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Home My WebLink AboutWPO201600072 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: 110 ❑ IIC ❑ REGISTRATION STATEMENT 2019 NEW ISSUANCE ❑ RE -ISSUANCE i" MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION VMQUTACREAGE �INCREASE ❑ Existing Permit Coverage Number (If applicable, VAR10fff N)• �� 1- O � I i b 9dtg� 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: baNAt-56N (aI`ISTrzut-r?,sN( COMPANI Contact person: '�2HRI s b W41-5 04 Address: �;i + cAAt -ry 2 ,3 L12 Y R D City, State, Zip Code: \1 A 9,?-'1b 3 Phone Number: (.540) 7z1 - 3 i 3 4 Primary Email: clyx}�SariCo[�ST2�n FFo� .0 CC Email: B. Billing Information (leave blank if same as the Operator Identified In Section 1. 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 Emall: CC Email: Maywe transmit correspondence electronically? You must choose XF ,,and include a valid email in order to pay by credit cam and to receive your permit coverage approval letter via email: YES M" NO ❑ Rev 04/2019 PAGE 1 . 7 1! a CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section 11. Construction Activity Location infonmation. Project site Infonrnation. 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 Code: Latitude and Longitude (6-digit, decimal degrees format): arsLLni Mu_t-s L-lc?A7- f /}2K ! 706- B IZcAD 0AY 5',fla-e 1 HA21 d 71 5 V I l<LE 0 V A a 9 9 0 oZ C. Construction Activity Entrance Location (description, street address and/or latitude/longitude In decimal degrees): - 1 N'?-EnJ 1=cTr o ns c i= FOCAN K L-i r j Sr Ar4D f ((3' e2C'g Qw-ar- 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. Offslte areas not included on this registration may need to obtain coverage under separate VPDES permit. A. Offsite Activity Name: Address: City and/or County and Zip Code: Latitude and Longitude (6-digit, decimal degrees format): B. Offslth Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section iV. site Information. A. Acreage tota Is 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 14, 6 Ca Management Plan): Primary estimated area to be disturbed (portions with 7 Erosion and Sediment Control Plan approval on : • Offsite estimated area to be disturbed (if applicable): C. Property Owner Status: B. Estimated Project Dates (MM/DD/YYYY) Start date: ((�! 4 /17 Completion date: j (�I tp/a2 FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE D. Nature of the Construction Activity Description (i e. commercial, Industrial, residential, agricultural, environmental): ► PJ NA S T!Z 1 A-t-- E. Municipal Separate Storm Sewer System (MS4) A 4 name cif discharging to a MS4): Rev04/2019 PAGE 2 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 F. Is this construction activity part of a common plan of development or safe? YES❑ No G. & Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC I RECEIVING WATERBODY(S) TR15" 0a20TCac4,0-f a Moanes CR CK TR17 can geao+a4oL.INF} Zlv:%, 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 resubmitting the Registration Statement. By signing the Registration Statement, the operator is certifying that the SWPPP has been prepared. M ES B. Has an Erosion and Sediment Control Plan been submitted to the VESCP Authority for review? YNO r-1 Erosion and Sediment Control Plan ApprovalDate(for estimated area to be disturbed).:_ q/.24/ 2 n 17 C. Has land disturbance has commenced? YES iYNO 0 D. if this project is using approved Annual Standards and Specifications (ASBS), attach the completed AS&S Entity Form. AS&S Entity Name (if different from the Operator identified in Section If. 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 foilo ws: 10perator"means the owner or operator of anyfudlityor activity subject to the Act and this chapter. In the context of stormwater associated with a large or small construction aCt1 *Y. operatormeans onyperson associated with a construction project that meets either of the following two criterla: (f) the person has direct operational control over construction plans and speciftcations, Including the ability to make modifications to those plans and speclflcatims or (il) the persona has day -today operational control of those ottivities at a project that are neaessmy to ensure compliance with a stomrwater pollution prevention plan for the side or otherstate permit or VSMP authority permit conditions (Le„ they are authorized to direct workers at a site to carry out activities required by the stormwater pollution prevention pion or comply with other permit conditions). In the cantextof stormwater discharges from Municipal Separate Storm SewerSysterms (MS4s), operator means the operator of the regulated MS4 system. 9VAC25-880-70. Part Iil. K. Signatory Requirements. Registration Statement. AN Registration Statements shall be signed as fafty s: a. For a corporation: by a respans W corporate officer. For the purpose of this chapter, a responsible corporate offer means. (1) a president, secretary, treasurer, or vice-president of the Corporation Jr; charge of a prindpol business junction, or any other person who pedkWmslmiiar poflcy-making or dsdslon making fungtons for the corporation; or the manager of one or more manufacturing, production, or operating foolides provided the manageris authorized to make management decisions that govern the operation of the regulated facillty Including havhing the explldt or imp" duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term compliance with environmentallaws and regulations, • the manager can ensure that the necessary systems are established or actions taken to gathercomplete and accurate Information for state permit appruadon requirements; and where authority to sign documents has been assigned ar delegated to the manager in accordance with corporate procedures; b. For a partnership orsole propriemrshoip: bya general partner or the proprietar, respectively, or c. For a municipality, state, federat or other public agency: by either a principal executive officer or ranking elected offidal. For purposes of this chapter, a principal executive offraerof a pubic agencyindudes: (►) the chief executive officer of the agency or (ii) a senior executive offrrerhav€ng responsibility far the overall operations of a principal geogrophicunit 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 eva luated 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: oVgLsc,-f C6NSTkL&cT,--i�'-.r,l MJ0 C-AV -S a�fl�So Signature(s�nedlnink)� � war-�,ryoavw.�g fr,%,�;,� Date: + l 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 Iocal€ty; do NOT send this form to DEQ. A list of local VSMP Authorities Is available here: VSMP Authorities. If DEQ Is tb e VSM P Authority, please send to: Department of Environmental Quality Office of Stormwater Management Suite 1400 PO Bore 1105 Richmond VA 23218 constructiongn@dea.virainia.gov_ Rev 04/2019 ifthelocality is the VSf1j1P Authorityplease send to: PAGE 4 17