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Home My WebLink AboutWPO201600074 Correspondence 2019-07-08VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY r FOR OFFICE USE ONLY GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM #IDNumber; CONSTRUCTION ACTIVITIES (VAR10) cal Criteria: 115 ❑ IIC ❑ "EGISTIRAiION STATEMENT 201S NEW ISSUANCE ❑ RE-ISSLIANCEX MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITMOU I ACREAGE INCREASE O Existing Permit Coverage Number (if applicable, VAR10####) r"< I, I O j Section 1. 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: Contact person: Address: City, State, Zip Code: Phone Number: Primary Email: CC Email: / �b8Mrk1Y��° �OtVY�Il 4'Gl-?i1e.i:ddv�. Vic: q5q - 937° - 01340 ,�Ci B k iZGl�i�rmax i..v ,UrC. B. Billing Information (leave blank if same as the Operator Identified In Section I, A. above). This entity will net owt, Annual Permit Maintenance and Permit Modification Fee Invoices (If applicable), rn < 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 V NO ❑ Rev 04/2019 a . PAGE 1) 7 f` r ' CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section II. Construction Activity Location Informadon, 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 format): C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): ti�Ui't,�Dvll� , 4a4', '33.aB 1? 1z 7 y 'ra 06 45 N A �.:amv �s o,►�cv�, ) Section ill. Offsite Support Activity Location Information. List all offsfte 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. Of fte 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 B. Estimated Project Dates permit coverage. Report to the nearest one -hundredth of an acre. (MM/DD/YYYY) Total land area of development (including the entire area to be disturbed as approved in the Stormwater M.314 AC Start date: 0L,/ZOf 7 I Management Plan): i Primary estimated area to be disturbed (portions with I $zp 4 Erosion and Sediment Control Plan approval only): . i Completion date: as / Zola _ Offsite estimated area to be disturbed (If applicable_): II i C. Property Owner Status. FEDERAL ❑ STATE ❑ PUBLIC ivf PRIVATE ❑ D. Nature of the Construction Activity Description (i.e. commercial, Industrial, residential, agricultural,L environmental): E. Municipal Separate Storm Sewer System (MS4)dtn4Y(°c. (owr+ name (if discharging to a MS4): Rev 04/2019 PAGE 2 17 CONSTRUC?ION GENERAL RVIARIT (VAIT110) REGISrRX. O[e STATFNIEMT 2019 F. Is this construction activity part of a common plan of development or sale? YES ❑ NOT6 G. 6 h Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list If needed. �HUC iECGiVING 4VATEROOOY(S) I_ 5 / l Section V. Other Information. A. A stormwater pollution prevention plan (5WPPP) 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 0 NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbedl C. Has land disturbance has commenced? YES J) 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 T HE FOLLOWING PAGE F(--)k, SIGNATURE AND CERTIFICATIOrd REQUIREMENTS AND INFrORMAl ION' Rev 04/2019 PAGE 3 17 CO.AiSTRUCTIORI MERAL PERMIT (VA530) REGISTR,°,TIO?J STATEMENT 1T 2019 Section Vt. 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 arry, facility or ocdvlty 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 pm]Wthat meets either of the following two criteria: (1) the person has direct operational control ov er construction plans and specifications, including the ability to make mod(fcatlons to those plans and specifications or (I/) the person has day-to-day operational contra! of those activities at a project that are necessary to ensure compliance with a stormwater pollution prevention plan for the site or otherstate permit or VSMP authority permit conditions iie., they are authorized to direct workers at a site to carry out activities required by the stormwoter pollution prevention plan or comply with other permit conditions). in the context of stormwater discharges from Municipal Separate Storm Sewer Systems iMS4s), operator means the operator of the regulated M54 system. 9VAC25-880-70. Part 111. K. Signatory Requirements. Registration Statement. All Registration Statements shall be signed as follows: a. For a corporation: by a responsible corporate offlcer. For the purpose of this chapter, a responsible corporate o oer means: (l) a president secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar pollcy-making or decision -making functions for the corporation, orill) the manager of one or more manufacturing production, or operating facilities, provided the manager Is authorized to make management decisions that govem 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 compilonce 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 munklpa0ty, store, fedeF04 or other public agency: by either a prindpal executive officer or ranking elected ojJlcial. For purposes of this chapter, a principal executive offker of a public ggenrylncludes. (i) the chief executive of/►ce, of the agency or (11) a senior executive officer having responsibility far 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. 1 am aware that there are significant penalties for submitting false Information Including the possibility of fine and Imprisonmentforknowing violations." Printed Name: oseh L , �t t t V .r eG%s�L cs f� se fV t K, ib S Signature(aiiew in ink): Date: Section VII. Submittal instru on$. 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 avallable here: VSMP Authorities. It, Dt ibis tho VSMP &rthtuily please send to: Department of Environmental Quality Office of Stormwatar Management Suite 1400 PO Box MS Richmond VA 23218 canstructIonao@deq,virR,;,, . Rev C4/2019 If ri,t, 41r bty a•, tht. Vil _rnteLfL4ar�y, please send to: The total VSMP Authunty ruhseet uddress helowi 1 .J PAGE A 17 0