Form Epa 4239 – Fill Out and Use This PDF

3. Is this a Federal facility?

YES

NO

5.a. Was the facility or site previously covered under an NPDES storm water permit or No Exposure Certification? b. If yes, enter the Ohio EPA NPDES facility permit number or Ohio EPA No Exposure Certification number:

YES

NO

8. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion?

YES

NO

Less than one acre

One to five acres

More than five acres

Who May File a No Exposure Certification

OAC 3745-39-04 prohibits point source discharges of storm water associated with industrial activity to waters of the State without first obtaining a National Pollutant Discharge Elimination System (NPDES) permit. However, NPDES permit coverage is not required for discharges of storm water associated with industrial activities identified at OAC 3745-39-04(B)(15)(a)-(i) and (k) if the discharger can certify that a condition of “no exposure” exists at the industrial facility or site.

Storm water discharges from construction activities identified in OAC 3745-39-04(B)(15)(j) and (B)(16) are not eligible for the no exposure exclusion. Additional guidance on the no exposure exclusion can be obtained by viewing the following USEPA guidance manual: http://www.epa.gov/npdes/pubs/noxguide.pdf

Obtaining and Maintaining the No Exposure Exclusion

This form is used to certify that a condition of no exposure exists at the industrial facility or site described herein. This certification must be re-submitted at least once every five years. The industrial facility operator must maintain a condition of no exposure at its facility or site in order for the no exposure exclusion to remain applicable. If conditions change resulting in the exposure of materials and activities to storm water, the facility operator must obtain coverage under an Ohio NPDES storm water permit immediately.

Where to File the No Exposure Certification Form

Ohio Environmental Protection Agency

Division of Surface Water

Storm Water Unit

P.O. Box 1049

Columbus, Ohio 43216-1049

Upon approval, Ohio EPA will process and mail a letter acknowledging receipt of your No Exposure Certification.

Completing the Form

You must type or print, using uppercase letters, in appropriate areas only. Enter only one character per space (i.e., between the marks). Abbreviate if necessary to stay within the number of characters allowed for each item. Use one space for breaks between words. One form must be completed for each facility or site for which you are seeking to certify a condition of no exposure. Please make sure you have addressed all applicable questions and have made a photocopy for your records before sending the completed form to the above address.

Section A. Facility Operator Information

Section B. Facility/Site Location Information

1.Enter the official or legal name of the facility or site.

2.Enter the complete street address (if no street address exists, provide a geographic description [e.g., Intersection of Routes 9 and 55]), city, county, state, and zip code. Do not use a P.O. Box number.

3.Indicate whether the industrial facility is operated by a department or agency of the Federal Government (see also Section 313 of the Clean Water Act).

4.Enter the latitude and longitude of your facility or site. Coordinates should be taken from the approximate center of the site. The latitude and longitude must be provided in decimal format (6 decimals) as indicated in the following example (i.e., Latitude: 39.958832, Longitude: -83.001022). These coordinates can be determined through the use of global positioning system (GPS) receivers and web-based tools. An example of a web-based tool to determine your facility/site’s latitude and longitude is Google Maps. Here are instructions for Google Maps:

1.Go to http://maps.google.com

2.Zoom the map to the location of your site.

3.Right-click on the map at the approximate center of your site.

4.Select “What’s here?” from the context menu.

5.Left-click on the green arrow. The latitude and longitude of your site will be displayed in the box.

5.Indicate whether the facility was previously covered under an NPDES stormwater permit. If so, include the Ohio EPA NPDES facility permit number.

6.Enter the 4-digit SIC code which identifies the facility’s primary activity and second 4-digit SIC code identifying the facility’s secondary activity, if applicable. SIC codes can be obtained from the Standard Industrial Classification Manual, 1987. Another source is the following website provided by the Occupational Health and Safety Administration: http://www.osha.gov/oshstats/sicser.html.

7.Enter the total size of the site associated with industrial activity in acres. Acreage may be determined by dividing square footage by 43,560, as demonstrated in the following example.

Example: Convert 54,450 ft2 to acres

Divide 54,450 ft2 by 43,450 square feet per acre:

54, 450 ft2 ) 43,560 ft2/acre = 1.25 acres.

1.Provide the legal name of the person, firm, public organization, or any other entity that operates the facility or site described in this certification. The name of the operator may or may not be the same as the name of the facility. The operator is the legal entity that controls the facility’s operation, rather than the plant or site manager.

2.Provide the telephone number of the facility operator.

3.Provide the email address of the facility operator.

4.Provide the mailing address of the operator (P.O. Box numbers may be used). Include the city, state, and zip code. All correspondence will be sent to this address.

8.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.