NO EXPOSURE CERTIFICATIO
N FOR EXCLUSION FROM NPDES STORM-
WATER PERMITTING (PAGE 1 OF
F 2)
£
es
i
NPDES UniTeD STATES ENVIRONMENTAL PROTECTION AGENCY Ferm Approved
FORM & WASHINGTON, DC 20460 OMB No. 2040-0211
3510-11 “ey No EXPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORMWATER
PERMITTING
Submission of this No Exposure Certification constitutes notice that the entily identified in Section A does not require permit authorization for its
stormwater discharges asanclated with industial activity In the State Wentified in Section B under EPA's Stormwater Multi Sector General Permit
due to the existence of a condition of no exposure.
& condition of no exposure exiets at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to
__| prevent exposure fo rain, snow. snowmelt, and/or runoff. Industral materials or activities include, but are nol 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 end unloading, transporiation, or conveyance of any raw material, intermediate product, final product or waste product.
Astorm resistant sheller is not required for the following industrial materials and activitlas:
— drums, berels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak, “Seaiad”
maans 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 stormwater discharges fe.g., rock sak)
A No Exposure Cerilfication must be provided for each facility qualifying for the na exposure exclusion. In addition, the exclusion from NPDES
permitting is available on a facility-wide basis only, not for individual outfalie. If any industrial activities or materials are er will be exposed to
precipitation, tha facility is not eligible for the no exposure exclusion.
By signing and submitiing this No Exposure Cerllfcation form, tha entity in Section A is carlifying that a candition of no exposure existe at its facility
of site, and is obligated to comply with the terms and conditions of 40 CFR 122. 28g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed Insiructions far compieting this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A Facility Operator Information
Name Wlulilvleletslaldl {Wlelelyclilnjal brlelel lal ol/fe lo lng. Prone [elols| -lzist4| - [311 alo]
aemat [plolr| th lols|é lelul nl vlelrisbal/[rlelelylel fel rs). below
4.Mating dtross: a. steat (Alsfals| [Ble{sJoliit] Wivlel LLL I LILI LL LEIS
vere [glalaelsil ill LL ETL L LLL LI) oom Wid «zoo: bplalstdg-L LLL
8. Facility/Site Location information
s-recviy ware: dll Wvlelelstal/| [elelelveltb'lnlg elelal dol /lol ab els| | I |
za.smectadéress: [6l/| Ilabdelellel'lal/| Mlalal ale LILLE ELT ELE
vow: Blofdel LILI L LLL LELLL LL EL) som bitelettibeleld [LLL TTT LL
a.state: |yjj] Zipcode: 2] 3] 912 LLU
3, Is the factity located on Indian Lands? =] YES BJ xno
4.18 this a Federal facility? [3 ves dq no
5, a. Latitude: wish tll Wal b, Longitude: {. frle is] Lt
6. a. Was the facility or site previously cavered under an NPOES stormwater permit? oO YES & NO
b. if yes, enter NPDES permit number or tracking number:
/ Secondary
7. SiC/Actlvity Codes Primary: sole 3| (if applicable}: Litt
8. Total size of site associated with industral activity: HO acres
8. a. Have you paved or roofed over a formerly exposed, pervious aree in order to qualify fer the no exposure exclusion? CJ ves RO
b. If yes, please indicate approximately haw much area was paved oF roafed aver. Completing this question dees not disqualily you for the no
exposure exclusion. Hawaver, your permitting authority may use this information in considering whether stormwater 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 thanone acre [_] One te five acree [] More than five acres [7]
EPA Form 3510-11 (09-08) Page 1 of 4
URT NEW HAMPSHIRE AUDIT PacKeT = GENIN
