NO EXPOSURE CERTIFICATION
I. Owner/Facility Information
Owner/Operator Name:
Mailing Address: City/State/Zip:
Contact Name: Phone No.:
Facility Name:
Street Address: City/State/Zip:
County: Latitude: Longitude: SIC Code:
II. Exposure Checklist
Are any of the fo
llowing materials or activities exposed to precipitation, now or in the foreseeable future? (Please check either “Yes” or “No” in the
appropriate bo
x.
)
If you answer “Yes” to
any of these questions (1) through (11), you are not eligible for the no exposure exclusion. YES NO
1
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
2
Materials or residuals on the ground or in stormwater inlets from spills/leaks
3 Materials or products from past industrial activity
4 Material handling equipment (except adequately maintained vehicles)
5 Materials or products during loading/unloading or transporting activities
6
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)
7 Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
8 Materials or products handled/stored on roads or railways owned or maintained by the discharger
9 Waste material (except waste in covered, non-leaking containers [e.g., dumpster])
10 Application or disposal of process wastewater (unless otherwise permitted)
11 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 storm water outflow
III. 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
SPDES stormwater permitting. I certify under penalty
of law that there are 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)). 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 SPDES 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.
Printed Name: Title/Position:
Signature: Date:
(4/11/19)
for Exclusion from SPDES Stormwater Permitting
Is there a No Exposure Certification currently on file with the Department? 9 Yes 9 No
Instructions: Complete this No Exposure Certification form and
submit with the NY-2A application to SPDESapp@DEC.ny.gov.
Enter SPDES ID #: NY _ _ _ _ _ _ _
click to sign
signature
click to edit
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