGS Charlotte plant is as follows:
SGS Charlotte
9201-A Forsyth Park Drive
Charlotte, NC 28273
Please let me know immediately if you have questions about the paperwork or if you need additional
information.
Sincerely,
Chris Walker
Plant Manager
- .�A � � , � Y'4. �„ ;,,,�� .� � "•'•�f+-":t. � ��a; "'z1iN. ,, v.a w'Je%�`"F, `t "'env'"',_ 'h1:�i6�+�:�..�
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Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
UJ
Alan W. Klimek, 11. E. Director
Division of Water Quality
0
Coleen li. Sullins, Deputy Director
Division of Water Quality
June 22, 2005
Mr. Chris Walker
Alcoa
201 Isabella Street
Pittsburgh, PA 15212-5858
Subject: No Exposure Certification NCGNE0230
Southern Graphic Systems
9201 A Forsyth Park Drive
Mecklenburg County
Dear Mr. Walker:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on April 14, 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.
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 Sarah Young at [phone], ext.
502, or at [e-mail].
cc: Mooresville Regional Office
Stormwater Permitting Unit Files
Sincerely,
for Alan W. Klimek, P.E.
Central Files — w/attachments ;
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
NODE NR
Customer Service
1-877-623-6748

A Michael F. Easley, Governor
`OHO RpG William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
0 Coleen H. Sullins, Deputy Director
Division of Water Quality
June 22, 2005
Mr. Chris Walker
Alcoa
201 Isabella Street
Pittsburgh, PA 15212-5858
Subject: No Exposure Certification NCGNE0230
Southern Graphic Systems
9201 A Forsyth Park Drive
Mecklenburg County
Dear Mr. Walker:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on April 14, 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.
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.
It you have any questions or need further information, please contact Sarah Young at [phone], ext.
502, or'at [e-mail].
- - • ..1
Sincerely,
ORJG1NAL SIGNED BY
BRADLEY SENNETT
for ' -Alan W-Klimek; `P:E
cc: Mooresville Regional Office Central Files - w/attachments
Stormwater Permitting Unit Files �
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
�Ah
NCDENR
Customer Service
1.877-623-6748

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Re: [I"wd: no -exposures]
CC�N� Sub,lect: Re: [Fwd: no -exposures] 3E)
From: Michael Parker <[e-mail]>
Date: Mon, 20 Jun 2005 14:04:52 -0400
To: Sarah Young <[e-mail]>
Sarah,
Feel free to issue the no exposure certifications for these two facilities.
Michael
Rex Gleason wrote:
Mike,
Is this something you would handle? If so, please reply.
Thanks,
Rex
Subject:
no -exposures
From:
sarah young <[e-mail]>
Date:
Thu, 16 Jun 2005 14:47:09 -0400
To:
Rex Gleason <[e-mail]>
To:
Rex Gleason <[e-mail]>
Hi Rex -
I have two no -exposure applications in for your region, and I was wondering if it
was ok to issue these certifications. I have scanned them and attached them to
this email. If you are not the contact person for this, please forward it to the
appropriate person. I will now be handling these for the SH2O group, and I am
trying to develop a process. If I have not heard from you within 30 days, and will
assume that it is ok to issue. Thanks, Sarah Young
Michael Parker - [e-mail]
Environmental Engineer II
North Carolina Dept. of Environment & Natural Resources
Division of Water Quality
610 East Center Avenue
Suite 301
Mooresville, NC 28115
Ph: [phone] Fax: [phone]
I of 1 6/20/2005 2:23 PM

D n roe t d,
United States Environmental Protection Agency Form Approved
g Y OMB No. 2040-021 1
NPDES Washington, DC 20460
EPA
FORM ` r;
3511J-11 NO EXPOSURE CERTIFICATION for Exclusion from
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities include the storage,
loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product. A storm resistant shelter is
not required for the following industrial materials and activities:
- drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational taps or valves;
- adequately maintained vehicles used in material handling; and
- final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual outfalls. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detalied instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information
1. Name: A L cio, Al 1 I _ I 4_ I l _I I _t I I. I I L 1_ 1 _I..1I 1 I 12. Phone: 0_1I lz I SIS I� I �l5-Y I,- I
3, Mailing Address: a. Street: IE P 1 1 4 1 f 1 S I A l e i 61 L I L I .A I L, I I 4 I I, I I l I I
b.laiy: ��i1iTt�lsiQi�iRt�?if�t 1 I L 1 1 1 i 1 1 1 1 1 c.State: �� d.ZipCode: 151211 IL1-151�1511S1
B. FacilitylSfte Location Information
1. Facility Name: p Iolullt t16lel rinl I F1�tP1ht_t_�_tsl $1-+��i a1_% I t 1 t __) J
2. a. Street Address: IULAILF D C i -V_L�u -LbAtRA4i2 1 t/ E
b. City: It!10 A I Lit) 177iT 115 L I I„ 1 I I _I I I I I I 11 I c. County: I& I C I +-1 I I I I I I
d. State: IN IC-1e, Zip Code: IZ 1712. t-7131- 1 I t 1 I
3. Is the facility located on Indian Lands? Yes ❑ Nov
4. Is this a Federal facility? Yes ❑ No
5. a. Latitude: Iy b. Longitude: F lot I 11 I
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes ❑ No
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: Zj7 i9 1(;21 Secondary (if applicable): I I t I I
8. Total size of site associated with industrial activity: _� A acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes ❑ No k
b. If yes, please indicate approximately how much area was paved or rooted 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 ❑
(a5
EPA Form 3510.11 { 10-99) Page 1 of 4

i
NPDES Form Approved
FORM .EPA NO EXPOSURE CERTIFICATION for Exclusion from OMB No. 2040-0211
3510-11 NPDES Storm Water Permitting
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) If you answer "Yes" to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion,
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing
El
jal
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
❑
K
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during load inglunloading or transporting activities
6. Materials or products stored outdoors (except final products intended for outside use je,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 ID;
8. Materials or products handled'stored on roads or railways owned or maintained by the discharger
9. Waste material (except waste in covered, non -leaking containers (e.g., dumpstersl)
EJ
Z
10. Application or disposal of process wastewater (unless otherwise permitted)
Ej
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
ElIX
�X
I
(i.e., under an air quality control permit) and evident in the storm water outflow
`"�'
D. Certification Statement
t certify under penalty of law that l 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 an 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 penaltios for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name: 1� t n 1 1z I f I,5 I 1�v A1 L. I V I F i& f f f I I I I I I I_ I I I I„I I,l ! I 1]
PrintTitie: LI ILLIiATl
Signature:
Date:
EPA Form 3510-1 1 (10-99) Page 2 of 4