02-23-2004 Council Packet - Laserfiche WebLink

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No Expofiijrc? Exclusion from NPDLS 1. Wa» the site or faelllty previously covered ur>der an NPDES storm water permit? If yes, enter NPDES penait identification nuniber (l.e.A 00000001) ________ 2. What is the total size of site associated with Industrial activity? □Yes Acres 3. Have you paved or roofed over a formerly exposed, parvio^sarpa in order to qualify for the no □Yea (3N o exposure exduaion? lUsponding yo to ihli quertion doe* not disqualify you for the no expostj^ welusion However, the N2>CA may use thit inlbfmiUon in coiuidsrlng whether itnnn water disdw'ges from your site are likely to have srt ndvsrw irntnet on water Quality, io which case you could be rtQuircd to obtain penT^il coverage. If yes, please indicate approximately how much arts was paved or roofed over. O ^***^^*” D More than five acres 4. Are any of tho following materials or aedvitlas exposed to p eclpiUtlon or storm water runoff, now or in the foreseeable future? s) Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, wYes aNo storing or cleanwg industrisi machinery or equipment rctnqin and are exposed to stont water b) Materials or residuals on the ground or uistonn water inlets from spills or leaks c) Materials or products from past industrial activity d) Material handling equipment (except adequately maintained vehicles) e) Materials or products during loading or unloading or transporting activities f) Materials or products stored outdoors (except final inducts intended for outside use, .such as new cais, where exposure to storm water does not result in the discharge of pollutants) g) Materials contained in open, deteriorated or leaking storage drums, barrels, tanks aod similar containers □Yes SNo □Yes 02No □Yes SNo □Yes SjNo □Yes (3N o □Ves QBNo h) Materials or products handled or stored on roads or rsilwayp owned or maintained by the discharger □Yes SlNe Ores Qno □Yes SNo □Yes BNo i) Westc material (except waste in covered, non-lesking conifers like a covered dumpster) j) Applicatioo or disposal of process wastewater (unless otherwise permitted) k) Particulate matter or visible deposits of residuals from roofjstacks aod/or vents not otherwise regulated (i.e. under an air quality control pennit) and evident in the Storm water outflow If you checked yes to ANY of the items in question E. 4. a - k, you are not eligible for die no exposure exclusion. Skip to partO. If you cheeked no to ALL of the items in question E. 4. a • k, you are not required to obaia permit covenge. Continue to part P and sign the No Exposure Certification. f4o Exposure Certification 1 certify ■m'iw penalty of law that 1 have read and understand the eligibility requirements for claiming a condition of “no exposure "and obtaining an exclusion from NPDES storm water pennitting. I certify under penalty of law tiiat there arc no discharges of storm water 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)). 1 understand that I am obligated to inibmit a no exposure ceitificatioo form once every five years to the MPCA and, if requested, to the operator of the local municipal separatr atonn sewer system (MSS) inU) which the facility discharges ('vbere applicable). I understand fiut 1 must allow the MPCA, or MS4 operator where the discharge is into the local MS4, to peilbnn inspectians to confirm the condition of no exposure and to make such inspection reports publicly available upon request I undcirjnd that I must obtain coverage under an NPDES pennit prior to any point source disebuge of storm water from <bc facility. wf^ifm3*S2 k4K4 trduMHat StBrm WaUi Fstmit Jqf4