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No Exposure Certification Appendix H
NO EXPOSURE CERTIFICATION
For High Priority Municipal Facilities
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EW Department of
RK in SPDES MS4 General Permit, GP-0-24-001
ATE Environmental
Conservation The co~ leted No Exposure- Certffication mus1be documented in lhe SWMP Plan.
Ptease do nor submit chis form ro rhe Depanmem u.nle&S requested.
I. Owner/Facility lnfonnation
Owned()perator Name:
Maling Address: I C'ity/StatelZip:
Contact Name: Phone No.:
Faci!ity Name:
Sireet Address:. I City/ S1ate/Zip,
Comly:
I Latitude: ILongitude:
U. Exposure Checkli-st
Ate any of the folowng materials or actiwies exposed to p-Eq).~ now or in the foreseeable future? (Please check ffher -Yes'" or
·No" ii the appropriate box.) If you anSWEf' "'Yes~k> any of these quesiions ( 1) through ( 11), 'fOJ are not eligible for no exposure-.
'\'ES NO
1 Usilg. st0mQ or cleri,g mac:hr.a:y or equpnE'nL and are..,s where residuals tom usi,g. st0mQ or d eaning machinery or
e.qu'pment fM'la~ and are exposed 10 stormwater
2 Materills or re.-sidu.is on ~ t,Otfld oc in stoonwater inlets from spills/leaks.
4 Material handling equpnent (except adequately maintained vehicles)
5 Materi:.lls or products <bing badingi\.rio.lding or transporting actMt,e,s
6 ~faterills oc products stored outdoors (except in.al products intended for outside t6e [e.g.• new cars] ¥fflefe exposure to
somwater does not resu'Rfl the discharge of pollutants)
7 Materi3Is contained in open, de-1eriorated or leaking storage dn.rns. barrels.. tanks. and simi:v con~
8 Matffl.'lls oc products hanciedlsl:l:lred on roads or ratt,ays owned Of rnantained by the discharger
9 Wa.s1e nuterial (exoept waste in covered, non-lea.king cutainers (e.g.. dumpsterD
UL Certification
I cer1ify \lldeJ penalty of law that I have- read ~ oodersa-w:I the eligb i ty requirat'IE'l'ts rot d arning a oonditoo d ·no exposure~and obtainif'JQ an
exdusion from SPOES stormwater permitting. I certify under penally d law !hat 1here are no discharges o; storm water cortbmnated by exposise to
indus'lrfal ac:6vities or materia'ls:trom the m us-tlu facility orsi!e identified in !his docunent (except as all owed under .;,o CFR 122.26(g)(2)). I
undersbnd chat I am obligated to submit a no expos1n certif£ation form ~ reqJeSt to the NPOES pamitting aithcriy cclO lhe Operai.Of d the 10¢31
l'l'Kricipal separate storm sewer system (MS4) into which the bcfty dscharges{where applicable). I t.ndascand that I must allow the SPOES
perm,~g authority. or MS4 Operator where the discharge is S'lt o the local MS4, to perfonn inspections to confinn the conclilion d no exposure and to
make such inspection reports publicly avail~ upon request.
Printed Name: Tide/Positiori:
Signature: Date:
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