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Home My WebLink AboutWPO202000018 Construction General Permit Registration Statement 2020-05-18VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT #: GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM PLAN/ID #: CONSTRUCTION ACTIVITIES (VAR10) TECHNICAL CRITERIA: 1113 ❑ IIC ❑ REGISTRATION STATEMENT 2019 Application type. ® NEW PERMIT ISSUANCE (CHOOSE ONE) ❑ MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ EXISTING PERMIT RE -ISSUANCE 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). Operator Name: Contact person: 'Stine McGuirl Address: 1626 East Jefferson SAncel City, State Zip Code: Rockville.VA 20852 Phone Number: Primary Email: 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 ® NO ❑ Section 11. 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: ?9th Place Restaurant with a Drive ThrL -Window Address: 1500 Seminole Rnad_ City and/or County and Zip Code: Charlottesville, VA 2?901 Latitude and Longitude (6-digit, decimal degrees format): 3 1 3 C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Service drive inside shopping center Rev 01/2020 PAGE 1 1 6 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 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 format): _WA B. Offsite Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): N/A Section IV. Site Information. A. Property Owner Status: B. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): C. Municipal Separate Storm Sewer System (MS4) name(s) (if the site is discharging to a MS4): FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE D. Acreage totals for all land -disturbing activities to be included under this permit coverage. Report to the nearest one -hundredth of an acre. Total land area of development (including the entire area to be disturbed as approved in the Stormwater 0.68 Management Plan): Primary estimated area to be disturbed (portions with 0.68 Erosion and Sediment Control Plan approval only): Offsite estimated area to be disturbed (if applicable): N/A E. Estimated Project Dates (M M/DD/YYYY) Start date: 9/1/2020 Completion date: 1/1/2021 F. Is this construction activity part of a common plan of development or sale? YES ❑ NO N G. 6`n Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC RECEIVING WATERBODY(S) 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 vior 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 submitted to the VESC Authority for review? YES N NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES ❑ NO D. Annual Standards and Specifications. If this project is utilizing 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.): Rev 01/2020 PAGE 2 1 6 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section VI. Certification. A person representing the operator as identified in Section I. A. and meeting the requirements of 9VAC25-880-70. Part III. K must physically sign this certification. A typed signature is not acceptable. 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 stormwater 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 stormwater 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. 9VAC25-880-70. Part III. K. Signatory Requirements. 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: �,+J '(?,&r:-z- . P �- Signature (signed in ink): Date Signed: Section VII. Submittal Instructions. Submit this form to the VSMP Authority. If the locality is the VSMP Authority, please send your Registration Statement submittal directly to the locality; do NOT send this form to DEQ. A list of local VSMP Authorities is available here: VSMP Authorities. If DEQ the VSMP Authority, please send to: Department of Environmental Quality Office of Stormwater Management Suite 1400 PO Box 1105 Richmond VA 23218 construction de .vir inia. ov If the locality is the VSMP Authority, please send to: The Local VSMP Authority insert address below) Albemarle County Community Development 401 McIntire Road North Wing Charlottesville, VA 22902 (434) 296-5832 Rev 01/2020 PAGE 3 16