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Home My WebLink AboutNCG050277_MONITORING INFO_20120309March 8, 2012 Ron Boone Division of Water Quality 585 Waughtown Street Winston-Salem, NC 27107-2241 Subject Reply— Compliance Evaluation Inspection & Notice of Deficiency NPDES General Stormwater Permit NCG050000 Certificate of Coverage NCGOS0277 Hayward Industries Incorporated; Clemmons Plant Forsyth County Dear Mr Boone Following is Hayward's response to the above referenced Stormwater Permit Inspection conducted on February 9, 2012 All areas noted as deficiencies in the Documentation & Monitoring Review have been addressed The following is the status of each line item 1 Stormwater discharge outfalls (SDO) 001 and 002 have been added to the general location map with accurate latitudes and longitudes for each (SDO 00136 004636N 80 378314W, SDO 002 36 005022N 80 380081W) as required in Part II, Section A, Paragraph 1(a) of the general permit Site Plan attached Updated site plan to follow from Kale Engineering (Contact letter attached) 2 Kale Engineering contracted 3 Kale Engineering contracted 4 As per our conservation, there have been no spills in the last three (3) years so l have updated the snill list I have ahm :mnlPmPntPri a work nrdpr that will ha Ppnaraterl anniially ac nart of tha plan review (Form attached) 5 Signed rectified forms attached (Certification of Elimination of Non-Stormwater Discharges and Certification of Stormwater Pollution Prevention Plan) 6 Spill Prevention and Response Plan Emergency Contacts (attached) 7 Facilities personnel have been trained in the new procedure and provided forms that will be filled out, even if no deficiencies are found (Inspection form attached) 8 Facilities personnel have been retrained in the inspection process of outfalls 9 In agreement No action required 10 Pictures of added outfalls (3, 4, and 5) are attached Kale Engineering will review during site visit the passibility of additional SDO's QM forms have been generated and inspections have been put into placed as required (Forms attached) I will continue to be in contact with updates on items that are not presently complete S`ncerely, a e5 Kinney c :ties Manager P\ /e--DE-6) Q Table 3.2 List of Minor or Significant Spills or Leaks Date of Release Material Released Location Approximate Quantity Action Taken m Response to Spill of Material Released Unknown I lydrauhc Oil Dock Arca I ess than 2 gallons Pre,ssurc hose on dumpster truck ruptured spravnig livdraulic fluid on the ground around the dumpstei Spill was cleaned up by Waste Management NOTE Table 3 2 is to be revised as nccessan bN the facilm Nc -DEn, P, Table 3 3 NON-STORMWATER DISCHARGE INSPECTION FORM Name of Inspector _Jim Kinney Date Ol �— Title _Facilities Manager, Hayward Industries Uuttall HOW Color Odor Solids I-oam Outfaii Staining Observed Visible Sheens Observed -L Remarks Number Observed Observed Detected Observed Observed NC- E 0 ?-- STORMWATER DISCHARGE OUTFALL (SDO) QUALITATIVE MONITORING REPORT Certificate of Coverage No Facility Name County COA S Inspector Date of Inspection od JrLsir Phone No ) 7 «— By this signature, I certify that this report is accurate and complete to the best of my knowledge j . (algiruature vj rc 'rumcc ur �wa�rwc� r 1 Outfall Description Outfall No Structure (pipe, ditch, etc) E- Var Receiving Stream 2 :5;ec)�e 'C) Describe the industrial activities that occur within the outfall drainage area 2. Color _ - Describe the color of the discharge using basic colors (red, brown, blue, etc ) and tint (light, medium, dark) as descriptors 3 Odor Describe any distinct ordors that the discharge may have (i a smells strongly of oil, weak chlorine odor, etc ) 8/22/97 4. Clarity } Choose the number which best describes the clanty of the discharge where I is clear and 10 is very cloudy 1 2 3 4 5 6 7 8 9 10 5 Floating Solids Choose the number which best descnbes the amount of floating solids in the stormwater discharge where 1 is no solids and 10 is the surface covered in floating solids 1 2 3 4 5 6 7 8 9 10 6 Suspended Solids Choose the number which best describes the amount of suspended solids in the stormwater discharge where 1 is no solids and 10 is extemely muddy 1 2 3 4 5 6 7 8 9 10 7 Foam Is there any foam in the stormwater discharge) YES NO } 8 Oil Sheen Is there an oil sheen in the stormwater discharge) YES NO 9. Other Obvious Indicators of Stormwater Pollution - List and describe NOTE Low clarity, high solids and/or the presence of foam or oil sheens may be indicative of pollutant exposure These conditions may warrant further investigation 9/22/97 j1 (Z. I") e *4 (Z— STORMWATER DISCHARGE OUTFALL (SDO) QUALITATIVE MONITORING REPORT Certificate of Coverage No NCr r D 0020 _ ` Facility Name �� f4 �1 �3 C Phone No f ,4~ 6 4 County f < Inspector Date of Inspection s C By this signature, I certify that this report is accurate and complete to the best of my knowledge y (Signature of Permxnee or Designee) r 1. Outfall Description OutfalI No Structure (pipe, ditch, etc Receiving Stream 2e1 f : o� 6 C Describe the industrial activities that occur within the outfall drainage area 2. Color ,Describe the color of the discharge using basic colors (red, brown, blue, etc ) and tint (light, medium, dark) as descriptors 3. Odor Descnbe any distinct ordors that the discharge may have (i a smells strongly of oil, weak chlonne odor, etc ) 9/22197 4 Clarity Choose the number which best describes the clarity of the discharge where I is clear and 10 is very cloudy 1 2 3 4 S 6 7 8 9 10 5 Floating Solids Choose the number which best describes the amount of floating solids in the stormwater discharge where 1 is no solids and 10 is the surface covered in floating solids 1 2 3 4 5 6 7 8 9 10 6 Suspended Solids Choose the number which best describes the amount of suspended solids in the stormwater discharge where I is no solids and 10 is extemely muddy 1 2 3 4 S 6 7 8 9 10 7 Foam Is there any foam in the stormwater discharge? YES NO 8 Oil Sheen Is there an oil sheen in. the stormwater discharge? YES NO 9 Other Obvious Indicators of Stormwater Pollution: List and describe NOTE Low clarity, high solids andfor the presence of foam or oil sheens may be indicative of pollutant exposure These conditions may warrant further investigation 0 PI 11/n17 N)�bE0(*t" STORMWATER DISCHARGE OUTFALL (SDO) QUALITATIVE MONITORING REPORT Certificate of Coverage No NCr___Q 0 0 !� Facility Name iAiqV r k\n c• 4 -C 4 a U St Cc CS County Inspector Date of Inspection Phone No (M 7/ 61 220 CD1 By this signature, I certify that this report is accurate and complete to the best of my knowledge (Signature of Permirtee or Designee) I Outfall Description Outfall No Structure (pipe, ditch, etc) 0 4 & 1?051� Receiving Stream t i e r d u S e + K,•( -t qcp Descnbe the industna activities that occur within the outfall drainage area. 2. Color Descnbc the color of the discharge using basic colors (red, brown, blue, etc ) and tint (light, medtum, dark) as descriptors 3. Odor Describe any distinct ordors that the discharge may have (i a smells strongly of oil, weak chlorine odor, etc ) 8122/97 4 Clarity Choose the number which best describes the clarity of the discharge where l is clear and 10 is very cloudy 1 2 3 4 5 6 7 8 9 to 5 Floating Solids Choose the number which best describes the amount of floating solids in the stormwater discharge where 1 is no solids and 10 is the surface covered in floating solids 1 2 3 4 5 6 7 8 9 10 6 Suspended Solids Choose the number which best describes the amount of suspended solids in the stormwater discharge where L is no solids and 10 is extemel_y muddy 1 2 3 4 5 6 7 8 9 10 7 Foam Is there any foam in the stormwater discharge? YES NO 1 t R 8 Oil Sheets Is there an oil sheen in the stormwater discharge? YES NO 9 Other Obvious Indicators of Stortawater Pollution List and describe NOTE Low clarity, high solids and/or the presence of foam or oil sheens may be indicative of pollutant exposure These conditions may warrant further in v estigatio I i. 8/22/97 NC-bEf-i C>- Sanitary Water Sampling Tractor Station ..� Trailer .� Oren0 C4 jarking f a8 osan ooeI 1 BMP new j� ` Screen Swlmmin9 Compactor \� To Johnso `y Pool Location Creek 1 I[ Outfall A5 i\ Employee 3e omzxM+ i\ Parking __ Truck T.M. \eoa�ereew \ 1{ � BMP ff// � Shipping Flnishe l Team 03 BMP Re l.hod _ Flniallod Goods SPIII Prevention Equipment I.. Battery Chargers Spill Provertbn Equipment Employee Parking —I o° Manufacturing DIC Warehouse Area Down � R-ohing Down Employee Spout Finished Spom � Dada Te V— m _ Parking I Stream _ r _ ferfba From Root From Roof BMP \v 1 Ounall a2 Outfall pf x oosmz eaaeroa Ory �m'63bn BMi Crank Raw Sill Storage Matedal Str J o as c Potan I Pellets Spill Ar GENERAL NOTES IMPEftVt0U94RE4 C4LCULATONS 1 VC> E 9 (z- PROPERTY SURVEYS CONSI RUC[ ]ON SURVEYS DESIGN OF ROADS AND STRFETS WArER AND SF WAGF SYSI EMS SUBDIVISION PLANNING & 1 Al OUT Mr Jim Kinney Hayward Industries Inc One Haywood Industrial Drive Clemmons, NC 27012 KALE ENGINEERING 3530 Vest Mill Road WINS COIN SALEiNI N C 27103 336768 0250 email kaleenir0betlsouth net March 1 2012 MEMBERS OF 'NATIONAL SOCIETI OF PROFFSSIONA1 ENGINFFRS AMERICAN CONCiRH SS OF SURVEY[\(, AND DIAPPING Subject Confirmation of conli act for Kale Engineering to provide the necessary engineering services as required by the Compliance Evaluation Inspection and Notice of Deficiency from NCDENR References 1 Letter of Compliance Evaluation Inspection znd Notice of Deficiency letter from Mr Ron Boone of NCDE;NR dated 02/10/12 Copies of letter were made available to Kale Engineering by Mr Kinney 2 SPPP Site Plan prepared for Hayward for use in previous year s and made avail able to Kale Engineering by Mr Kinney 3 Telephone c.ory er5ation between Mr Kinney and Randall G Kale of Kale Engineering on Wednesday 02/29/12 during which it was agreed that Kale Lngineering would provide the subject services as noted below 4 Kale Engineering hourly i ates for professional sei vices Dear Mi Kinnev The purpose of this letter is to confirm and define the verbal contract between Hayward Industries Inc and Kale Engineering which was agreed to on Wednesday 02/29/12 Kale Engineering plans to provide the necessary services listed in the reference 1 letter which the clients are not equipped In do K-ile Engineering is able t0 begin providing these services immediately and will be ready to submit the reference 2 map to meet the subject stormwater requirements to NCDENR on or before March 10 2012 foi a fixed price of $ 1 300 It is our understanding that Kale Engineering will need to provide the services listed in thl, referenet, I leitei under items 1 2 3 and 10 The items listed under 4-9 art, being handled by the client Kale Engineering plans to u,e the information from the reference 2 map the Forsyth Count) iertal topogi aphtc maps and information that can be obtained from Village of Clemmons stormwater depai iment to prepare the reference 3 map with the necessary infoiniation to ineet these, requirements Kale Engineering will ..Sit the site to obScr.e the dr image ,tructurt,, on ri11 de.c,-;—.,,._ and provide the necessar y calculations and will prepare a new stormwater map Kale Engineering also proposes to piepare the NEC (No Exposure Certification) application and guide, the client through the approval process fhe NEC application is not listed in the 10 items however it is recommended by Mr Boone in an iriLmnt to <rmnlif� tha Vnrmu.atPr inanageme„, .,.cce« and le —en the long term cost for the owners Kale Engineei ring will be able to prepare the NEC apphclrion aftu Kale Engineering has completed the requirements listed in the subjc,et leitet Kale Engineei ing can prepare and submit the application after approval of the reference 1 letter has been received for a price of S 400 00 I his will be a total of S 1 700 to provide all of the sers ices listed above Should you htive need of services in addition to those listed above Kale Engineering will be able to provide them with the cost based upon the reference 4 rates for professional services or an agreed upon pi ice KALE ENGINEERING 3550 Veu Mill Road WLNSTON SALEAI A C 27103 PROPFRI Y SURVEYS V4F\1BERS OF CON,,] RUCt ]ON SURVFYS N At IONAL SOC II I Y OF DESIGN OF ROADS AM) SI RFETS PROFFSSIONAL F\GINEERS WAIFR AND SF -WAGE SYSTFVIS 336 7680250 AMFRICAN CO\GRFSS 01 SUBDPbISION Pt ANNING & t A)OL r email kaleeng@hellsouth net SURVFYING AND MAPPING Thank you for allowing Kale Engineering to provide these tier%ices If You have any questions o1 would like to make some re%upon,, to this contract please contact me b� phone or email to let me know It 1 do not hear from you within one week I will assume that the contract is accept tble Sincerely Randall G Kale P I P L S 0 C— 3( e �) k-- O-e vt 4e 01 '*�s CERTIFICATION OF STORMWATER POLLUTION PREVENTION PLAN "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 ensure that qualified personnel properly gather and evaluate the information submitted Based on my inquiry of the person(s) 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" Hayward Industries Inc Jim Kinney (Typed Name) (Signature) (Title) (Date) Page 24 / v`� i) E- 0 {� ke vice c> 5 } CERTIFICATION OF ELIMINATION OF NON-STORNWATER DISCHARGES "I certify under penalty of law that the outfall(s) covered under the Permit have been tested or evaluated for the presence of non -storm water discharges, and that any non-stormwater discharges identified in these outfalls(s) have been eliminated or covered by a separate NPDES Permit" Hayward Industries Inc Jim Kinney (Typed Name) (SiiWature) a�a3�oc� (Title) (Date) Page 25 KL,,q, _D E rJ 2. -. f�_ e V i e .� =w C Title 5 3 Emergency Contacts a Local Fire Department and/or HAZMAT 336-766-4114 b Local Police Department and Medical Services 336-727-8083 c Local and/or county environmental and public health services 336-703-3210 d Environmental clean-up contractors Geo-Tec 336-896-1300 e Environ Health 336-703-3225 f NC Division of Water Quality and 336-771-5000 g U S EPA National Response Center 1-800-424-8802 h Village of Clemmons 336-766-9170 Preventative Maintenance Inspection Form Na=of I4wAor L i l- - - ;- s tt+...,1'f.��-1... n wi�u}.•..t'�u'-.Lasr7"'i-�. ^ lw `w L?8►1� O[TIIS s,=„v. ,'.�«y "'�� ..:-r'�- � n�=:�x�....,zvu�:�Y• �r�^Y�� ,� sent '75�1 Yr.. t 2f-b'-ter Y "�ri��'f'�.ri�E"%"- t'- or rotennai problems << e. leaks, debrLs buildup and other sighs of potential poiiutionj Corrective actions necessary Follow-up on corrective actions c CN Work Order No 0062795 ��Close Date 12/30/2009 2/29/2012 9 22 54AM Page iflonommulu STORM WATLR POLLUTION PREVENTION PLAN PLAN REVIEW (AMENDMENT) Task No 99 SWPPPPR Request Date 1/12/2009 Tenant Request Time 07 20 30 Assigned By Originator Assigned To KINNLYJ Telephone No Scheduled Start Date 1/12/2009 00 00 00 Extension Scheduled Finish Date 1/12/2009 WO Type PM Perform by Warranty No Completion Date 6/11/2009 Priority 1 00 Completion Time 09 00 00 Expense Class POOL Craft Crew Size I stimatc,d Labor I loaf Equipment No Equipment Deseription I ocation Prod Line Station No Company ADM -I AC MAINT ADMINISI RAI ION - Item No Equipment No Description Qty Required Date Used Qty Used List extra Darts and comments here Emplo)te Code Equipment No Work Date, l irst Name Last Name Regular Hours Overtime, Hours Safety Notes iC. quipment No P.D;VI-[ PLC -IVIAI IN Task Instructions REVIEW TRAINING RECORDS AND ALL ANNUAL TASKS DOCUMENTATION INCLUDING STORM WATER MONITORING PREVENTIVE MAINTENANCE FORM, AND THE SWPPP PLAN FOR ANY NECESSARY CHANGES, UPDATE SPILL LIST PART 11 RE-CERTIFICATTON THAT STORMWATER OUTFALLS HAFE SEEN EVALUATED FOR THE PRESENCE OF NON-STORMWATER DISCHARGES COMPLETE NON- STORMWATER DISCHARGE INSPECTION FORM COMPLETED BY DATE f Do%ision of Water Quality / Surface Water Protection NCDENRNational pollutant Dv charge Elimination S}Ntcin NO EXPOSURI- CERTIFICATION torl-xclu-ton r n �+ •• n't NCGNEaoaa I OR V I Ni 5 11I ON-) Dill, It, i"J J TEEI rl1 1 it 1, 11! t( �L „ N �1tJJ._ NO EXPOSURE CERTIFICATION National Pollutant Discharge Elimination System application for exclusion from a stormwater Permit based on NO EXPOSURE Submission of this No Exposure Certification constitutes 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, snowmelf, 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 fallowing industrial materials and activities drums; barrels lanlrr anri Qimilar _on►sonars 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 bans only —not for individual outtalls if any industrial activities or materials are, or will be, exposed to precrpitation, 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) l Fur questiuirs, pieazw 4v114avi lire VVVW rivylunai Wince for your area (See page 6) (Please print or type) 1) Mailing address of owner/operator (address to which all certification correspondence will be malted Name H C, N4 42 12 r at _Zn dos f -Le-'5 Contact _ M r r a4 ,I t/ 7_� _ Street Address tri n,+ � o,� & :TK._ A u<;j± i —� _ /i r' Y� _— City ih rna r)'5 State MC ZIP Code SL . C Telephone No 3 36 7 j 2- - �Id1 Fax XF46 Email S _havLuNra7jo SWU NE 12Aug2010 Page 1 of 7 RECEIVED N C De, t of ENR DEC 3 12012 Winston Salem Regional Office_ D;= u 2 7 !pi? DENR - WATE OUA!_ITY J NCGNE0000 No Exposure Certification 2) Location of facility producing discharge Facility Name Facility Contact M/' S1_ yl�, Facility Street Address City Cle MOZOA-4 County Telephone No Email 7kitriteuea-ko 3) Physical location information Stale hjC _. ZIP Code _ -70 ram_ 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) Sr--SL "ttocj,vcj LjjjJ i N IF O.f-7 o ✓) S (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 *0 5) Is this a Federal facility9 ❑ Yes )if No 6) Latitude %'00 �30"N Longitude 90'Z . ' jq" (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 K Existing 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?^Yes 13 No If ves what is the NPDES Permit Number? hl t^ r O5O9!:)4Q 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 a a 10) Provide a brief descrip on of the types of industrial activities and products produced at this facility ► k :c,. . Nt<1 _ _�.IL rS 11) this facility have any Non -Discharge permits (ex recycle permits)9 z 0 Yes If yes list the permit numbers for all current Non Discharge permits for this facility SWU NE 12Aug2010 Page 2 of 7 NCGNE0000 No Exposure Certification "xpasure Checklists (12 - f 4 ) 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 M No residuals from using, storing or cleaning industrial machinery or equipment remain and are exposed to stormwater b Materials from Yes VNo or residuals on the ground or in stormwater inlets spills/leaks ❑ c Materials or products from past industrial activity ❑ Yes 2 No Material handling /NNo d equipment (except adequately maintained vehicles) ❑ Yes Materials during loadinglunloading e or products or transporting activities Yes 7No f Materials or products stored outdoors (except final products intended for outside u Yes use (e g new cars) where exposure to stormwater does not result in the discharge of pollutants) /No g Materials contained in open deteriorated or leaking storage drums barrels tanks Yes and similar containers h Materials or products handled/stored on roads or railways owned or maintained by r, Yes V40 the discharger i Waste material (except waste in covered non leaking containers (e g dumpstersj) ❑ Yes /No I Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes /No k Particulate matter or visible deposits of residuals from roof stacks and'or vents not ❑ Yes W' No otherwise regulated (i a under an air quality control permit) and evident in the stormwater outflow Empty containers that previously contained materials that are not property stored ❑ Yes ZNo (i a not closed and stored upside down to prevent precipitation accumulation) m For any exterior ASTs as well as drums, barrels tanks and similar containers C Yes � No stored outside has the facility had any releases in the meet throa (3) year9 13) Above Ground Storage Tanks (ASTs) H 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 0 Yes LiNo A A deterioration or evidence of leaks? b Is secondary containment provided for all exterior ASTO If so is it free of any ❑ Yes ❑ No bs NIA cracks holes or evidence of leaks and are drain valves maintained locked shut? Page 3 of 7 SWU 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 ,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 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 Amendments and Reauthorization Act (SARA) Vlater Qrigrily chemicals d Is secondary containment provided for hazardous substances" designated in 40 CFR §116? e Are release valves on all secondary containment structures locked? 15) Hazardous Waste a is this facility a Hazardous Waste Treatment, Storage or Disposal Facility? b Is this facility a Small Quantity Generator (less than 1000 kg of hazardous waste generated per month) of hazardous waste? c is this faciity a Large Quantity Generator (1000 kg or more of hazardous waste 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 ❑ Yes Il No V<A C Yes D No 5►]AVfA El Ye s =, N o VN, A �, Yes E No AA Yes /No -3 Yes V No J.. Ll Yes M NO *Note that amniints helow the 660 gallon (c�nnlal and 1 39n gallon Icnmh�nor41 hulk atnr�nn minimums ton urn secondary containment However some exceptions may be made for de minimis amounts of certain substances andlor other qualifiers as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFO §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 SWu NE 12Aug2010 + 0 NCGNE0000 No Exposure Certification 16j 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 eo a Does your facility store used recycled or otherwise reclaimed pallets outside? 3 Yes b Does your facility have coal piles on site? 3 Yes V�// c Does your facility store other fuel sources outside in piles such as wood chips u Yes V' O sawdust etc 7 ao d Does your facility have air emissions associated with its industrial activity (e g 2 Yes deareasina ooeralions Dlatino oaintina and meta_ I finshinall If so de_ s_crihe_ t_he_ industrial activity e If you answered yes to d are those emissions permitted by an Au Quality Permit? G Yes C No ❑ NfA Please specify f Please hsl any other e ._iron rental program. porrnit, (f-A—1 M,f— ate) riot 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 SWU NE 12Au92016 Page 5 of 7 All 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 f 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 Sell re -certify No Exposure and it requested submit the re corliflcation 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 erl2r to any -paint sourcf!&schafge of stormwater from the facility Additionally I certify under penalty of law that this document and oil aVachments were prepared i niter direction or s� pervisnor � „rdan „ti; ._ prep..._ _.. . my ...... ..,._ . ,,, �„w ,.,� .. 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 mformation 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 imorisonment for knowing violations I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief such Information is true complete and accurate f 'r Pnnted Name of Parcnn Sinninn �izli�Me_s tr�. ir`�� ey Title FQC % k% Vi t@ S M a Al C�4 e r rg ature of Applicant) (Date Srgned) 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 hiispeal Your r-dellrry of eery rlrrrC f!r [rres ruriirC rVr r,yrrrplrtince rlYilrl rite Na CxppSlliE CxG1uSlOn - North Carolina General Statute 143-215 6 B(i) provides that Any person who knowingly makes any false statement representation or certification in any appllcafion record report plan or other document filed or required to bo maintained under this Article or a cute implementing this Article or who knowingly makes a false statement of a matenal fact in a rulemaking proceeding or Contested case under this Article or vrho falsdies tampers with or Knowirgly renders inaccurate any recording or monitoring device or method requirod to bo operated or maintained under this Arliclo or n les of the (Environmental Management] Commtsslan implementing this Article shall be quilry of a Class 2 misdemeanor which may include a fine not to exceed tell thousa1-01 dollars (y1 V VVV) SWU NE 12Aug2010 There is currently no fee fora No Exposure Exclusion Page 6 of 7 NCGNEOOOO No Exposure Certification Final Checklt This application should include the following items G This completed application and all supporting documentation L_f H rTidiJ whir fire IVVdti[Jir of the raciuty clearly marked ❑ If the site currently has an NPD>_S Stormwater Permit, be sure to indicate the permit number in Question 8 Mail the entire package to Stormwater Permitting Unit Oivision 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 DWG Regional Office for your area DWQ Regional Office Contact Information_ Asheville Office (828) 296 4500 r_.._.._..u..r.u.,... rayaacviuc virwo mom boa Bann is rv) wJ� a.7vv Mooresville Office (704) 663 1699 Raleigh Office (919) 791 4200 4V C 11 Washington Office (252) 946 6481 Wilmington Office (910) 796 7215 Winston Salem (336) 771 5000 Central Office (919) 807 6300 f Page 7 of 7 SWU NE 12Aug2010