HomeMy WebLinkAboutWPO201800056 Permit WPO VSMP 2018-09-11 DRAFT
Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
(Please Type or Print All Information)
1. Construction Activity Operator: (General permit coverage will be issued to this operator The Certification in Item #12 must be
signed by the appropriate person associated with this operator)
Name Malloy Properties III LLC c/o Malloy Companies
Contact: Mark Fontaine
Mailing Address. 8605 Westwood Center Drive.Suite 410
City. Charlottesville State VA Zip' 22182 Phone (7031404-2346
Email address(if available):mfontaineOrenaudconsulting.net
Indicate if DEQ may transmit general permit correspondence electronically. Yes Q No❑
2. Existing General Permit Registration Number(for renewals only):N/A
3. Name and Location of the Construction Activity:
Name Wawa
Address(if available) 3267 Proffit Road
City- Charlottesville State- VA Zip: 22911
County(if not located within a City).Albemarle County
Latitude(decimal degrees): 38.132255 Longitude (decimal degrees): -78.434323
Name and Location of all Off-site Support Activities to be covered under the general permit:
Name N/A
Address(if available):N/A
City:N/A State.N/A Zip- N/A
County(if not located within a City):N/A
Latitude(decimal degrees)- N/A Longitude(decimal degrees): N/A
4. Status of the Construction Activity(check only one): Federal ❑ State❑ Public❑ Private 0
5. Nature of the Construction Activity(e.g.,commercial, industrial, residential,agricultural,oil and gas,etc.):
Commercial
6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC):
Name: North Fork Rivanna River-Jacobs Run Name:
HUC- JR11 HUC:
7. If the discharge is through a Municipal Separate Storm Sewer System (MS4),the name of the MS4 operator:
Albemarle County
8. Estimated Project Start and Cof pletion Date:
Start Date(mm/dd/yyyy):_ 5 /001 q Completion Date(mm/dd/yyyy).
9. Total Land Area of Development(to the nearest one-hundredth acre): 1.95
Estimated Area to be Disturbed(to the nearest one-hundredth acre): 1.95
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes❑ No QX
11. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General
VPDES Permit for Discharges of Stormwater from Construction Activities prior to submitting this Registration Statement.
By signing this Registration Statement the operator is certifying that the SWPPP has been prepared.
12. Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this document
and all attachments were prepared 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."
Printed Name: Mark Fontaine Title: f!,?/�+''
Signature: Date: 40/ Ay-
(Please sign in INK. ratio must be signed by the appropriate person associated with the operator identified in
Item#1.)
07/2014
Page 1 of 1
Instructions for Completing the Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
GENERAL The entities that are considered operators will commonly consist of the
owner or developer of a project (the party with control of project plans
A.Coverage Under this General Permit. and specifications)or the general contractor(the party with day to day
operational control of the activities at the project site which are
Any operator applying for coverage under this general permit who is necessary to ensure compliance with the general permit).
required to submit a Registration Statement (see Section B below)
must submit a complete Registration Statement to the Department. Provide the legal name(do not use a colloquial name),contact,mailing
The Registration Statement serves as a Notice of Intent for coverage address, telephone number, and email address (if available) of the
under the General VPDES Permit for Discharges of Stormwater from construction activity operator;general permit coverage will be issued to
Construction Activities(VAR10). this operator. Indicate if the Department may transmit general permit
correspondence electronically.
B.Single-family Detached Residential Structures.
Item 2:Existing General Permit Registration Number.
Operators with an existing stormwater discharge or proposing a new
stormwater discharge associated with the construction of a single- For reapplications only, provide the existing general permit registration
family detached residential structure are not required to submit a number for the construction activity. This item does not need to be
Registration Statement or the Department of Environmental Quality completed for new construction activities applying for general permit
(DEQ)portion of the general permit fee. coverage.
Operators of these types of discharges are authorized to discharge Item 3: Name and Location of the Construction Activity
under this general permit immediately upon the general permit's Information.
effective date of July 1,2014.
Provide the official name,street address(if available),city or county(if
C.To Apply for Permit Coverage. not located within a City)of the construction activity. Also, provide the
latitude and longitude in decimal degrees of the approximate center of
1. New Construction Activities. Any operator proposing a new the construction activity(e.g.,N 37.5000,W 77.5000).
stormwater discharge from construction activities shall submit a
complete Registration Statement to the Department prior to the Name and Location of Off-site Support Activity Information.
commencement of land disturbance, unless exempted by Section B
above. Any operator proposing a new stormwater discharge from This general permit also authorizes stormwater discharges from
construction activities in response to a public emergency where the support activities (e.g., concrete or asphalt batch plants, equipment
related work requires immediate authorization to avoid imminent staging yards, material storage areas, excavated material disposal
endangerment to human health or the environment is immediately areas, borrow areas) located on-site or off-site provided that (i) the
authorized to discharge under this general permit and must submit a support activity is directly related to a construction activity that is
complete Registration Statement to the Department no later than 30 required to have general permit coverage;(ii)the support activity is not
days after commencing land disturbance; documentation to a commercial operation, nor does it serve multiple unrelated
substantiate the occurrence of the public emergency must construction activities by different operators; (iii) the support activity
accompany the Registration Statement. does not operate beyond the completion of the construction activity it
supports; (iv) the support activity is identified in the registration
2. Existing Construction Activities. Any operator that was statement at the time of general permit coverage; (v) appropriate
authorized to discharge under the general permit issued in 2009, control measures are identified in a SWPPP and implemented to
and who intends to continue coverage under this general permit, address the discharges from the support activity areas; and (vi) all
shall submit a complete Registration Statement to the Department applicable state, federal, and local approvals are obtained for the
on or before June 1,2014,unless exempted by Section B above. support activity.
D.Where to Submit Registration Statements. Provide the official name,street address(if available), City and County
(if not located within a City) of all off-site support activities to be
All Registration Statements should be submitted to: covered under this general permit. Also, provide the latitude and
longitude in decimal degrees of the approximate center of the off-site
Department of Environmental Quality support activities (e.g., N 37.5000, W 77.5000). Also, if an off-site
Office of Stormwater Management,10th Floor support activity is going to be covered under this general permit the
P.O.Box 1105 total land area of the off-site support activity and the estimated area to
Richmond,VA 23218 be disturbed by the off-site support activity need to be included in Item
#9.
LINE-BY-LINE INSTRUCTIONS
Item 4:Status of the Construction Activity.
Item 1:Construction Activity Operator Information.
Indicate the appropriate status (Federal, State, Public, or Private) of
"Operator" means the owner or operator of any facility or activity the construction activity.
subject to the Stormwater Management Act and regulations. In the
context of stormwater associated with a large or small construction Item 5:Nature of the Construction Activity.
activity, operator means any person associated with a construction
project that meets either of the following two criteria.(i)the person has Provide a brief description of the construction activity, such as
direct operational control over construction plans and specifications, commercial, residential, agricultural, oil and gas, etc. This list is not all
including the ability to make modifications to those plans and inclusive.
specifications or (ii) the person has day-to-day operational control of
those activities at a project that are necessary to ensure compliance Item 6:Receiving Waters(s)and HUC Information.
with a stormwater pollution prevention plan for the site or other state
permit or VSMP authority permit conditions(i.e.,they are authorized to Provide the name of the receiving water(s)and corresponding HUC for
direct workers at a site to carry out activities required by the all stormwater discharges including any stormwater discharges from
stormwater pollution prevention plan or comply with other permit off-site support activities to be covered under this general permit.
conditions). Hydrologic Unit Code or HUC is a watershed unit established in the
most recent version of Virginia's 6th order national watershed boundary
dataset.
07/2014 Page 1 of 2
Item 7:MS4 Information. assigned or delegated to the manager in accordance with
corporate procedures.
If stormwater is discharged through a municipal separate storm sewer
b. or a partnership or sol
system(MS4), provide the name of the MS4 operator.The name of the heFproprietor,rrespectively!e proprietorship by a general partner or
MS4 operator is generally the Town, City, County, Institute or Federal
facility where the construction activity is located. c. For a municipality, state, federal, or other public agency. by either
Date a principal executive officer or ranking elected official. For purposes
Item 8: Construction Activity Start and Completion
Information. of this part,a principal executive officer of a public agency includes:
Provide the estimated start date (month/day/year) of the construction (i)The chief executive officer of the agency,or
activity. Provide the estimated completion date (month/day/year) of (ii)A senior executive officer having responsibility for the overall
the construction activity.
operations of a principal geographic unit of the agency.
Item 9:Construction Activity Area Information.
Provide the total area (to the nearest one-hundredth acre) of the
development (i.e.., the total acreage of the larger common plan of
development or sale). Include the total acreage of any off-site support
activity to be covered under this general permit.
Provide the estimated area (to the nearest one-hundredth acre)to be
disturbed by the construction activity. Include the estimated area of
land disturbance that will occur at any off-site support activity to be
covered under this general permit.
Item 10:Common Plan of Development or Sale Information.
Indicate if the area to be disturbed by the construction activity is part of
a larger common plan of development or sale. Larger common plan of
development or sale is defined as a contiguous area where separate
and distinct construction may be taking place at different times on
different schedules. Plan is broadly defined as any announcement or
documentation, including a sign, public notice or hearing, sales pitch,
advertisement, drawing, permit application, zoning request, etc., or
physical demarcation such as boundary signs, lot stakes, or surveyor
markings indicating that construction activities may occur.
Item 11:Stormwater Pollution Prevention Plan(SWPPP).
A Stormwater Pollution Prevention Plan(SWPPP)must be prepared in
accordance with the requirements of the General VPDES Permit for
Discharges of Stormwater from Construction Activities(VAR10)prior to
submitting this Registration Statement. By signing this Registration
Statement the operator is certifying that the SWPPP has been
prepared.
Item 12:Certification.
A properly authorized individual associated with the operator identified
in Item 1 of the Registration Statement is responsible for certifying and
signing the Registration Statement. Please sign the Registration
Statement in INK.
State statutes provide for severe penalties for submitting false
information on the Registration Statement. State regulations require
that the Registration Statement be signed as follows.
a. For a corporation. by a responsible corporate officer. For the
purpose of this part,a responsible corporate officer means:
(i) A president, secretary, treasurer, or vice-president of the
corporation in charge of a principal business function,or any other
person who performs similar policy-making 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 that 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 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
07/2014
Page 2 of 2
DRAFT VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY
GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM FOR OFFICE USE ONLY
CONSTRUCTION ACTIVITIES ID Number:
(VAR10) REGISTRATION STATEMENT Technical Criteria: IIB CI IIC CI
NEW ISSUANCE Wr RE-ISSUANCE ❑
MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑
Existing Permit Coverage Number (if applicable):
Section I. Operator/Permittee Information.
A. Construction Activity Operator(Permittee). The person or entity that is applying for permit coverage and will have
operational control over construction activities to ensure compliance with the general permit. A person with
signatory authority for this operator must sign the certification in Section VI. (per Part III. K. of the VAR10 Permit).
Construction Activity
Operator Name: Charlottesville Proffit,LLC.
Contact person: Mark Fontaine
Address: 8605 Westwood Center Drive, Suite 410
City, State Zip code: Vienna,VA 22182
Phone number: 703-404-2346
Primary email: mfontaine@renaudconsulting net
CC Email:
B. Billing Information (leave blank if same as the Operator identified in Section I.A. above). This entity will receive
Annual Permit Maintenance and Permit Modification Fee invoices (if applicable).
Name:
Contact person:
Address:
City, State Zip code:
Phone number:
Primary email:
CC Email:
C. May we transmit correspondence electronically? You must choose YES and include a valid email in order to pay by
credit card and to receive your permit coverage approval letter via email:
YES I] NO
DEQ 199-DRAFT PAGE 1 1 8
CONSTRUCTION GENERAL PERMIT(VAR10) REGISTRATION STATEMENT
Section II. Construction Activity Location Information. Project site information.
A. Include a site map showing the location of the existing or proposed land-disturbing activities,the limits of land
disturbance, construction entrances and all water bodies receiving stormwater discharges from the site.
B. Construction Activity Name: Wawa
Address: 3967 Profitt Road
City and/or County and Zip code: Charlottesville.VA 22911
Latitude and Longitude
(6-digit decimal degrees): 38.132255; -78.434323
C. Construction Activity Entrance Location
(description, street address and/or
latitude/longitude in decimal degrees): 38.13195; -78.43434
Section III. Offsite Support Activity Location Information. List all offsite support activities to be included under this
permit registration. Enter additional areas on a separate page. Offsite areas not included on this registration will need
to obtain coverage under a separate VPDES permit.
A. Offsite Activity Name: N/A
Address: N/A
City and/or County and Zip code: N/A
Latitude and Longitude
(6-digit decimal degrees): N/A
B. Offsite Activity Entrance Location
(description, street address and/or
latitude/longitude in decimal degrees): N/A
Section IV. Site Information.
A. Acreage totals for all land-disturbing activities to be included under B. Estimated Project Dates
this permit coverage. (MM/DD/YYYY)
(to the nearest one-hundredth of an acre)
Total land area of development(include the entire
area to be disturbed under the approved Stormwater 1 95 Start date: 06/01/2019
Management Plan):
Estimated area to be disturbed (portions with Erosion
and Sediment Control Plana approval1 95
pp only): 06/01/2020
Completion date:
Offsite estimated area to be disturbed (if applicable):
C. Property owner status: FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE KI
D. Nature of the construction activity description (i.e.
commercial, industrial, residential, agricultural,
environmental): Commercial
E. Municipal Separate Storm Sewer System (MS4)
name (if discharging to a MS4): Albemarle County
DEQ 199-DRAFT PAGE 2 18
CONSTRUCTION GENERAL PERMIT(VAR10) REGISTRATION STATEMENT
F. This construction activity is part of a common plan of development or sale: YES ❑ NO x❑
G. 6th Order Hydrologic Unit Code (HUC) and associated Receiving Water Name(s). Include additional HUCs and
receiving waters on a separate page.
HUC RECEIVING WATERBODY(S)
JR I I North Fork Rivanna River-Jacobs Run
Section V. Other Information.
A. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the
General VPDES Permit for Discharges of Stormwater from Construction Activities prior to submitting the registration
statement. By signing the registration statement,the operator is certifying that the SWPPP has been prepared.
B. Has an Erosion and Sediment Control Plan been approved for the disturbance in Section IV A.? YES ❑ NO ❑
If yes, provide the date of Erosion and Sediment Control Plan approval:
C. Land disturbance has commenced: YES ❑ NO
O. Stormwater management maintenance agreement included (if applicable): YES IN Not Applicable ❑
E. If this project is using approved Annual Standards and Specifications (AS&S), attach the completed AS&S Entity
Form. AS&S Entity Name (if different from the Operator identified in Section II. A.):
SEE THE FOLLOWING PAGE FOR SIGNATURE AND CERTIFICATION REQUIREMENTS
AND INFORMATION
DEQ 199-DRAFT PAGE 3 18
CONSTRUCTION GENERAL PERMIT(VAR10) REGISTRATION STATEMENT
Section VI. Certification. This Certification must be signed by a person representing the operator identified in Section II.
A. and meeting the requirements of 9VAC25-880-70. Part III. K. Please note that operator is defined in 9VAC25-870-10
as follows:
"Operator"means the owner or operator of any facility or activity subject to the Act and this chapter. In the context of storm water
associated with a large or small construction activity, operator means any person associated with a construction project that meets
either of the following two criteria:(i)the person has direct operational control over construction plans and specifications,including
the ability to make modifications to those plans and specifications or(ii)the person has day-to-day operational control of those
activities at a project that are necessary to ensure compliance with a stormwater pollution prevention plan for the site or other state
permit or VSMP authority permit conditions(i.e., they are authorized to direct workers at a site to carry out activities required by the
storm water pollution prevention plan or comply with other permit conditions).In the context of stormwater discharges from
Municipal Separate Storm Sewer Systems(MS4s), operator means the operator of the regulated M54 system.
9VAC25-880-70. Part Ill. K Signatory Requirements:
1.Registration statement.All registration statements shall be signed as follows:
a. For a corporation•by a responsible corporate officer.For the purpose of this chapter, a responsible corporate officer
means:(i)a president,secretary, treasurer,or vice-president of the corporation in charge of a principal business function, or
any other person who performs similar policy-making 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 that 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
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 state permit application requirements;and where authority
to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;
b.For a partnership or sole proprietorship:by a general partner or the proprietor,respectively;or
c.For a municipality,state,federal, or other public agency:by either a principal executive officer or ranking elected official.
For purposes of this chapter, a principal executive officer of a public agency includes:(i)the chief executive officer of the
agency or(ii)a senior executive officer having responsibility for the overall operations of a principal geographic unit of the
agency.
Certification: "I certify under penalty of law that I have read and understand this registration statement and that this
document and all attachments were prepared 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."
Printed Name: Mark Fontaine
Signature (signed in ink):
Date:
Submit this form to the VSMP Authority. If DEQ is the VSMP Authority, please send to:
Department of Environmental Quality
Office of Stormwater Management Suite 1400
PO Box 1105
Richmond VA 23218
constructiongp@dea.virginia.gov
DEQ 199-DRAFT PAGE 4 18
INSTRUCTIONS
CONSTRUCTION GENERAL PERMIT REGISTRATION STATEMENT
PLEASE DO NOT SUBMIT WITH THE REGISTRATION STATEMENT.
This registration statement is for coverage under the General VPDES Permit for Discharges of Stormwater from
Construction Activities. The following permit actions are covered by this form: new issuance, re-issuance, modification
with an increase in acreage and plan modifications that do not result in an increase in acreage.
Choose NEW ISSUANCE if this registration statement submittal is to obtain a new permit coverage, RE-ISSUANCE to
renew an active, expiring permit coverage or MODIFICATION to modify an active permit coverage When modifying
permit coverage, indicate if the modification is increasing the amount of acreage previous covered (MODIFICATION
WITH ACREAGE INCREASE) or changing the site design with no increase in acreage (MODIFICATION WITHOUT ACREAGE
INCREASE).
Existing Permit Coverage Number. Provide the permit number for a modification or reissuance (i.e. VAR10####).
Section I. Operator/Permittee Information.
A. Construction Activity Operator(Permittee). The person or entity that is applying for permit coverage and will have
operational control over construction activities to ensure compliance with the general permit. For companies, use the
complete, active, legal entity name as registered with a state corporation commission. Entities that are considered
operators commonly consist of the property owner, developer of a project(the party with control of project plans and
specifications), or general contractor(the party with day-to-day operational control of the activities at the project site
that are necessary to ensure compliance with the general permit). If an individual person is named as the operator,that
person (or a representative of) must sign the certification in Section V. I. An operator can be one of the following:
9VAC25-870-10. Definitions.
"Operator"means the owner or operator of any facility or activity subject to the Act and this chapter. In the context of
storm water associated with a large or small construction activity, operator means any person associated with a
construction project that meets either of the following two criteria: (i) the person has direct operational control over
construction plans and specifications, including the ability to make modifications to those plans and specifications or(ii)
the person has day-to-day operational control of those activities at a project that are necessary to ensure compliance
with a storm water pollution prevention plan for the site or other state permit or VSMP authority permit conditions(i.e.,
they are authorized to direct workers at a site to carry out activities required by the storm water pollution prevention plan
or comply with other permit conditions). In the context of stormwater discharges from Municipal Separate Storm Sewer
Systems(MS4s), operator means the operator of the regulated MS4 system.
"Owner"means the Commonwealth or any of its political subdivisions including, but not limited to,sanitation district
commissions and authorities, and any public or private institution, corporation, association,firm or company organized
or existing under the laws of this or any other state or country, or any officer or agency of the United States, or any
person or group of persons acting individually or as a group that owns, operates, charters, rents, or otherwise exercises
control over or is responsible for any actual or potential discharge of sewage, industrial wastes, or other wastes or
pollutants to state waters, or any facility or operation that has the capability to alter the physical, chemical, or biological
properties of state waters in contravention of§ 62.1-44.5 of the Code of Virginia, the Act and this chapter.
"Person"means any individual, corporation, partnership, association, state, municipality, commission, or political
subdivision of a state, governmental body, including a federal, state, or local entity as applicable, any interstate body or
any other legal entity.
B. Billing information. If the person or entity responsible for billing/invoicing is different from the operator, please
complete this section. If they are the same, leave this section blank.
DEQ 199-DRAFT PAGE S 18
INSTRUCTIONS
CONSTRUCTION GENERAL PERMIT REGISTRATION STATEMENT
PLEASE DO NOT SUBMIT WITH THE REGISTRATION STATEMENT.
C. May we transmit correspondence electronically? If you choose YES to this question and provide an email address in
Section I. A., all correspondence, forms, invoices and notifications will be transmitted by email to the operator. This will
also allow the operator to pay by credit card and receive permit coverage approval letters immediately upon approval.
Section II. Construction Activity Location Information. Location information related to the project site
A. A site map indicating the location of the existing or proposed land-disturbing activities,the limits of land disturbance,
construction entrances and all water bodies receiving stormwater discharges from the site must be included with the
submittal of this form.Aerial imagery maps or topographic maps showing the required items are acceptable. Plan sheet
sized site maps are not required. Please consult your VSMP authority if you have additional questions regarding site
map requirements.
B. Provide a descriptive project name (it is helpful to use the same naming convention as listed on the Stormwater
plans), 911 street address (if available), city/county of the construction activity, 6-digit latitude and longitude in decimal
degrees format for the centroid, main construction entrance or start and end points for linear projects (i.e. 37 1234N/-
77.1234W).
C. Construction Activity Entrance Location. Provide an address or decimal degrees coordinates and a description of the
main construction entrance where the permit coverage letter will be posted.
Section III. Offsite Support Activity Location Information.
This general permit also authorizes stormwater discharges from support activities (e.g., concrete or asphalt batch plants,
equipment staging yards, material storage areas, excavated material disposal areas, borrow areas) located on-site or off-
site provided that (i) the support activity is directly related to a construction activity that is required to have general
permit coverage; (ii) the support activity is not a commercial operation, nor does it serve multiple unrelated
construction activities by different operators; (iii)the support activity does not operate beyond the completion of the
construction activity it supports; (iv)the support activity is identified in the registration statement at the time of general
permit coverage; (v) appropriate control measures are identified in a SWPPP and implemented to address the discharges
from the support activity areas; and (vi) all applicable state,federal, and local approvals are obtained for the support
activity.
If requesting permit coverage for offsite activities, please complete this section. List additional offsite areas to be
included under this permit coverage on a separate page. Offsite areas not included on this registration will need to
obtain coverage under a separate VPDES permit.
A. Offsite activity location information. Provide a descriptive offsite project name, 911 street address(if available) and
city/county of all off-site support activities. Provide the 6-digit latitude and longitude in decimal degrees (i.e. 37.1234N,-
77.1234W). Please note that off-site activities not covered under this permit may require separate permit coverage.
B. Offsite activity entrance location. Provide an address or decimal degrees coordinates and a description of the main
construction entrance.
Section IV. Site Information.
A.Acreage totals for all land-disturbing activities, on-and off-site,to be included under this permit. Acreages are to be
reported to the nearest one-hundredth acre (two decimal places; i.e. 1.15 acres). Provide the total acreage of the
development as approved on the Stormwater Management Plans and the estimated acreage to be disturbed by the
construction activity as approved under the Erosion and Sediment Control Plans.The offsite estimated area to be
disturbed is the sum of the disturbed acreages for all offsite support activities to be covered under this general permit.
DEQ 199-DRAFT PAGE 6 8
INSTRUCTIONS
CONSTRUCTION GENERAL PERMIT REGISTRATION STATEMENT
PLEASE DO NOT SUBMIT WITH THE REGISTRATION STATEMENT.
Permit fees are calculated based on your disturbed acreage total for all areas being disturbed under this permit coverage
(the sum of all onsite and offsite disturbed acreages).
B. Estimated Project Dates. Provide the estimated project start date and completion date in Month/Day/Year or
MM/DD/YYYY format (i.e. 07/30/2019).
C. Property owner status. The status of the construction activity property owner. Any property not owned by a
government entity or agency(i.e.federal, state or local governments) is PRIVATE.
D. Nature of the construction activity description. Choose the designation that best describes the post-construction use
of this project (you may choose more than one). (i.e. Residential, Commercial, Industrial, Agricultural, Environmental,
Educational, Oil and Gas, Utility,Transportation, Institutional, etc.). Describe the project (i.e Commercial—one new
office building and associated parking and utilities;Transportation—Roads, sidewalks and utilities;Agricultural—3
Poultry Houses, etc.).
E. Municipal Separate Storm Sewer System (MS4) name(s) if discharging to a MS4. If stormwater is discharged through a
MS4(either partially or completely), provide the name of the MS4(s)that will be receiving water from this construction
activity. The MS4 name is typically the town,city, county, institute or federal facility where the construction activity is
located.
F.This construction activity is part of a common plan of development or sale. "Common plan of development or sale"
means a contiguous area where separate and distinct construction activities may be taking place at different times on
different schedules per 9VAC25-870-10. Definitions. I.e a subdivision, commercial development, business park, etc.
G. 6th Order Hydrologic Unit Code (HUC) and associated Receiving Water Name(s). Provide all 6th order HUCs and
receiving waters for the site and offsite areas that could potentially receive stormwater runoff discharging from this
activity. The HUC can be either a 12-digit number(i.e 0208010101) or 2-letter, 2-number code (i.e.JL52). Include
additional HUCs or receiving waters on a separate page. You may utilize DEQ's web-based GIS application,VEGIS, to
obtain this information.
• VEGIS application link: DEQ's VEGIS Mapping Application
• Instructions for utilizing DEQ's VEGIS application link: CGP-GIS HUC Instructions
Section V. Other Information.
A. A stormwater pollution prevention plan (SWPPP) must be prepared prior to submitting the registration statement per
9VAC25-880. See 9VAC25-880-70. Part II. of the General Permit for the SWPPP requirements.
B. Indicate if the Erosion and Sediment Control Plan for the estimated area to be disturbed listed in Section IV. A. has
been approved. If YES, indicate the date of original plan approval.
C. If land disturbance has commenced,choose YES. "Land disturbance" or"land-disturbing activity" means a man-made
change to the land surface that may result in soil erosion or has the potential to change its runoff characteristics,
including construction activity such as the clearing,grading, excavating, or filling of land per§62.1-44.15:24. Definitions.
D. Stormwater Management Maintenance Agreement per 9VAC25-870-112 A. Choose YES if a maintenance agreement
has been included for review and approval.
E. If this project is using approved Annual Standards and Specifications(AS&S), attach the completed AS&S Entity Form.
If the AS&S Entity is different than the operator identified in Section I.A., list the AS&S Entity Name. . The AS&S entity is
the entity or agency that holds the approved annual standards &specification.
DEQ 199-DRAFT PAGE 7 8
INSTRUCTIONS
CONSTRUCTION GENERAL PERMIT REGISTRATION STATEMENT
PLEASE DO NOT SUBMIT WITH THE REGISTRATION STATEMENT.
• AS&S Entity Form link: Annual Standards and Specifications Entity Information Form
Section VI. Certification.
A properly authorized individual associated with the operator identified in Section I. A. of the Registration Statement is
responsible for certifying and signing the Registration Statement. State statutes provide for severe penalties for
submitting false information on the Registration Statement. State regulations require that the Registration Statement be
signed as follows per 9VAC25-880-70 Part Ill. K. 1.:
a. For a corporation:by a responsible corporate officer. For the purpose of this part, a responsible corporate officer
means:
(i)A president, secretary, treasurer, or vice-president of the corporation in charge of a principal business
function, or any other person who performs similar policy-making 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 that 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 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.
b. For a partnership or sole proprietorship:by a general partner or the proprietor, respectively.
c. For a municipality, state,federal, or other public agency:by either a principal executive officer or ranking elected
official. For purposes of this part, a principal executive officer of a public agency includes:
(i) The chief executive officer of the agency, or
(ii)A senior executive officer having responsibility for the overall operations of a principal geographic unit of the
agency.
DEQ 199-DRAFT PAGE 8 8