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VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 1 of 6 USVI Department of Planning and Natural Resources No Exposure Certification for Exclusion from Stormwater Permitting for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the 2017 TPDES Multi-Sector General Permit (VI MSGP) No. VIR050000 Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its stormwater discharges associated with industrial activity under VIDPNR’s Stormwater Multi Sector General Permit 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 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, but are not limited to, 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 TPDES 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 entity in Section A 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). ALL INFORMATION MUST BE PROVIDED ON THIS FORM. Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4. A. Reason for Submission Select the purpose for filling out this form (check 1 only). To obtain a new No Exposure Certification. Fill in Sections B, C, D and E. 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)*. Provided the following information and fill out Section F. Provide the existing TPDES ID for the No Exposure Certification that you would like to discontinue: TPDES Permit Tracking No. * 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 VI MSGP or an individual permit. VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 2 of 6 B. Facility Operator Information 1. OPERATOR Information: Operator Name _______________________________________________________________________________ Mailing Address _______________________________________________________________________ _______________________________________________________________________ Phone (_____)_______________ Fax: (_____)_______________ Email ____________________________________________________________________________________ 2. OPERATOR Point of Contact Information: First, Middle Initial, Last Name: ___________________________________________________________________ Title: _______________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ C. Facility Information 1. Facility Name _____________________________________________________________________________ 2. Facility Physical Address _____________________________________________________________________________ _____________________________________________________________________________ 3. 4. Are you a “federal operator” as defined in Appendix A? YES NO 5. What is the ownership type of the facility? Federal Facility (US Gov’t) Municipality State Government School District Privately Owned Facility Corporation District Mixed Ownership 6. Have stormwater discharges from your facility been covered previously under a TPDES Permit? YES NO If yes, provide the TPDES ID for your previous No Exposure exclusion: TPDES Permit Tracking No. 7. Sector Specific Information 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 the VI MSGP: Primary SIC Code: OR Primary Activity Code: VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 3 of 6 8. Total size of site associated with industrial activity: _____________ (to the nearest quarter acre) 9. 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 D. Discharge Information 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 VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 4 of 6 E. 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 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: ______________ Email: __________________________________________________ VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 5 of 6 Instructions for Completing the No Exposure Certification (NOE) for Exclusion from Stormwater Discharges Associated with Industrial Activity Under the VIDPNR TPDES Multi-Sector General Permit (VI MSGP) Who May File A No Exposure Certification (NOE) Form. The Clean Water Act, 33 USC §1251 et. seq., (hereafter referred to as the “CWA” or the “Act”), as amended by the Water Quality Act of 1987, P.L. 100-4, and the Virgin Islands Water Pollution Control Act, 12 V.I. CODE ANN. §184 (1998 & Supp. 2004) et. seq. prohibits operators of industrial activities from discharging stormwater to waters of the United States Virgin Islands unless authorized under a Territorial Pollutant Discharge Elimination System (TPDES) permit. However, TPDES permit coverage is not required for discharges of stormwater associated with industrial activities identified at 40CFR 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. Where To File the No Exposure Certification Form. No Exposure Forms must be submitted to VIDPNR at the office in the district where the facility operates, as follows: St. Croix Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 45 Mars Hill Frederiksted, VI 00841 St. Thomas Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 8100 Lindberg Bay, Ste. #61 Cyril E. King Airport Terminal Bldg., 2nd Floor St. Thomas, VI 00802 Please submit the original with a signature in ink – Do Not Send Copies. Also, faxed copies will not be accepted. Completing the Form Do not file your NOE until you have obtained and thoroughly read a copy of the VI MSGP. Obtain and read a copy of this form and a copy of the 2017 VI MSGP, viewable at http://dpnr.vi.gov/environmental-protection/water-pollution- control-program/. A copy of the VI MSPG can also be obtained by contacting DPNR-DEP-WPC at (340) 773-1082 in St. Croix or (340) 774-3320 in St. Thomas. Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. Please submit original document with signature in ink - do not send a photocopied signature. Fees Fees are due on submittal of a NOE form. See 12 VIRR §184-35 for exact fees due. Section A: Reason for Submission Select the reason for submission of this NOE form. Section B: Facility Operator Information 1. Provide the legal name of the person, firm, public organization or any other public entity that operates the facility described in this certification. The operator of a facility is a legal entity that controls the operation of the facility. 2. Provide the operator’s mailing address here. Correspondence will be sent to this address. 3. Provide the telephone number of the line at the facility. 4. Provide a fax number (if one exists). 5. Provide an email address available to receive electronic correspondence. Section C: Facility Information 1. Provide the facility’s official or legal name. 2. Provide the facility’s physical address here. Do not use a P.O. Box. 3. Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds. 4. Note whether you are a federal operator. 5. Check the box that best describes the ownership of your facility. 6. Indicate whether the facility was previously covered under a TPDES stormwater permit. If so, include the permit number or permit tracking number. 7. Enter your facility’s sector specific information. 8. Enter the estimated total size of the site associated with industrial activity in acres. 9. 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. Section D: Discharge Information Check “Yes” or “No” as appropriate to describe the exposure condition at your facility. If you answer “Yes” to ANY of the questions (1) through (11) 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 a TPDES 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 E: Certification Statement Territorial statutes provide for severe penalties for submitting false information on this application form. Territorial regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or VIDPNR Permit No: VIR050000 No Exposure Certification Form Page 6 of 6 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; or For a municipal, State, Federal, or other public facility: by either a principal executive or ranking elected official. .