DWQ-2023-200081

STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY
195 North 1950 West, P.O. Box 144870, Salt Lake City, Utah 84114-4870 [phone]
NDC
No Discharge Certification (NDC) Form for Exclusion from the UPDES Multi-Sector General Permit for Storm Water Discharges Associated with Industrial Activity; No. UTND00000
Industrial facilities required to comply with the Utah Pollutant Discharge Elimination System (UPDES) requirements include mines (including gravel pits), cement plants, wood mills, airports,
scrap yards, trucking yards, bulk fueling stations, and other manufacturing facilities. Coverage is required for facilities that operate under qualifying Standard Industrial Classification
(SIC) Codes found in Appendix I of the Multi-Sector General Permit on the Division of Water Quality’s website at http://waterquality.utah.gov.
An industrial facility with a SIC code that requires coverage but does not discharge storm water to waters of the state may formally opt for an exclusion. By definition, a discharge
to waters of the state includes discharges to surface water or groundwater (UAC R317-8-1.5(59)). A no discharge exclusion is obtained by completing and submitting this form with appropriate
supporting documentation to demonstrate that no storm water can discharge from the site via surface runoff or sub-surface infiltration. This exclusion is available on a facility-wide
basis only and is not applicable to individual outfalls.
A no discharge exclusion cannot be obtained if the facility discharges storm water, even if storm water is not exposed to industrial materials or activities. In this situation a No Exposure
Certification form may be appropriate.
The form is non-transferable. If a new operator takes over the facility, the new operator must complete and submit a new form to claim no discharge. OWNER INFORMATIONCheck here if Operator
Information is the same as Owner Information
Owner Name: ________________________________________________ Status of Owner (circle one):Federal Public State Private
Address: ______________________________________________________________________________
City: ____________________________________________ State: ______ Zip: ________________
OWNER POINT OF CONTACT INFORMATION:
First Name: __________________________ Last Name: _____________________________ Phone: ___________________________
Title: __________________________________________________ Email: _________________________________________________
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OPERATOR INFORMATION(Do not fill out if Operator is same as Owner)
Operator Name: ________________________________________________________________________
Mailing Address: _______________________________________________________________________
City: ____________________________________________ State: ______ Zip: ________________
OPERATOR POINT OF CONTACT INFORMATION:
First Name: __________________________ Last Name: _____________________________ Phone: ___________________________
Title: __________________________________________________ Email: _________________________________________________FACILITY SITE/LOCATION INFORMATIONFacility Name: _______________________________________________________________________________

Address: _______________________________________________________ County: ____________________________
City: ___________________________________________________________ State: _____ Zip: _________________
Latitude: ________ ________ _______ Longitude: _______ _______ ______ Municipal Separate Storm Sewer System (MS4) Operator Name: ____________________________________________
N/AWas the facility or site previously covered under a UPDES stormwater permit? Y N If yes, what is the most current UPDES Permit Number? Permit No. UTR_____________________The
General Multi-Sector Permit covers all industrial activity that is required by law to be covered by a storm water permit. Please select each sector that covers industrial activities
which occur at your facility or site. The sector covered in Sector AD is the catchall sector and should only be used if positively no other sector covers your industrial activity. If
you should select AD, please call the Storm Water Coordinator at DWQ to discuss the need for choosing Sector AD (Non-Classified Facilities).Primary Regulated Sector: ______ Primary
SIC Code: __________________Co-Located Sector or Activity Code: _________ Co-Located SIC Code: _____________________Co-Located Sector or Activity Code: _________ Co-Located SIC Code:
_____________________Co-Located Sector or Activity Code: _________ Co-Located SIC Code: _____________________
BASIS FOR NO DISCHARGE EXCLUSION
Provide a detailed description of your facility and operations including the best practices and/or control measures used to ensure that stormwater does not discharge from your facility.
Examples of best practices include using berms to prevent stormwater from leaving the site, using detention basins to collect uncontaminated stormwater on site, and frequent inspections
of berms.
INDICATE STORMWATER FLOW DISCHARGES
Attach with this form a map of the facility or site that shows stormwater flow directions.
CERTIFICATION INFORMATION
I understand that if conditions change and the facility no longer operates without discharging storm water, that I must obtain coverage under a UPDES permit prior to any point source
discharge of storm water from the facility.
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 gather and evaluate 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:
OBTAINING AND MAINTANING THE NO DISCHARGE EXCLUSION
This form is used to certify that a condition of no discharge exists at the industrial facility or site described and must be re-submitted at least once every five years. The industrial
facility operator must maintain a condition of no discharge its facility or site in order for the no discharge exclusion to remain applicable. If conditions change resulting in the discharge
of stormwater, the facility operator must obtain coverage under a No Exposure Certification, if applicable, or a UPDES storm water permit immediately.

Where to File NDC Form
The preferred method of submitting a NDC is by completing it electronically on the NPDES eReporting Tool (NeT) Storm Water Database: https://cdx.epa.gov/. If you submit a waiver from
electronic reporting, in accordance with Part I.I of the permit, you may also submit a paper form to the following address:
Department of Environmental Quality
Division of Water Quality
P.O. Box 144870
Salt Lake City, UT 84114-4870
Fees
The fee is $150.00 for the five-year certification period. The fee is paid on-line by VISA/MASTERCARD/echeck or by mailing a check.
Completing the Form
You must type or print legibly. One form must be completed for each facility or site for which you are seeking to certify a condition of no discharge. Please make sure you have addressed
all applicable questions. If mailing, please make sure to make a photocopy for your records before sending the completed form to the above address.
SECTION I – OWNER AND OPERATOR INFORMATION
Supply the legal name(s) of the person(s), firm(s), public organization(s), or any other entity(ies) that qualifies as the owner of the project (see permit definitions). Do the same
for the operator that conducts facility operations at the permitted site. The owner and the operator of the project may be the same.
Enter the complete address and telephone number of the owner and operator and a point of contact person and number for each.
SECTION II – FACILITY INFORMATION
Enter the facility name of the site and complete street address, including city, state and ZIP code. The latitude and longitude of the facility must be included to the approximate center
of the site. Specify which coordinate system is used, either Decimal Degrees or Degrees Minutes Seconds.
If the facility is located within a municipal separate storm sewer system (MS4) boundary, enter the name of the operator of the MS4 (e.g., the name of the City or County of jurisdiction).
A municipal separate storm sewer system is defined as a conveyance or system of conveyances (including roads with drainage systems, municipal streets, catch basins, curbs, gutters, ditches,
man-made channels, or storm drains) that is owned or operated by a state, city, town, county, district, association or other public body which is designed or used for collecting or conveying
storm water.
Indicate whether the facility was previously covered under a UPDES storm water permit. If so, include the permit number.
Enter the 4-digit SIC code or 2-digit activity code which identifies the primary activity,and second 4-digit SIC code identifying the facility secondary activity, if applicable.
Activity codes are:
AD1 – Other stormwater discharges designated by the Director
HZ – Hazardous Waste Treatment, Storage, or Disposal Facilities
LF – All landfill, land application sites and open dumps
SE – Steam electric generating facilities
TW – Treatment works treating domestic sewage
SECTION III – BASIS FOR NO DISCHARGE EXCLUSION
Provide a description of the facility and operations, including any best management practices or control measures (i.e. berms to prevent stormwater from leaving the site, using lined
detention basins to collect uncontaminated stormwater on site) being used to ensure stormwater is not discharging from the facility or site.
SECTION IV – INDICATE STORMWATER FLOW DISCHARGES
Attach a copy of the facility or site map showing the stormwater flow directions. This should include any roof drain downspouts, parking lot drains, conveyance channels, and overland
flow directions. All areas of the site must be accounted for.
SECTION IV – CERTIFICATION STATEMENT
State statutes provide for severe penalties for submitting false information on this application form. State regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, which means:
President, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions
for the corporation, or
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.