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Home My WebLink AboutWPO201800040 Correspondence 2019-03-21DRAFT VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM CONSTRUCTION ACTIVITIES (VAR10) REGISTRATION STATEMENT NEW ISSUANCE ❑ RE -ISSUANCE FOR OFFICE USE ONLY Plan Number: Technical Criteria: 118 ❑ IIC El MODIFICATION WITH ACREAGE INCREASE El {� MODIFICATION WITHOUT ACREAGE INCREASE ❑ �) Existing Permit Coverage Number (if applicable): Ns 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 Ill. K. of the VAR10 Permit). Construction Activity Operator Name: Contact person: Address: City, State Zip code: 5 �, pp 1 Sri LC Phone number: . _ 3 Z:. _ ' Primaryemail:}(' , t , .. .}� 5_i_4 , _ )=.-(��. y } , ��F / �, CC Email:ysi��- f�.15i'��CW °}''r 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: Primaryemail: 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: YESZ[ NO ❑ DEQ 199-DRAFT PAGE 1 1 8 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 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: Address•. City and/or County and Zip code Latitude and Longitude (6-digit decimal degrees): 041 C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): 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 will 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): B. Offsite Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section IV. Site Information. r A. Acreage totals for all land -disturbing activities to be included and this permit coverage. (to the nearest one -hundredth of an acre) Total land area of development (include the entire area to be disturbed under the approved Stormwater Management Plan): Estimated area to be disturbed (portions with Erosion (( �r�— and_Sedim_ent Control Plan approval only): 5 , cd- Offsite 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. Municipal Separate Storm Sewer System (MS4) name (if discharging to a MS4): DEQ 199-DRAFT B. Estimated (MM) Start date: Completion date: Project Dates DD/YYYY) 05l) FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE 1 r : �... t .. �.• fit. p r -i PAG 2 18 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT F. This construction activity is part of a common plan of development or sale: YES Y NO 61hOrder Hydrologic Unit Code (HUC) and associated Receiving Water Name(s).. InclwI—G. receiving waters on a separate page. HUC I RECEIVING WATERBODY(S) r0l, Section V. Other Information. additional HUCs and 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 approved forthe disturbance in Section IV. A.? YES ❑ NO ❑ If yes, provide the plan number: and date of Erosion and Sediment Control Plan approval: C. Land disturbance has commenced: YES �NO ❑ D. Stormwater management maintenance agreement included (if applicable): YES ❑ PREVIOUSLY sUBMITTEO�Not Applicable ❑ E. 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 DEQ 199-DRAFT PAGE 3 1 8 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT Section VI. Certification. This Certification must be signed by a person representing the operator identified in Section II A. and meeting the requirements of 9VAC25-880-70. Part 111. K. 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 storm water pollution prevention plan for the site or other state permit orVSMP authority permit conditions (i.e., they are authorized to direct workers at a site to carry out activities required by the storm water pollution prevention plan or comply with other permit conditions). In the context of storm water 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: 1. 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 orsole 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 responsibilityfar 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 orthose 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." A Printed Name: i+di� fir i' Signature (signed in Ink): _.. - Date: Registration Statements should be submitted to: Fairfax County Department of Land Development Services (LDS) Site Application Center, 2nd Floor, Herrity Building 12055 Government Center Parkway Fairfax, VA 22035-5506 Ir r,tt Ytg+. t n.,;sr f. DEQ 199-DRAFT PAGE 4 18