3510-11 No Exposure Certification for Exclusion from EPA's

P roposed 2020 MSGP Appendix K – No Exposure Certification Form

NOTE: EPA proposes the text in this Appendix as part of the Proposed 2020 MSGP.

Proposed Appendix K - No Exposure Certification Form

Part 7.1 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your No Exposure Certification (NEC) form. However, if you are given a waiver by the EPA Regional Office to use a paper NEC form, and you elect to use it, you must complete and submit the following form.

NPDES FORM 3510-11

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460

NO EXPOSURE CERTIFICATION (NOE) FOR EXCLUSION FROM EPA’S MULTI-SECTOR GENERAL PERMIT FOR

STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY (MSGP)

OMB No. 2040-NEW

Submission of this No Exposure Certification constitutes notice that the operator identified in Section C does not require permit authorization under EPA’s Stormwater Multi Sector General Permit for its stormwater discharges associated with industrial activity from the facility identified in Section D of this form 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 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 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 operator in Section C 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).

1. Approval to Use Paper NOE Form

1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*? YES NO

If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:

Waiver granted: The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as under-served for broadband Internet access in the most recent report from the Federal Communications Commission.

The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that granted the waiver:

Date approval obtained: / /

* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOE form. If you have not obtained a waiver, you must file this form electronically using the NPDES eReporting Tool (NeT) at https://www.epa.gov/npdes/stormwater-discharges-industrial-activities

2. Reason for Submission

Select the purpose for filling out this form (check only 1).

To obtain a new No Exposure Certification. Fill in Sections C, D, E and F.

To discontinue an existing No Exposure Certification. Select this option if you would like to discontinue an existing No Exposure Certification because your facility is no longer subject to regulation under 40 CFR 122.26 (e.g., the facility has ceased the industrial activity that necessitated the No Exposure Certification)*. Provide the following information and fill out Section G.

Provide the existing NPDES ID for the No Exposure Certification that you would like to discontinue:

* Note that if your facility no longer qualifies for the No Exposure Certification because permit coverage is required for exposed industrial materials or activities, you should not check this box, and must instead file for coverage under the Multi-Sector General Permit or an individual permit. Your No Exposure Certification will be automatically discontinued after you obtain coverage under the MSGP or an individual permit.

3. Facility Operator Information

1. Operator Name:

2. Mailing Address Street:

City: State: ZIP Code: -

3. Phone:

4. E-mail:

- - Ext.

5. Operator Point of Contact Information:

First Name, Middle Initial, Last Name:

Title:

D. Facility Information

1. Facility Name:

2. Facility Address:

Street/Location:

City:

State:

ZIP Code:

-

County or Similar Government Subdivision:

3. Latitude/Longitude for the facility:

Latitude:

. _ _ ° N (decimal degrees)

Longitude:

_ . _ _ ° W (decimal degrees)

Latitude/Longitude Data Source: Map GPS Other:

If you used a USGS topographic map, what was the scale?

Horizontal Reference Datum: NAD 27 NAD 83 WGS 84

4. Is your project/site located on Indian country lands? YES NO

If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable):

5. Are you a “federal operator” as defined in Appendix A? YES NO

6. What is the ownership type of the facility? Federal Facility (U.S. Government) Privately Owned Facility Municipality

County Government Corporation State Government Tribal Government School District

District Mixed Ownership (e.g. Public/Private) Municipal or Water District

7. Have stormwater discharges from your facility been covered previously under an NPDES permit? YES NO

If yes, provide the NPDES ID if you had coverage under EPA’s MSGP or the NPDES permit number if you had coverage under an EPA individual permit:

8. Has your facility previously been covered by a No Exposure exclusion? YES NO

If yes, provide the NPDES ID for your previous No Exposure exclusion:

9. Identify the 4-digit Standard Industrial Classification (SIC) code or 2-letter Activity Code that best represents the products produced or services rendered for which your facility is primarily engaged, as defined in MSGP:

Primary SIC Code:

OR

Primary Activity Code

10. Total size of site associated with industrial activity: (to the nearest quarter acre)

11. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? YES NO

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 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 than one (1) acre One (1) to five (5) acres More than five (5) acres

E. 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, you are not eligible for the no exposure exclusion.

Yes

No

Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing or cleaning industrial machinery or equipment remain and are exposed to stormwater

Materials or residuals on the ground or in stormwater inlets from spills/leaks

Materials or products from past industrial activity

Material handling equipment (except adequately maintained vehicles)

Materials or products during loading/unloading or transporting activities

Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where exposure to stormwater does not result in the discharge of pollutants)

Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers

Materials or products handled/stored on roads or railways owned or maintained by the discharger

Waste material (except waste in covered, non-leaking containers [e.g., dumpsters])

Application or disposal of process wastewater (unless otherwise permitted)

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 stormwater outflow

F. Certification Information

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. I 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 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 stormwater 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.

First Name, Middle Initial, Last Name:

Title:

Signature:

Date:

/

/

E-mail:

G. Discontinuation of No Exposure Certification Information

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.

First Name, Middle Initial, Last Name:

Title:

Signature:

Date:

/

/

E-mail:

Instructions for Completing EPA Form 3510-11 No Exposure Certification (NOE) for Exclusion from Stormwater Discharges Associated with Industrial Activity Under an NPDES General Permit Proposed NPDES Form Date (01/20) Expiration Date (##/##) This Form Replaces From 3510-11 (06/15) OMB No. 2040-NEW

Who May File a No Exposure Certification Federal law at 40 CFR Part 122.26 prohibits point source discharges of stormwater associated with industrial activity to waters of the U.S. without a National Pollutant Discharge Elimination System (NPDES) permit. However, NPDES permit coverage is not required for discharges of stormwater associated with industrial activities identified at 40 CFR 122.26(b)(14)(i)-(ix) and (xi) if the discharger can certify that a condition of “no exposure” exists at the industrial facility or site. Stormwater discharges from construction activities identified in 40 CFR 122.26(b)(14)(x) and (b)(15) are not eligible for the no exposure exclusion. Obtaining and Maintaining the No Exposure Exclusion This form is used to certify that a condition of no exposure exists at the industrial facility or site described herein. This certification is only applicable in jurisdictions where EPA is the NPDES permitting authority and must be re-submitted at least once every five years. The industrial facility operator must maintain a condition of no exposure at its facility or site in order for the no exposure exclusion to remain applicable. If conditions change resulting in the exposure of materials and activities to stormwater, the facility operator must obtain coverage under an NPDES stormwater permit immediately. Completing the Form You must type or print, using uppercase letters, in appropriate areas only. Enter only one character per space (i.e., between the marks). Abbreviate if necessary to stay within the number of characters allowed for each item. Use one space for breaks between words. One form must be completed for each facility or site for which you are seeking to certify a condition of no exposure. Please make sure you have addressed all applicable questions and have made a photocopy for your records before sending the completed form to the above address. Section A. Approval to Use Paper NOE Form You must indicate whether you have been granted a waiver from electronic reporting from the EPA Regional Office. Note that you are not authorized to use this paper No Exposure Certification (NOE) form unless the EPA Regional Office has approved its use. Where you have obtained approval to use this form, indicate the waiver that you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date that approval was provided. See https://www.epa.gov/npdes/contact-us-stormwater for a list of EPA Regional Office contacts. Section B. Reason for Submission You must check your reason for submitting this form. You may submit this form for obtaining a new No Exposure Certification, for renewing a previous No Exposure Certification, or for discontinuing an existing No Exposure Certification (for facilities that no longer need the exclusion from permit coverage for industrial stormwater discharges). Section C. Facility Operator Information Provide the legal name of the person, firm, public organization, or any other entity that operates the facility described in this certification form. An operator of a facility is the legal entity that controls the operation of the facility. Refer to Appendix A of the

MSGP for the definition of “operator”. Provide the operator’s mailing address, phone number, and e-mail. Correspondence for the NOE will be sent to this address. Also provide the name and title for the operator point of contact (note that the point of contact name may be the same as the operator name). Section D. Facility Information Enter the official or legal name and complete street address, including city, state, ZIP code, and county or similar government subdivision of the facility. If the facility lacks a street address, indicate the general location of the facility (e.g., Intersection of State Highways 61 and 34). Complete facility information must be provided for permit coverage to be granted. Provide the latitude and longitude of your facility in decimal degrees format. The latitude and longitude of your facility can be determined in several different ways, including through the use of global positioning system (GPS) receivers and U.S. Geological Survey (U.S.G.S.) topographic or quadrangle maps. Refer to http://transition.fcc.gov/mb/audio/bickel/DDDMMSS- decimal.html/ for assistance in providing the proper latitude/longitude format. For consistency, EPA requests that measurements be taken form the approximate center of the facility. Specify which method you used to determine latitude and longitude. If a U.S.G.S. topographic map is used, specify the scale of the map used. Enter the horizontal reference datum for your latitude and longitude. The horizontal reference datum used on USGS topographic maps is shown on the bottom left corner of USGS topographic maps; it is also available for GPS receivers. Indicate whether the facility is on Indian country lands, and if so, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable). Indicate whether you are a “federal operator” as defined in Appendix A of the MSGP. Also check the facility’s ownership type. Indicate whether the facility was previously covered under an NPDES stormwater permit. If so, include the NPDES ID (i.e., NOI tracking number). List the four-digit Standard Industrial Classification (SIC) code or two character activity code that best describes the primary industrial activities performed by your facility. Enter the total size of the site associated with industrial activity in acres. Check “Yes” or “No” as appropriate to indicate whether you have paved or roofed over a formerly exposed, pervious area (i.e., lawn, meadow, dirt or gravel road/parking lot) in order to qualify for no exposure. If yes, also indicate approximately how much area was paved or roofed over and is now impervious area.

Instructions for Completing EPA Form 3510-11 No Exposure Certification (NOE) for Exclusion from Stormwater Discharges Associated with Industrial Activity Under an NPDES General Permit Proposed NPDES Form Date (01/20) Expiration Date (##/##) This Form Replaces From 3510-11 (06/15) Form OMB No. 2040-NEW

Section E. Exposure Checklist Check “Yes” or “No” as appropriate to describe the exposure condition at your facility. If you answer “Yes” to ANY of the questions in this section, a potential for exposure exists at your site and you cannot certify to a condition of no exposure. You must obtain (or already have) coverage under an NPDES stormwater permit. After obtaining permit coverage, you can institute modifications to eliminate the potential for a discharge of stormwater exposed to industrial activity, and then certify to a condition of no exposure. Section F and G. Certification Information The NOE form must be signed as follows: For a corporation: By a responsible corporate officer. For the purpose of this Section, a responsible corporate officer means: a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively; or For a municipality, state, federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this Part, a principal executive officer of a federal agency includes (i) the chief executive officer of the agency, or a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrator of EPA). Include the name and title of the person signing the form and the date of signing. Include the name, title, and email address of the person signing the form and the date of signing. An unsigned or undated NOE certification will not be considered valid. Paperwork Reduction Act Notice Public reporting burden for this certification is estimated to average 0.75 hour per certification, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose to provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and

disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate, any other aspect of the collection of information, or suggestions for improving this form, including any suggestions which may increase or reduce this burden to: Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number of this form on any correspondence. Do not send the completed No Exposure Certification form to this address. Submitting Your Form If you have been granted a waiver from your Regional Office to submit a paper No Exposure Certification form, you must send your No Exposure Certification form by mail to one of the following addresses: For Regular U.S. Mail Delivery: Stormwater Notice Processing Center Mail Code 4203M, ATTN: MSGP No Exposure U.S. EPA 1200 Pennsylvania Avenue, NW Washington, DC 20460 For Overnight/Express Mail Delivery: Stormwater Notice Processing Center William Jefferson Clinton East Building - Room 7420 ATTN: MSGP No Exposure U.S. EPA 1201 Constitution Avenue, NW Washington, DC 20004 Visit this website for instructions on how to submit electronically: https://www.epa.gov/npdes/stormwater-discharges-industrial-activities

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