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Home My WebLink AboutWPO201700040 Construction General Permit (VAR10) Registration Statement 2019-06-05t/ VIRGINIA 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 -ISSUANCE N MODIFICATION WITN ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ Existing Permit Coverage Number (if applicable, VARIOW##): l- Iz ! 0 L31 ;2 Q �� Section I. Operator/Permittee Infi rffmdon. 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 genera I 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: 04A-LSarJ (fON57-fZIAGT/0rJ CcPf40 h) ' Contact person: Clf2/S ,aaNA 1-5-5 rJ Address: CAAFT42 DU 2Y l2}� City, State, Zip Code: (�ff4kL67rc5 d it-1-6 VA a.2 9 03 Phone Number. (5 r"l,2-9 — 3 13 4- Primary Ema [k �oM14LSa114 CaNjST2 eia 461—CcM CC Email: 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 ,XS and include a valid ema H in order to pay by cnedit card and to receive your permit coverage approval letter via email: YES ❑ NO ❑ Rev 04/2019 PAGE 1 7 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: _/ 1p �)Riy' WA i Address: 3S J 9 S t,L'%} 0_4I- AP4 1) City and/or County and Zip Code: NDP-T4 [�RPi}r nl , I/A ;Mcl4 Latitude and Longitude _ (6-digit, decimal degrees format): 3 r]. 75+ 13 6 r% � � O. (s �3 � 2 5 2 C. Construction Activity Entrance Location (description, street address and/or 3.�r latitude/longitude in decimal degrees): - r 7 �' V 6 Section III. Offsite Support Activity Location Infonnation. List all offske support activities to be included under this permit registration. Enter additional areas on a separate page. Ofisite areas not included on this registration may need to obtain coverage under separate VPDES permit. A. Offisite Activity Name: Address: City and/or County and Zip Code: Latitude and Longitude (6-digit, decimal degrees format): B. OfFsite Actly ty 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 nearestone-hundredth of an acre. Total land area of development (including the entire area to be disturbed as approved in the Stormwater 69 2. 74- Management Plan): Primary estimated area to be disturbed (portions with 3 7 Erosion and Sediment Control Plan approval only): • -2 Offsi a estimated area to be disturbed (if applicable): C. Property Owner Status: B. Estimated Project Dates (MM/DD/ M) Start date: 51; /2d 17 Completion date., 511 LIO.20 FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE Lg D. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): 26-5 f DzwT i Ai— E. Municipal Separate Storm Sewer System (MS4) name (if discharging to a MS4): Rev 04/2029 PAGE 2 1 7 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 F. Is this construction activity part of a common plan of development or sale? YES ❑ NO lU/ G. 61' Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC RECEIVING WATERBODY(S) NorzT?} re/Lrc RAAo wPozG 'Rwrk 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 of5tormwater from Construction Activities nrktr 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 VNO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: S 0 i I?M C. Has land disturbance has commenced? YES 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 difkrent from the Operator identified in Section II. A.): SEE THE FOLLOWING PAGE FOR SIGNATURE AND CERTIFICATION REQUIREMENTS AND INFORMATION Rev 04/2019 PAGE 3 1 7 CONSTRUCTION GENERA! 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 9VAC25470-10 as follows: 'operator" means the owneror operator of onyfacility, or activitysubject to the Actand this chapter. in the context of stormwater associated with a large or small construction activity, operatormeans any persan associated with a construction project that meets either of the following two criteria: (i) the person has direct operational control over construction pkrns and spedf ications, including the ability to make modifications to those plans and specifications or(ii) the person has day-to-day operational control of those acdWies at a project that are necessaryto ensure compliance with a stormwater pollution prevention plan for the site or other state permit or VSMP authoritypermit conidiMins (i.e., they are authorized to direct workers at a site to carry out activities required by the stiormwaterpollution prevention plan or comply with otherpermit conditions). In the aantw.xtof stormwater discharges from Municipal SeparateStorm SewerSysmms (MS4s), operotar means the operator of the regulated M54 system. 9VAC25-880-70. Part Ili. K. Signatory Requirements. Registration Statement. All Registration Stotementsshall be signed as fdlaws. 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 otherperson who perfonnisslmllar policy -making or dfeddon-makingfunctions for the corporation; or (A) the manager of one or more manufacturing, production, or operating facilities, provided the manageris authorized to make management decisions that govern the operation of the regulated fadilty including having the explicit or implicit duty of making major capital in vestment recommendations and initiating and directing other comprehensive measures to assure long-term compliance with environmentollaws and regulations; the manager can ensure that the necessorysystems are established or actions taken to gather compplete 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 ofidal. For purposes of this chapter, a principal executive officer of a public agency indudes; (r) the chief executive officer of the agency or (ii) a senior executive c0cerhaving 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: jib.' At..sa�1 60N Signature (signed in C6MPA4Jy CHRIS ,()drJA1,5AM Date: Section VII. Submittal Instructions. Submit this form to the Virginia Stormwater Management Progra m (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 DE4 A list of local VSMP Authorities is available here: VSMP Authorlties. If DEQisthe VSMP Authority please send to: Department of Environmental Quality Office of Stormwater Management Suite 2400 PO Box 1105 Richmond VA 23218 construction¢oLEDdeg.v-irizinia.eov If thg locality is the VSMP Authoplease send to: I1•a- • 1 L11-111 Rev 04/2019 PAGE 4 17