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Home My WebLink AboutWPO201700076 Construction General Permit (VAR10) Registration Statement 2019-06-05VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY FOR OFFICE USE ONLY GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM ID Number. CONSTRUCTION ACTIVITIES (VAR10) Technical Criteria: IIB 0 IIC 0 REGISTRATION STATEMENT 2019 NEW ISSUANCE 0 MODIFICATION WITH ACREAGE INCREASE ❑ RE -ISSUANCE 12 MODIFICATION WlTHOIITACREAGE INCREASE ❑ Existing Permit Coverage Number (if applicable, VAR10####): VAR 1OL050 1A./ Pe)2 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: University of Virginia Foundation Contact person: Acidness: P O Box 400218 City, State, Zip Code: Charlottesville, VA 22904-42,1,8 _ Phone Number: (434) 982-3777 Primary Email: eschooley@uvafoundation.com CC Email: fmissel@uvafoundation.com & pfiggattCuyafoundation.com B. Billing Information (leave blank if some 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 Viand include a valid email in order to pay by credit card and to receive your permit coverage approval lettervia email: YES IX NO ❑ Rev 04/2019 117 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 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: Address:. City and/or County and Zip Cade: Latitude and Longitude (6-digit, decimal degrees format): Golf Coursa Connector Temporary Road Charlottesville VA 22903 V , ogf,-1 Art V 75. "5381 C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Route 250 Boar's Head Drive Section Ill. 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 may need to obtain coverage under a separate VPDFS permit. A. Offsite Activity Name: Address: City and/or County and Zip Code: Latitude and Longitude (6-digit, decimal degrees format): B. Offsite Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section IV. Site Information. A. Acreage totals far 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 kc, Management Plan): Primary estimated area to be disturbed (portions with, Erosion and Sediment Control Plan a roval only : _+ bffsite estimated area to be disturbed (if applicable): C. Property Owner Status: D. Nature of the Construction Activity Description (Le. commercial, industrial, residential, agricultural, environmental): E. Munlcipal Separate Storm Sewer System (MS4) name (if discharging to a MS4): B. Estimated Project Dates (M M/DD/YYYY) Start date: tz, Dr Completion date: FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE Qk Commercial Rev 04/2019 PAGE 2 1 7 CONSTRUCTION GENERAL. PERMIT (VAR10) REGISTRATION STATEMENT 2019 F. Is this construction activity part of a common plan of development or sale7 YES ❑ NO ®C G. 6"' Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate Ilst If needed. HUC RECEIVING WATERBOAY(S) 02080204 RIvanna �- 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 submitted to the VESCP Authority for review? YES IN NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES IN NO ❑ D. 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 Rev 04/209.9 PAGE 3 17 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 operatorof any facility or.activity subject to the Act and this chapter. In the context of stormwater associated with a large orsmall construction activity, operator means any person associated with a construction project that meets eltherof the following two criteria: (I) the person has direct operational control over construction plans and specyleations, Including the ability to make modifications to those plans and specifications or (11) the person has day -today operational control of those activities at a project that are necessary to ensure compliance with a stormwaterpollution 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 permir conditions). In the context of stomawater 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: (1) a president, secretary, treasurer, orvlce presidentof the corporation in charge of a principal business function, or any other person who performs similar pollcy-making or dedslonmaking functlons for the carpowtion, or (11) the manager of one or more manufacturing, production, or operating facilities, provided the managerls authorized to make management decisions that govern the operation of the regulated faciftty Including having the explicit or Implicit duty of making major capital investmentrecommendations, and initiating and directing other comprehensive measures to assure fang -term compliance with environmental laws and regulations, the manager can ensure that the necessarysystems 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 publk agency: by either prindpal 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 (N) a senlor executive officer having responsibility for the overall operations of a pdndpal geographic unit of the agency. Certification: N certify under penalty of law that l 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: Signature (signed 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 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 is the VSMP Authority, please send to. Department of Environmental Quality Office of 5tormweter Management Suite 1400 PO Box 1105 Richmond VA 23218 constructiongo0decimirainia.gov If the locality, is the VSMP Authority., please send to The Local. VSMP Authors insert address below Rev 04/2019 PAGE 4 17