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Home My Public Portal AboutCity of Woodson TerraceMISSOURI DEPARTMENT OF NATURAL RESOURCES WATER PROTECTION PROGRAM NO EXPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORMWATER PERM ITTING UNDER MISSOURI CLEAN WATER LAW PLEA SE READ ALL THE ACCOMPANYING INSTRUCTIONS BEFORE COMPLETING THIS FORM. SUBMITTA L OF AN INCOMPLETE FORM MAY RESULT IN THE FORM BEING RETURNED UNPROCESSED . Submission of this No Exposure Certification (NEC) constitutes notice by the facility representative identified in Section 7 of this form that there is no expo sure of the facility's industrial activities, equipment and materials to stormwater in accordance with the requirements of 10 CSR 20-6.200 Stormwater Regulations. 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 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 (including recyclable) 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: • Storage of 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. • Final products, other than products that would be mobilized in stormwater discharges (e.g., rock salt). A NEC must be provided for each facility qualifying for the no exposure exclusion. In addition, the certification of 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, or if the facility discharges any effluent other than stormwater to waters of the state, the facility is not eligible for the no exposure exclusion. By signing and submitting this NEC, the facility representative in Section 7 certifies that a condition of no exposure exists at their facility or site, and is obligated to comply with the terms and conditions of 40 CFR 122.26(g). 1. FACILITY FACILITY NAME 7 / /- 14 /5 L L L i✓v-2 S �iZ..:a'v?./1 t-- TELEPHONE ,//''NUMBER WITH AREA CODE 317— Li 27 '2 k p ADDRESS (PHYSICAL LOCATION) -/6-e--/,a-rk a2v CITY Wo ods,„0 -,__ ;24<c COUNTY S.I • Loa_ r5 STATE v',"1, c . ZIP CODE L; 3 1 3`-f- 1.2 PLEASE SELECT ONE: Era. This facility is now in operation under for renewal No Exposure Certification MO- for a new No Exposure Certification Missouri State Operating Permit permit. plant with a design flow equal approved pretreatment system NXe03' 1 and is submitting a certification . a new NEC, per day or a (for a new facility) . MO - , is requesting b. This is a facility submitting a request c. This facility is now in operation under to or greater than 1.0 million gallons and is requesting a NEC . and wishes to terminate existing operating d. This facility is a wastewater treatment treatment plant required to have an 2. OWNER NA ME �L. EMAIL ADDRESS TELEPHONE NUMBER WITH AREA CODE ADDRESS (MAILING) CITY STATE ZIP CODE 3. CONTINUING AUTHORITY, N AME \/ EMAIL ADDRESS TELEPHONE NUMBER WITH AREA CODE ADDRESS (MAILING) CITY STATE ZIP CODE 4. FACILITY CONTACT NAME �Z., vl / Z TELEPHONE NU MBER WITH AREA CODE 31,-4- 3-',3 ._/ SL 6 2 - TITLE Li 1 ---et d- 7,v „,c,r_S -7,2 .....r,—, EMAIL ADDRESS 7z4r Ze La;:)5C��-P7r2,4-c� , ND C.' 780-2828 (08-19) 5. ADDITIONAL INFORMATION 5. 1 Does the discharge(s) for which you are seeking an exclusion discharge to a combined sewer system? ri Yes [ 7No If yes, provide the name of the combined sewer system entity 5. 2 Does the discharge(§Lfor which you are seeking an exclusion discharge through a M unicipal Separate Storm Sewer System (MS4)?ILI Yes _ No If yes, provide the name of the MS4 entity bni D /4 )00 3 (:),-,) 5. 3 Primary SIC Code of Facility Other SIC Codes (Optional) Primary NAICS Code of Facility 5.4 Provide an attached list of any materials that are stored outside and exposed to stormwater including wood pallets, empty storage barrels, waste disposal containers (except for a secured covered dumpster). Materials other than final product such as raw material or by-product of your industrial activities that can be mobilized by stormwater do not qualify for no exposure exclusion. 5. 5 Attach a 1:1,000 aerial photograph (preferred) or USGS topographic map showing the location of the facility . Indicate on the map the facility, the property boundaries of the facility, the receiving water body, any septic tanks/lateral lines, stormwater basins, the location of items stored outside and all outfall locations. 5. 6 Is the facility causing an adverse impact on water quality due to major changes at the site to achieve no exposure? For example, pnstructing new buildings/shelters or constructing structures to prevent run-on in a formerly vegetated area . Yes No If yes, please indicate approximately how much area was paved or roofed over . The department may use this information in considering whether stormwater discharges from your site are likely to have an adverse impact on water quality, in which you could be required to obtain permit coverage for land disturbance activities . I I Less than 1 acre El 1 to 5 acres More than 5 acres 6. NO EXPOSURE CERTIFICATION CHECKLIST The purpose of this checklist is to 1) help you determine whether the exposure of industrial activities, materials, or equipment to stormwater has been eliminated at the facility, and 2) help department staff evaluate the adequacy of your compliance activities and NEC. For the purpose of this checklist, " outdoors" are areas of the facility that are not beneath permanent roofed structures where stormwater cannot run into or out of. Are any of the following materials or activities exposed to precipitation or occurring on -site, now or in the foreseeable future? Please answer all questions by checking " Yes" or "No. " Using, storing, or cleaning industrial machinery or equipment, and areas where residuals from using, storing, ❑ Yes or cleaning industrial machinery or equipment remain and are exposed to stormwater . Materials or residuals on the ground or in stormwater inlets from spills or leaks. Yes M aterials or products from past industrial activity . ri Yes Material handling equipment (except adequately maintained vehicles) . Yes Materials or products during loading/unloading or transporting activities . 0 Yes Materials or products stored outdoors (except final products intended for outside use [e .g ., new cars] where n Yes exposure to stormwater does not result in the discharge of pollutants). Materials contained in open, deteriorated, or leaking storage drums, barrels, tanks, or similar containers. El Yes Materials or products handled/stored on r oads or railways owned or maintained by the facility . 0 Yes Waste Material (except waste in covered, non -leaking containers [e.g., dumpsters]). Yes On -site land application or discharge of wastewater . Yes Particulate matter or visible deposits or residuals from roof stacks or vents not otherwise regulated Yes (i.e ., under an air quality control permit) and evident in the stormwater outflow. If you answ ered "Yes" to any of these questi ons, y ou are not eligible for the no exposure exclusion . 780-2828 (08-19) �✓ No I No IV No No No No No 'No No E- No � No 7. 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. 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 M S4 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. NAM E (TYPE OR PRINT)) /G' /��iLf�s /--- ----- l--rCZ O FICIAL TITLE Ini �Gll�c-Lis i7W4ZCC, 2 EMAIL TELEPHONE NUMBER WITH AREA CODE i<-1- 3- 7 71( ).-- xZ 4 i'��(. vFSv 4t'�12/2. 4-cam,. A -)E I SIGNATURE ---DN DATE SIGNED 2/Z 7 2 780-2828 (08-19)