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HomeMy WebLinkAboutWPO201900025 VSMP - SWPPP 2019-08-02WP0201900025 VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATEIR FROM CONSTRUCTION ACTIVITIES WAR10) REGISTRATION STATEM ENT 7-019 NEW ISSUANCE L� MODIFICATION {KITH ACREAGE INCREASE �1 Existing Permit Coverage Number (if applicable) VAR1o###I#f#): REASSUANCE ❑ FOR 3FFICE USE ONLY ID Number: Technical Criteria- IIB ❑ IIC :❑ MODIFICATION UUITHOUT AC REAGE INCREASE ❑ Section I. OperatorlPermittee Information. A. Construction Activity Operator (Permittee). The person or entity that Is applyingfor permit coverage and will have operational control over construction activities to ensure compliance with the general permit, A person with signatory authority forth -is operator must sign the certification in Section Vl. (per Part Ill, K. of the VARY.© permit); Construction Activity %' Operator Name: Contact Person: Address: }_ City, state, Zip Code: `I Phone Number: Primary Email: CC Email: B. Billing information (leave blank if same as the Operator identified in Section LA. 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 Ernaik C. May we transmit correspondence electronically? You must choose YES and include a valid ama l in order to pay by credit card and to receive your permit coverage approval letter via email: YES NO. Rev 04/2019 PAGE 1) 7 CONSTRUCTION GENERAL PERMIT (VAR1d) REGISTRATION STATEMENT 2019 Section II, Construction Activity Location Information. Project site information. A. Include a site reap 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 -rom the site. B. Construction Activity Name: yi r ,address: �t�5 �n�t���� City and/or County and Zip Code: Ccnz& V/1 Z213Z Latitude and Longitude (6-digit, decimal degrees fo.rrnat): , 39, 19.1 %(2, C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section Ill. €]ffsite Support Activity Location Information. List all offsite support activities to b included under this permit registration, Enter additional areas on a separate page. Off -site areas not included on this registration may need to obtain coverage under a separate VPDES permit. A. Offsite Activity Name: Address: City and/or County and Zip Code: Latitude and longitude (6-digit, decima[ degrees format): B. Offsite Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section IV. Site Information. A. Acreage totals for all land --disturbing activities to be included under this permit coverage. Report to the nearest one -hundredth of an acre. Total lard area of development (including the entire area to be disturbed as approved in the 5tormwater Management Plan): Primary estimated area to be disturbed (portions with 3, OL-4 Erosion and Sediment Control Plan approval only): Mite estimated area to be disturbed (if applicable): C. Property Owner Status: D. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): E. Municipal Separate Storm Sewer System (M54) name (if discharging to a M54): B. Estimated Project [fates (M M/DID/YYYY) Start dzte: 7/20/19 Completion date: 7/20/20 FEDERAL. ❑ STATE ❑ PUBLI+. ❑ PRIVATE 12 Rev 04/2019 PACE 2 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 E. Is this construction activity part of a common plan of development or sale? YES ❑ NOVI f G. 6th Order Hydrologic Unit Code (HUC) and Receiving Water Narne(s). Attach a separate list i" needed. HUC 0© v /e-S dk ve r- Section V. other Information:. RECEIVING WATERBODY(S) A. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the i equirernents of the General VPD€5 Permit for Discharges of5tormwater from Construction Activities prior to su amittingthe Registration' Statement, By signing the Registration 5fiatement, the operator is certifying that the SWPPF has been prepared. B. Has an Erosion and Sediment Control Plan been submitted to the VESCP Authvrityfor revievf? YES ❑ No ❑ Erosion and Sediment Control Plan Approval .Gate (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES ❑ No L/ D. If this project is using approved Annual Standards and Specifications (AS&5), attach the corn aleted AS&S Entity Form. AS&S .Entity name (if different from the operator identified in Section 11. A.): SEE THE FOLLOWING PAGE FOR SIGNATURE AND CERTIFICATION REQUIREMENTS AND INFORMATION Rev04/2019 PAGE 3 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT �-019 Section VI. Certification. A person representing the operator as identified in Section 1. A. and rieeting the .requirements of 9VAC25-880-70. Part 111.. K roust physically sign this certification. A typed signature is not accoptable. Please note that operator is defined in 9VAC25-870-10 as follows: "Operator" means the owneror operator of any facility or activitysubject to the Act and this chapter. in t7e context of stormwater associated with a forge orsmall construction activity, operator means any person associated with a construction project that meets either o, f the following two criteria: (i) the person has direct operational control over construction plans at id specifications, including the ability to make modifications to those plans and specifications or (ii) the person has day-to-day opera `ional control of'those activities at a project that are necessary to ensure compliance with a stormwater pollution prevention plc n far the site or otherstate permit or VSMP authority permit conditions (i.e., they are authorized to direct workers at a:site to carry o it 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 (NIS4s), operator means the operator of the regulates` MS4 sysl em. 9VAC25-880-70. Part III• K. Signatory Requirements. Registration Statement. All Registration Statements ohall he 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 far the corps ration; or (ii) the manager of one ormore manufacturing; production, or operating facilities, provided the manager is outhrirized to make management decisions that govern .the operation of the regulated facility including having the explicit or impli :it dray of making major capital investmentrecommendiations, and initiating and directing other comprehensive measums to assure long-term compliance with environmental laws and regulations; the manager can ensure that the necessat y systems are established or actions taken to gather complete and accurate information forstate permit application requirements; and where authority to sign documents -has been assigned or delegated to the manager in accordance with corporote procedures; b...For a partnership orsoie proprietorship: by a general partner or the proprietor, respectively; o r c. For a municipality, state, federal; or other public agency: by either principal executive offices or ranking elected official. For purposes of this chapter, a principal executive officer ofa public agency includes: fl) the chiej'executive officer of the agency or (Y) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency. Certification: N 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 :hat qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system orthose persons directly responsible for gathering the information, the informatior submitted is to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significam penalties for submitting false information including the possibility of fine and imprisonment for knowing violations." Printed Name: Signature �s;gned in ink): Date: Section VII. Submittal Instructions. Submit this form to the Virginia Stormwater Management Program (VSMP) Authority. If the locality is the VSMP Authority, please send your Registration Statement subm teal directly to the locality; do NOT send this form to DEQ. A list of local VSMP Authorities is available here: VSM1' Authorities. If DEQ is the VSMP ,Authority, please send to: Department of Environmental Quality Office .of Star-rnwater Management Suite 1400 PO Box 1105 Richmond VA 23218 coristructiongpPdeci.virginia.gov If the locality is the VSMP Autho. r'rty, please send to: below, Rev 04/2019 PAGE 4 17