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HomeMy WebLinkAboutWPO201900061 Application WPO VSMP 2020-04-22Virginia Stormwater Management Program (VSMP)+ ' =T Application for Albemarle County " Project Name: Georgetown Hydraulic Professional Offices (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No Rl Is this a revision or resubmission for review? Yes a No ❑ County File Number: WP0201900061 (to be provided by the Countyfor new applications) The following are required elements of new applications [from code section 17-401 J. For revisions or amendments, please indicate which items are being amended. Signatures must be provided for any submission. 0 A. Signature of the Owner for each parcel: (Required with every submission or revision, NOT TO BE SIGNED BY AN AGENT OR CONSULTANT) By signing this application as the owner, I hereby certify that all requirements of these plans and permits will be complied with, and I have the authority to authorize the land disturbing activities and development on the subject property. I hereby grant the County of Albemarle the right to enter upon the prop as required to ensure compliance with the approved plans and permits. l�l dray.t�c- �C� 0600-00-00-00300 f=v=z2X;E;F,— 04/22/20 Tax Map & Parcel Print Name of Owner Tax Map & Parcel Print Name of Owner Tax Map & Parcel Print Name of Owner Signature of OwI(6r/" I J Date Signature of Owner Date Signature of Owner Date Tax Map & Parcel Print Name of Owner Signature of Owner Date Contact Information for the Owner(s) to receive correspondence: Print Name Reid Murphy, BMC Address 400 Locust Avenue, suite 2 City. Charlottesville VA 7ir, 22901 Daytime Phone (434 ) 977-6406 E-mail reid@bmcholdingsgroup.com Revised 07/24/18 Page 1 of 2 0 B. All Fees [Code section 17-208] 0.88 acres For new or modified plans; Total acres proposed to be disturbed Acres to be disturbed I Total Fee Fee Due with this I Application Fee with Transfer or I modification of permit Less than 1 $290 $145 S20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 S300 50 and less than 100 $6,100 $3,050 S450 100 and more $9,600 $4,800 S700 For (minor) amendments to an approved plan; $200 per review Variances; $150 Mitigation Plan; $150 0 C. Registration Statement on the official DEQ form. 0 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. 0 E. Storrnwater Management Plan satisfying the requirements of code section 17-403. 0 F. Pollution Prevention Plan satisfying the requirements of code section 17-404. l� Y� LU r-A % W =; > ' Q- C-, O cc: W 0 G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence (usually the plan preparer, consultant or agent) Print NameJeremy Fox Address 172 South Pantops Drive City Charlottesville Stateva Zip 22911 Daytime Phone (540 ) 290-0932 E-mail lfox@roudabush.eom *When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 months from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO # Fee Amount $ Date Paid By who? Receipt # Ck# By: Ri-vi-zed 07/14/1 R Pnaf- 11. of Virginia Stormwater Management Program (VSMP) Application for Albemarle County .. , Project Name: Georgetown Hydraulic Professional Offices (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No 0 Is this a revision or resubmission for review? Yes R No ❑ County File Number: WP0201900061 (to be provided by the Countyfor new applications) The following are required elements of new applications [from code section 17-401]. For revisions or amendments, please indicate which items are being amended. Signatures must be provided for any submission. 0 A. Signature of the Owner for each parcel: (Required with every submission or revision, NOT TO BE SIGNED BY AN AGENT OR CONSULTANT) By signing this application as the owner, I hereby certify that all requirements of these plans and permits will be complied with, and I have the authority to authorize the land disturbing activities and development on the subject property. I hereby grant the County of Albemarle the right to enter upon the prop as required to ensure compliance with the approved plans and permits. ^ J' cJA i---��y, 0600-00-00-00300_ 8/10/2020 Tax Map & Parcel Tax Map & Parcel Print Name of Owner Print Name of Owner Tax Map & Parcel Print Name of Owner Signature of Owjkr/" I J Date Signature of Owner Date Signature of Owner Date Tax Map & Parcel Print Name of Owner Signature of Owner Date Contact Information for the Owner(s) to receive correspondence: Print Name Reid Murphy, BMC Address 400 Locust Avenue, suite 2 City. Charlottesville VA Tin 22901 Daytime Phone (434 ) 977-6406 E-mail reid@bmcholdingsgroup.com Revised 07/24/18 Page 1 of 2 i, 0 B. All Fees [Code section ,-208] For new or modified plans; Total acres proposed to be disturbed 0.88 acres Acres to be disturbed Total Fee Fee Due with this Application Fee with Transfer or modification of permit Less than 1 $290 $145 $20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 $300 50 and less than 100 $6,100 $3,050 $450 100 and more $9,600 $4,800 $700 For (minor) amendments to an approved plan; $200 per review Variances; $150 Mitigation Plan; $150 Registration Statement on the official DEQ form. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. Stormwater Management Plan satisfying the requirements of code section 17-403. Pollution Prevention Plan satisfying the requirements of code section 17-404. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section l 7-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence (usually the plan preparer, consultant or agent) Print NameJeremy Fox Address 172 South Pantops Drive City Charlottesville StateVa Zip 22911 Daytime Phone (540 ) 290-0932 E-mail Jfox@roudabush.eom *When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 months from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY NN"Po # Fee Amount Date Paid By who? Receipt # Ck# By: RPvi zed 07/7d/1 R Pnaa 7. of 7 COUNTY OF ALBEMARLb Department of Community Developmen 401 MclntimRoad Charlottesville, Virginia 22902 VSMP Application Completeness Check Project Title:F" _ File Number: Date: i Reviewer: Your application has been checked for completeness per section 17-409 of the County Code. All items must be received and correct for the application to be deemed complete. ❑ This application is complete and plan review has begun ❑ This application is not complete. Please provide the missing items checked below. Received y N Correct ❑ Completed application Y N N/A ❑ Signatures of the Property Owners for each parcel affected ❑ ❑ ❑ � ❑ Correct Fees Paid ❑ ❑ O .I" ❑ Registration Statement on the official DEQ form with correct LDA ❑ ❑ ❑ ❑ ❑ Erosion and'Sediment Control Plan satisfl'i g the n requirements ❑ ❑ ❑ of code section 17-402. ❑ ❑ Stormwater Management Plan satis g Eying the requirements of code ❑ ❑ ❑ section 17403. ❑ ❑ Pollution Prevention Plan satisfying the requirements of code ❑ ❑ ❑ section 17-404. The EPA template should be used. ❑ ❑ Stormwater Pollution Prevention Plan satisfying the requirements ❑ ❑ ❑ of code section 17405. The EPA template should be used. ❑ Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ Requested Variations or Exceptions as provided in code sections D ❑ ❑ ❑ 17407 and 408, if applicable. (ssF, MMT, etc) Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. ❑ ❑ D Comments: C-1 Albemarle Count, la .i Planning Application 'ARCEL_ OWNER INFORMATION Tf,1PI 060FO-00-00-00300 Owner(s): CKW 2 L L C Application #I WP020f 900061 11ON Legal Description i ACREAGE PARCEL B i ,ommunib; DevelopmentDepartmeent 401 Mch Rca.4 Char!onesviile. VA22902-4595 'Voice. (4341 29F-5832 Fax: (434) 972-4125 Pla cterial Dist. lack Jouett w 9 - Land Use Primar, Forest iv Current -.FD Not in A/F District E' Current Zoning Primar, Neighborhood Model District .. APPLICATION INFORMATION - Street 4ddre;s Entered By -.„ Jennifer Smith.+ .pplicationTvpc Water Protection Ordinances �. 10 28f2019 Project ITMP 60E-3 - VSMP Receked Date 10/25/19 Received Date Final F I Submittal Date Total Fee; Closing File Date L Submittal Date Final 145 Total Paid 145 Revision Number Comments ; i f i i Legal -d SUB APPLICATION(s) _ Type __]_Sub Applicatio Conirroent Stormwater Nanagement/BMP Plan ..... 10/25/19 i .... ... Erosion and SedinzentControl Plan ....................................................._ ........... .......... _.. 10/25/ 19 _ . --_._ ....._................ ............_...... ....... ._..._ ... _..... ....... . . _..... APPLICANT % CONTACT INFORMATION_ ContaetT pme r Na I :address C&b Statee p J, Phone PhoneCell awrer 4c _-, CK'A' 2 L L C 1747 EARLY'S4TLLE RD CHARLOTTES'41LL 2^901 - .................... ....................................>.. �T= r == '• ' ]EREM, FOX . ... 172 S. P PITOPS DR. _ CH .RLOTTES•:1LL 22911 4349,98121 : ........._._............ REID I•IUR.RH'r Bh1C HOLDIhIGS 400 LOCUST - '.JE„ STE 3 - CH=RLOTTE .'ILL 2292 .4348251560 Signature of Contractor or Authorized Agent Date Virginia Stormwater Management Program (VSMP) Application for Albemarle County Project Name: (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No 0' Is this a revision or resubmission for review? Yes ❑ No 2' cape.aL y r �W.1 County File Number: (to be provided by the Countyfor new applications) The following are required elements of new applications [from code section 17-401]. For revisions or amendments, please indicate which items are being amended. Signatures must be provided for any submission. ❑ A. Signature of the Owner for each parcel: (Required with every submission or revision, NOT TO BE SIGNED BY AN AGENT OR CONSULTANT) By signing this application as the owner, I hereby certify that all requirements of these plans and permits will be complied with, and I have the authority to authorize the land disturbing activities and development on the subject property. I hereby grant the County of Albemarle the right to enter upon the property as required to ensure compliance with the approved plans and permits. p(oOFO —DO ,00- G03b0 Z C�1 k.� /d 25 /9 Tax Map & Parcel Print Name of Owner Si are of Owner ate Tax Map & Parcel Print Name of Owner Tax Map & Parcel Print Name of Owner Signature of Owner Signature of Owner Date Date Tax Map & Parcel Print Name of Owner Signature of Owner Date Contact Information for the Owner(s) to receive correspondence: Print Name T✓vtL I 1G���tC�\ /1 On Address IDS+— p\w 3 CityCJ3 a- 012tt S .V1 State V k Zip Daytime Phone 424 K - E-mail r id IChY1LVlyl C<< nol Ciro K (C1�/�, Revised 07/24/18 Page 1 of 2 B. All Fees [Code section 17-208] For new or modified plans; Total acres proposed to be disturbed c*t S Acres to be disturbed Total Fee Fee Due with this ation Fee with Transfer or modification of permit Less than 1 $290 $14 $20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 $300 50 and less than 100 $6,100 $3,050 $450 100 and more $9,600 $4,800 $700 For (minor) amendments to an approved plan; $200 per review Variances; $150 Mitigation Plan; $150 eC. Registration Statement on the official DEQ form. aD. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. &E. Stormwater Management Plan satisfying the requirements of code section 17-403. ❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence (usually the plan preparer, consultant or agent) Print Name lny)FLx Address-] -7 2— 1�-, Ban 2s, 22C City C�l� it. ✓� �"f'S�%� State \/A' Zip Daytime Phone *When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 months from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY wpo # �h� r�(� �� G Fee Amount $ 1-1 � Date Paid X I qBy who? 11�� +`—` `'J �l \ i` Reee pt # 1 �� V Ck# � 1 By. LC`C. 11 Revised 07/24/18 Page 2 of 2 WJ.strya Conservation October 24, 2019 Jeremy Fox Roudabush, Gale & Associates 172 South Pantops Dr., Suite A Charlottesville, Va 22911 Re: Slate River Nutrient Bank Nutrient Offset Availability Project Name: Georgetown Hydraulic Professional Offices Mr. Fox, This letter is to confirm the availability of authorized nonpoint nutrient offsets at the Slate River Nutrient Bank located in Buckingham County. The Slate River Nutrient Bank has received operational status through the Chesapeake Bay Watershed Nutrient Exchange Program (Virginia Code § 62.1-44.19:12 et seq.) of the Virginia Department of Environmental Quality. DEQ approved this project and issued a Nonpoint Nutrient Credit Generation Certification: Certificate No. James- 045 and an initial credit release for this project on January 14, 2019. As of the date of this letter, Ostrya Conservation, Inc. has 18.18 pounds of phosphorus offsets and 60.85 pounds of nitrogen offsets available for transfer in the approved service area in the James River watershed (including the following HUCs: 02080201/Upper James; 02080202/Maury; 02080203/Middle James -Buffalo; 02080204/Rivanna; 02080205/Middle James -Willis; and 02080207/Appomattox). These offsets were certified pursuant to the Chesapeake Bay Watershed Nutrient Exchange Program by the Virginia Department of Environmental Quality and the Virginia Department of Conservation and Recreation to be used as compensation for state or local permit water quality requirements. These offsets have been generated and are transferable according to § 10.1- 603.8:1 of the Code of Virginia. Please contact me with any questions. Sincerely, James M. Eaton I Director Phone: +1-708-703-2552 Email: lames.eaton(@ostryaconservatio►i.com Ostrya Conservation, Inc., P.O. Box 153, Scottsville VA 24590 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 ❑ MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ Existing Permit Coverage Number (if applicable, VAR10####): 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: gu��i�ljlr�CGK� �ppocr-H Contact person: Q,Lut-p Address: LFOQ Lotu6� nc42 Sui3 City, State, Zip Code: 7;2AO Z Phone Number: 434 — 0111-- 64a(0 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 0 NO ❑ Rev 04/2019 PAGE 1 1 7 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section II. 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: (,��cpj �,1r� u y�`� �cn �p.Ao•` 6ffLy S Address: 2?6di4w�iC �.caOt City and/or County and Zip Code: \1 P� _12AP ) LJ Latitude and Longitude (6-digit, decimal degrees format): 3$,a'jILE83 �Q.lj C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): fi-w6 ixemeiQo,n Q 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 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 1.05 kfei ' Management Plan): Primary estimated area to be disturbed (portions with `� I pars Erosion and Sediment Control Plan approval only): Offsite estimated area to be disturbed (if applicable): C. Property Owner Status: 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): B. Estimated Project Dates (M M/D D/YYfYY) Start date: 041al l I zow Completion date: 64101 IZGZI' FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE [V 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 sale? YES ❑ NO Y' G. 61h Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC RECEIVING WATERBODY(S) OZ 0 $ OZd LI- QiVAn�a 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 1Z NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES ❑ NO 21, 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 1 7 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 111. 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 -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 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 (li) 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: 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 Stormwater Management Suite 1400 PO Box 1105 Richmond VA 23219 constructiopU de .vim iniA-.Lov If the locality is the VSMP Authority, please send to: The Local VSMP Authority insert address below �Gun� M %�l 44 I Mc l l Gl.•ot►- 4es'Ae V)k Rev 04/2019 PAGE 4 17 VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY FOR OFFICE USE ONLY GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM ID Number: _ CONSTRUCTION ACTIVITIES (VAR10) Technical Criteria: 1113 ❑ IIC ❑ REGISTRATION STATEMENT 2019 NEW ISSUANCE Z MODIFICATION WITH ACREAGE INCREASE ❑ Existing Permit Coverage Number (if applicable, VAR10####): Section I. Operator/Permittee Information. RE -ISSUANCE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ 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: Building Management Company Contact person: Reid Murphy Address: 400 Locust Avenue, suite 3 City, State, Zip Code: Charlottesville, VA, 22902 Phone Number: 434-977-6406 Primary Email: reidg_bmcholdingsgroup.com CC Email: rikina roudabush 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 0 NO ❑ Rev 04/2019 PAGE 1 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section II. 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: Georgetown Hydraulic Professional Offices Address: Corner of Georgetown and Hydraulic Road City and/or County and Zip Code: Charlottesville, Albemarle County, 22901 Latitude and Longitude (6-digit, decimal degrees format): 38.071626;-78.499379 C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): 38.071626,-78.499379 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 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 1.05 Management Plan): Primary estimated area to be disturbed (portions with 0.88 Erosion and Sediment Control Plan approval only): Offsite estimated area to be disturbed (if applicable): C. Property Owner Status: B. Estimated Project Dates (M M/D D/YYYY) Start date: 06/01/2020 Completion date: 06/01/2021 FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE 0 D. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): Commercial E. Municipal Separate Storm Sewer System (MS4) name (if discharging to a MS4): 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 ❑ NO 0 G. 6t" Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC RECEIVING WATERBODY(S) JR14 Rivanna River 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 0 NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES ❑ NO W 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 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 auth ority 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: 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 Stormwater Management Suite 1400 PO Box 1105 Richmond VA 23218 constructionep@deg.virginia.eov If the locality is the VSMP Authority, please send to: fhe Local VSMP Authority (insert address below County of Albemarle Rev 04/2019 PAGE 4 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS PLEASE DO NOT PRINT OR SUBMIT This Registration Statement is for coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities. The following permit actions are covered by this form: new issuance, re -issuance, modification with an increase in acreage and plan modifications that do not result in an increase in acreage. Choose NEW ISSUANCE if this Registration Statement submittal is to obtain a new permit coverage, RE -ISSUANCE to renew an active, expiring permit coverage or MODIFICATION to modify an active permit coverage When modifying permit coverage, indicate if the modification is increasing the amount of acreage previous covered (MODIFICATION WITH ACREAGE INCREASE) or changing the site design with no increase in acreage (MODIFICATION WITHOUT ACREAGE INCREASE). Existing Permit Coverage Number. Provide the permit number for a modification or reissuance (i.e. VAR10####). 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. For companies, use the complete, active, legal entity name as registered with a state corporation commission. Entities that are considered operators commonly consist of the property owner, developer of a project (the party with control of project plans and specifications), or general contractor (the party with day-to-day operational control of the activities at the project site that are necessary to ensure compliance with the general permit). If an individual person is named as the operator, that person (or a representative of) must sign the certification in Section VI. An operator can be one of the following: 9VAC25-870-10. Definitions. "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. "Owner" means the Commonwealth or any of its political subdivisions including, but not limited to, sanitation district commissions and authorities, and any public or private institution, corporation, association, firm or company organized or existing under the laws of this or any other state or country, or any officer or agency of the United States, or any person or group of persons acting individually or as a group that owns, operates, charters, rents, or otherwise exercises control over or is responsible for any actual or potential discharge of sewage, industrial wastes, or other wastes or pollutants to state waters, or any facility or operation that has the capability to alter the physical, chemical, or biological properties of state waters in contravention of § 62.1-44.5 of the Code of Virginia, the Act and this chapter. "Person" means any individual, corporation, partnership, association, state, municipality, commission, or political subdivision of a state, governmental body, including a federal, state, or local entity as applicable, any interstate body or any other legal entity. B. Billing information. If the person or entity responsible for billing/invoicing is different from the operator, please complete this section. If they are the same, leave this section blank. C. May we transmit correspondence electronically? If you choose YES to this question and provide an email address in Section I. A., all correspondence, forms, invoices and notifications will be transmitted by email to the operator. This will also allow the operator to pay by credit card and receive permit coverage approval letters immediately upon approval. Section II. Construction Activity Location Information. Location information related to the project site. A. A site map indicating 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 must be included with the submittal of this form. Aerial imagery maps or topographic maps showing the required items are acceptable. Plan sheet sized site maps are not required. Please consult your Virginia Stormwater Management Program (VSMP) authority if you have additional questions regarding site map requirements. B. Provide a descriptive project name (it is helpful to use the same naming convention as listed on the Stormwater plans), 911 street address (if available), city/county of the construction activity, 6-digit latitude and longitude in decimal degrees format for the centroid, main construction entrance or start and end points for linear projects (i.e. 37.1234N/-77.1234W). C. Construction Activity Entrance Location. Provide an address or decimal degrees coordinates and a description of the main construction entrance where the permit coverage letter will be posted. Rev 04/2019 PAGE 5 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS PLEASE DO NOT PRINT OR SUBMIT Section III. Offsite Support Activity Location Information. This general permit also authorizes stormwater discharges from support activities (e.g., concrete or asphalt batch plants, equipment staging yards, material storage areas, excavated material disposal areas, borrow areas) located on -site or off -site provided that (i) the support activity is directly related to a construction activity that is required to have general permit coverage; (ii) the support activity is not a commercial operation, nor does it serve multiple unrelated construction activities by different operators; (iii) the support activity does not operate beyond the completion of the construction activity it supports; (iv) the support activity is identified in the Registration Statement at the time of general permit coverage; (v) appropriate control measures are identified in a SWPPP and implemented to address the discharges from the support activity areas; and (vi) all applicable state, federal, and local approvals are obtained for the support activity. If requesting permit coverage for offsite activities, please complete this section. List additional offsite areas to be included under this permit coverage on a separate page. Offsite areas not included on this registration will need to obtain coverage under a separate VPDES permit. A. Offsite activity location information. Provide a descriptive offsite project name, 911 street address (if available) and city/county of all off -site support activities. Provide the 6-digit latitude and longitude in decimal degrees (i.e. 37.1234N,-77.1234W). Please note that off -site activities not covered under this permit may require separate permit coverage. B. Offsite activity entrance location. Provide an address or decimal degrees coordinates and a description of the main construction entrance. Section IV. Site Information. A. Acreage totals for all land -disturbing activities, on- and off -site, to be included under this permit. Acreages are to be reported to the nearest one -hundredth acre (two decimal places; i.e. 1.15 acres). Provide the total acreage of the primary development site as approved on the Stormwater Management Plans and the primary on -site estimated acreage to be disturbed by the construction activity as approved under the Erosion and Sediment Control Plans. The off -site estimated area to be disturbed is the sum of the disturbed acreages for all off -site support activities to be covered under this general permit. Do not include the off -site acreage totals in the primary, on -site total and estimated disturbed acreage totals. Permit fees are calculated based on your disturbed acreage total for all on- and off -site areas being disturbed under this permit coverage (the sum of all on -site and off -site disturbed acreages). B. Estimated Project Dates. Provide the estimated project start date and completion date in Month/Day/Year or MM/DD/YYYY format (i.e. 07/30/2019). C. Property owner status. The status of the construction activity property owner. Any property not owned by a government entity or agency (i.e federal, state or local governments) is PRIVATE. D. Nature of the construction activity description. Choose the designation that best describes the post -construction use of this project (you may choose more than one). (i.e. Residential, Commercial, Industrial, Agricultural, Environmental, Educational, Oil and Gas, Utility, Transportation, Institutional, etc.). Describe the project (i.e. Commercial — one new office building and associated parking and utilities; Transportation — Roads, sidewalks and utilities; Agricultural — 3 Poultry Houses, etc.). E. Municipal Separate Storm Sewer System (MS4) name(s) if discharging to a MS4. If stormwater is discharged through a MS4 (either partially or completely), provide the name of the MS4(s) that will be receiving water from this construction activity. The MS4 name is typically the town, city, county, institute or federal facility where the construction activity is located. F. This construction activity is part of a common plan of development or sale. "Common plan of development or sale" means a contiguous area where separate and distinct construction activities may be taking place at different times on different schedules per 9VAC25-870-10. Definitions. Le. a subdivision, commercial development, business park, etc. G. 6th Order Hydrologic Unit Code (HUC) and associated Receiving Water Name(s). Provide all 6th order HUCs and receiving waters for the site and offsite areas that could potentially receive stormwater runoff discharging from this activity. The HUC can be either a 12-digit number (i.e. 0208010101) or 2-letter, 2-number code (i.e. JL52). Include additional HUCs or receiving waters on a separate page. You may utilize DEQ's web - based GIS application, VEGIS, to obtain this information. • VEGIS application link: DEQ's VEGIS Mapping Application • Instructions for utilizing DEQ's VEGIS application link: CGP-GIS HUC Instructions Rev 04/2019 PAGE 6 17 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS PLEASE DO NOT PRINT OR SUBMIT Section V. Other Information. A. A stormwater pollution prevention plan (SWPPP) must be prepared prior to submitting the Registration Statement per 9VAC25-880. See 9VAC25-880-70. Part II. of the General Permit for the SWPPP requirements. B. If the Erosion and Sediment Control Plan for the estimated area to be disturbed listed in Section IV. A. has been submitted to the Virginia Erosion and Sediment Control Program (VESCP) Authority for review and plan approval, choose YES. If you are submitting this application to reissue an existing permit coverage, please provide the date that the VESC Authority approved the Erosion and Sediment Control Plan for the estimated area to be disturbed. C. If land disturbance has commenced, choose YES. "Land disturbance" or "land -disturbing activity" means a man-made change to the land surface that may result in soil erosion or has the potential to change its runoff characteristics, including construction activity such as the clearing, grading, excavating, or filling of land per §62.1-44.15:24. Definitions. D. If this project is using approved Annual Standards and Specifications (AS&S), attach the completed AS&S Entity Form. If the AS&S Entity is different from the operator identified in Section I. A., list the AS&S Entity Name. The AS&S entity is the entity or agency that holds the approved annual standards & specification. • AS&S Entity Form link: Annual Standards and Specifications Entity Information Form Section VI. Certification. A properly authorized individual associated with the operator identified in Section I. A. of the Registration Statement is responsible for certifying and signing the Registration Statement. A person must physically sign the certification, a typed signature is unacceptable. State statutes provide for severe penalties for submitting false information on the Registration Statement. State regulations require that the Registration Statement be signed as follows per 9VAC25-880-70 Part III. K. 1.: a. For a corporation: by a responsible corporate officer. For the purpose of this part, 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 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. c. For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this part 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. Section VII. Submittal Instructions. Submit this form to the VSMP Authority that has jurisdiction for your construction activity. The VSMP Authority may be either DEQ or your locality depending on the location and type of project. If your project is under the jurisdiction of a Local VSMP Authority, please contact the locality for additional submittal instructions. A blank area is provided for the Local VSMP Authority to include their mailing address. Who is the VSMP Authority for my project? DEQ or the locality? • DEQ: DEQ is the VSMP Authority and administers permit coverage for land -disturbing activities that are: ➢ within a locality that is not a VSMP Authority; ➢ owned by the State or Federal government; or ➢ utilizing approved Annual Standards and Specifications. • The Locality: The local government (locality) is the VSMP Authority and administers permit coverage for all other projects not covered by DEQ as listed above. For these projects, please submit permit forms directly to the Local VSMP Authority. A list of Local VSMP Authorities is available on DEQ's website here: Local VSMP Authority List. DEQ'S CONSTRUCTION GENERAL PERMIT WEBSITE http://www.deg.virginia.gov/Programs/Water/StormwaterManagement/VSMPPermits/ConstructionGeneraIPermit.aspx Rev 04/2019 PAGE 7 17