NO EXPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORM-
BATCD OCDARITTING (DACE 9 RE
WATER PERMITTING (PAGE 2 OF 2)
BaVER O a Oi on fo -
C. Exposure Checkilst
Are any of the following materials or activilies exposed to precipitation, now or in the foreseeable future?
(Please check elther “Yes" or *No™ in the appropriate box.) If you answer “Yes” to any of these questions
(1} through (14), you are not eligible for the no axposure exclusion, Yes
4, Using, atoring or cleaning Industrial machinery or equipment, and aregs where residuals fram using, storing or claaning
industrial machinery or equipment remain and ate exposed to stormwater
2. Materiale or rasiiuats on the ground or in stormwater inlets from spilisHeaks
3, Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
ME fw we
5, Materials or products during leading/unloading or transporting activities
6, Materials or products stored outdoors {except final products intended for outside use (e.g., new care} where
exposure to stormwater does net reauit In the discharge of pollutants}
By
7. Materials contained in open, deteriorated or (eaking storage drums, barrels, tanks, and similar containers
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8. Materials or products handled/atored on roade or railways owned cr mainteined by the discharger
9. Waste material (except waste in covared, non leaking containers [¢.9., dumpsiers))
40, Application or disposal of process wastewater (unless otherwise pennitted)
HDoooo onnese
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41, Particulate matter or visible deposits of residuals from roof stacks and/or vents not otharwise reguiated
the., under an alr quality contro! permit} and evident in the stormwater oulfiow
o
. Certification Statement
t certify under panalty of law that 1 have read and understand the eligibility requirements for claiming a condition of "na expogure” and obtaining
an exclusion from NPDES stormwater permitting.
| certify under penalty of faw that there are no discharges of stormwater contaminated by exposure to Industrial activities or materials fron the
induetriat facility or site identified in this document (except as allowed under 40 CFR 122.28(9}2)).
| understand thal | am obligated to submit a no exposure certificatlon form ance 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). |
understand that | must allow the NPDES permitting authority, or MS4 operster where the discharge Is into the local MS4, to perform Inspections
to confirms the condition of no exposure and to make such inspect ports publicly ileble upon request. | und d that i must obtaln
covarage under an NPDES permit prior to any point source discharge of stormwater from the facility,
Additionally, | certify under penalty of law that this document and ail attachments were prepared under my direction or supervision in accordance
with @ system designed to assure that qualified peracnnel properly gathered and evaluated the information submitted. Based on my ingulty of the
person or persons whe manage tha system, or those persons directly rasponsible for gathering the information, the Information submitted Is to
ihe best of my knowledge and bellef true, accurate and complete. | am uware that there are significant penalties for submitting false information,
including the possibilily of fine and Imprisenment for knowing vioiations.
rantwame: ALlall| folvlolulstele] LLL LL LLL ELT LIT
pant vite: feluls| foltrlelelHolml | LILI LILLIE EAT ET
PAGES
Signature:
Date: joist (sl e|/(2lof. is}
Mio Day Year
erat: Iplelelilobols| i tdlulalyIvle| ns lal/|etelel felletr{s]-Lelela |
EPA Form 3510-14 (09-08) Page 2 of 4
URT: NEW HAMPSHIRE AUDIT PACKET GIST
