HomeMy WebLinkAboutWPO201900004 VSMP - SWPPP 2019-12-23Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
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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: CA Senior Charlottesville VA Property Owner, LLC
2.
3.
Contact: Bethany Crispin
Mailing Address:_
City: Chicago
130 East Randolph Street, Suite 2100
Email address (if available):
State: IL Zip
bcrispin@ca-ventures.com
60601 Phone: 312-800-5391
Indicate if DEQ may transmit general permit correspondence electronically: Yes X❑ No ❑
Existing General Permit Registration Number (for renewals only): N/A
Name and Location of the Construction Activity:
Name: Brookhill Development - Block 8A
Address (if available): Route 29 (Seminole Trail Road) and State Route 643 (Polo Grounds Road)
City: Charlottesville State: VA
Zip:
County (if not located within a City): Albemarle County
Latitude (decimal degrees): 78°27'17.77 Longitude (decimal degrees): 38'06'13.47
Name and Location of all Off -site Support Activities to be covered under the general permit:
Name:
Address (if available):
City: State: Zip:
County (if not located within a City):
Latitude (decimal degrees): Longitude (decimal degrees):
4. Status of the Construction Activity (check only one): Federal ❑ State ❑ Public ❑ Private ❑x
5. Nature of the Construction Activity (e.g., commercial, industrial, residential, agricultural, oil and gas, etc.):
Residential
22902
6. Name of the Receiving Water(s) and Hydrologic Unit Code (HUC):
Name: South For Rivanna River Name:
HUC: JR08 HUC:
7. If the discharge is through a Municipal Separate Storm Sewer System (MS4), the name of the MS4 operator:
County of Albemarle
8. Estimated Project Start and Completion Date:
Start Date (mm/dd/yyyy): 01/20/2020 Completion Date (mm/dd/yyyy): 09/01/2021
9. Total Land Area of Development (to the nearest one -hundredth acre): 5.52 AC
Estimated Area to be Disturbed (to the nearest one -hundredth acre): 5.07 AC
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes ❑ No ❑
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 knowinq violations."
Printed Name: Bethany Crispin Title: Authorized Signatory
Signature: " -w Date: 12/20/2019
(Please sign in INK. T s rtification must be signed by the appropriate person associated with the operator identified in
Item #1.)
07/2014 Page 1 of 1
Section 9. Signed Certification
(Provide certification according to 9VAC25-870-370)
CERTIFICATION
"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."
Operator Name: Bethany Crispin
Company: CA Senior Charlottesville VA Property Owner, LLC
'title: Authorized Signatory
Signature: `
Date: 12/20/20 9
Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County
Section 10. Delegation of authority.
(Provide the persons or positions with authority to sign inspection reports or to modify the stormwater pollution
prevention plan. A formal, signed delegation of authority is needed.)
Delegation of Authority
1 Bethany Crispin (name), hereby designate the person or specifically described position below to be a duly authorized
representative for the purpose of overseeing compliance with environmental requirements, including the Construction General Permit,
at the CA Senior Charlottesville VA Property Owner, LLC onstruction site. The designee is authorized to sign any reports, stormwater
pollution prevention plans and all other documents required by the permit.
(name of person or position) Anthony Herzog
(company) Brinkmann Constructors
(address) 16650 Chesterfield Grove Road, Suite 100
(city, state, zip) Chesterfield, MO 63005
(phone) (636) 537-9700
By signing this authorization, I confirm that I meet the requirements to make such a designation as set forth in the Construction
General Permit (CGP), and that the designee above meets the definition of a "duly authorized representative".
Operator Name: Bethany Crispin
Company: CA Senior Charlottesville VA Property Owner, LLC
Title: Authorized Signatory
Signature: °
12/20/2
Date:
Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County