Stormwater-

Facility Name: BURROWS PACKAGING DIVISION

Permit Type: No Exposure Legal Status:

Address: 1722 53RD ST. - FORT MADISON , IA *

County: LEE Field Office: 6 SIC: 2671 Geospatial Information: 636387(X)/4497888(Y)

No Exposure Certification Application Date: MM/DD/YYYY Previously covered under a NPDES Storm Water permit? If yes, enter permit number: Certification Signed? Permit Type: --PERMIT TYPE-- GP #1 GP #2 GP #3 NO EXPOSURE SIC: Notes: Eligibility Confirmed Date: MM/DD/YYYY Not Eligible For Storm Water Exclusion Date: MM/DD/YYYY Application For Storm Water Exclusion Approved Date: MM/DD/YYYY Expiration Date Of Exclusion: MM/DD/YYYY