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Home My WebLink AboutWPO201800005 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 ❑ IIC ❑ REGISTRATION STATEMENT 2019 NEW ISSUANCE ❑ RE-MSUANCE)4 MODIFICATION WITH ACREAGE INCREASE ❑ Existing Permit Coverage Number (if applicable, Section I. Operator/Perrnittee Information. MODIFICATION WITHOUT G�GG� 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 f Operator Name: t�E ELL (IV, `mil (SS " j.44 C—. Contact person: W E N D F LL 6� L B S Q- Address: x. L4?> 5 ! City, State, Zip Code: 2-- - p Phone Number: ''t 3 2 C) 3 - Li 514 Primary Email: G I 'BS QA/ H O NIF S I r`o 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 Viand include a valid email in order to pay by creditcard and to receive your permit coverage approval letter via email: YES � NO ❑ Rev 04/2019 PAGE 1 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section IL 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: -B1 R N A M VV 6.JQI_b Address: )ra?LRi City and/or County and Zip Code: C "2T4E�79 Vl i L. v rf a Q 1 Latitude and Longitude (6-digit, decimal degrees format): 3 K• �� i �-�-� f -� $4 C. Construction Activity Entrance location (description, street address and/or latitude/longitude in decimal degrees): 0 Section III. Offslte 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 VPDES 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 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 '� 3 Management Plan): Primary estimated area to be disturbed (portions with 33 Erosion and Sediment Control Planapproval only): Offsite estimated area to be disturbed (if applicable): C. Property Owner Status: B. Estimated Project Dates (MM/DD/YYYY) Start date: 01615'1 19 Completion date: 06 10W FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE K D. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): E. Municipal Separate Storm Sewer System (MS4) name (if discharging to a MS4): 'A'a- 6e. Rev 04/2019 PAGE 2 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 F. Is this construction activity part of a common plan of development or sale? YES X NO ❑ G. 6 h Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUG 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 orior 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 b( NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).:_ _ — 2-<O — WE � T C. Has land disturbance has commenced? YESk 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 04/2019 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 operator of 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: (1) the person has direct operational control over construction plans anq specifications, including the ability to make modifications to those plans and specifications or (H) the person has day -today 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 stonnwater discharges from Municipal Separate Storm SewerSysterns (MW), operator means the operator of the regulated MS4 system. 9VAC25-880-70. Part 11I. K. Signatory Requirements. Registration Statement. All Registration Statements shall be signed as follows: a. Fora corporation: by a responsible corporate officer. For the purpose of this chapter, a responsible corporate officer means: (I) a president; secretary, treasurer, or vice-presiden t of the corporation in charge of a principal business function, or any other person who performs similar polity -making or decision -making functions for the corporation; or (Il) the manager of one or more manufacturing. production, or operating fadlldes, provided the manager is authorized to make management decisions that govern the operation of the regulated facility including haWng 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 necessarysystems are establishedor actions token to gather complete and accurate information for state permit application requirements; and where authority to sign documents has been assigned ordelegated 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 otherpublic agency: by either a principal executive officer or ranking elected offldal. For purposes of this chapter, a principal executive officer of a public agency includes: (i) the chief executive of of the agency or (ii) a senior executive officer having responsibilityfor 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: Signature (signed in ink): Date: 6.!f 15 Section Vli. Submittal Instructions. Submitthis 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 DECi 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 Stormwater Management Suite 2400 PO Box 1105 Richmond VA 23218 constructioneo#Ddea.virei nia.eov If the locality is the VSMP Authorityplease send to: The Local VSMP Author' insert address below Rev 04/2019 PAGE 4 RECEIVED JUN 0 5 2019 COMMUNITY DEVELOPMENT