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Home My WebLink AboutWPO202000035 VSMP - SWPPP 2020-10-08-0J ALttl9 COUNTY OF ALBEMARLE z Department of Community Development c . T 401 McIntire Road, North Wing Charlottesville, Virginia 22902-4596 Tel. (434) 296-5832 • Fax (434) 972-4126 Stormwater Pollution Prevention Plan (SWPPP) For Construction Activities At: Project Name: VALVOLINE INSTANT OIL CHANGE Address: GANDER DR CHARLOTTESVILLE, VA 22901 Prepared by: Name: CESO,INC. Prepared for: Name: VALVOLINE INSTANT OIL CHANGE SWPPP Preparation Date: SEPTEMBER 2020 (This document is to be made publicly available according to 9VAC25-880-70, Part II, section D) APPROVED by the Albemarle County Community D� plogment Department Date 70 U File WP0202000035 Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County CONTENTS: (from Albemarle County Code Sec. 17-405) 1. Registration statement 2. Notice of general permit coverage 3. Nature of activity 4. Erosion and Sediment Control Plan. 5. Stormwater Management Plan 6. Pollution Prevention Plan. 7. Discharges to impaired waters, surface waters within an applicable TMDL wasteload allocation, and exceptional waters. 8. Qualified personnel 9. Signed Certification 10. Delegation of authority. 11. General permit copy 12. Inspection logs Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 1. Registration statement (Provide a signed completed copy of the DEQ registration statement) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT #: GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM PLAN/ID #: CONSTRUCTION ACTIVITIES (VAR10) TECHNICAL CRITERIA: IIB ❑ IIC ❑ REGISTRATION STATEMENT 2019 Application type. ® NEW PERMIT ISSUANCE (CHOOSE ONE) ❑ MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ EXISTING PERMIT RE -ISSUANCE 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). Operator Name: VALVOLINE INSTANT OIL CHANGE Contact person: Garland Watkins Address: 100 VALVOLINE WAY City, State Zip Code: LEXINGTON, KY 40509 Phone Number: Primary Email: garland.watkins@valvoline.com 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 N NO ❑ 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: VALVOLINE INSTANT OIL CHANGE Address: GANDER DR City and/or County and Zip Code: CHARLOTTESVILLE, VA 22901 Latitude and Longitude (6-digit, decimal degrees format): 38.090833°N, 78.467778°W C. Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): NORTHEAST SIDE OF PARCEL FROM GANDER DR. Rev 01/2020 PAGE 1 1 6 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 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 format): B. Offsite Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Section IV. Site Information. A. Property Owner Status: B. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental): C. Municipal Separate Storm Sewer System (MS4) name(s) (if the site is discharging to a MS4): FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE COMMERCIAL D. 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 1.14 AC Management Plan): Primary estimated area to be disturbed (portions with 0.56 AC Erosion and Sediment Control Plan approval only): Offsite estimated area to be disturbed (if applicable): E. Estimated Project Dates (MM/DD/YYYY) Start date: TBD Completion date: 150 days after start F. Is this construction activity part of a common plan of development or sale? YES ❑ NO ❑ G. 6`n Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed. HUC RECEIVING WATERBODY(S) 020802040203 South Fork 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 VESC Authority for review? YES CK NO ❑ Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).: C. Has land disturbance has commenced? YES ❑ NO EN D. Annual Standards and Specifications. If this project is utilizing 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.): Rev 0112020 PAGE 2 16 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 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 (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): Gal'4A% i Watkins Date Signed: 09-29-20 Section VII. Submittal Instructions. Submit this form to the 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: If the locality is the VSMP Authority, please send to: Department of Environmental Quality Office of Stormwater Management Suite 1400 PO Box 1105 Richmond VA 23218 constructionkrp@deg.virginia.gov Rev 0112020 PAGE 3 16 Section 2. Notice of general permit coverage (This notice is to be posted near the main entrance according to 9VAC25-880-70, Part H, section C.) (Provide a copy of the DEQ coverage letter when obtained) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 3. Nature of activity (Provide a detailed narrative of the construction activities. Include or reference a construction schedule and sequence. Include any phasing.) The project site is located along Gander Dr. in Charlottesville, VA (38.0908330N, 78.467778°W). Construction takes place on an area of undeveloped land within a larger commercial development. Total parcel area is 1.14 acres and total disturbed area is 0.59 acres. Valvoline is proposing the construction of a 2,080 square foot instant oil change facility which will include a dumpster enclosure, paved parking, landscape improvements, and utility infrastructure. Utilities proposed for the site include water and sanitary service, storm sewer, gas service, and underground electric and telephone. Construction activities occur in 2 phases and will include: Phase 1: Installation of erosion and sediment controls. Stripping and stockpiling. Phase 2: Installation of erosion and sediment controls. Site grading. Installation of underground utilities and sewer. Building construction. Fine grading and pavement operations. Landscape operations. Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 4. Erosion and Sediment Control Plan. (Provide a reduced, 11x17 copy of the latest Erosion and Sediment Control Plan. Do not reference only.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Fe 0 \ 6 �p r 19 e Run R jog C [ 3 d R 4 A € g s $ 8g €3's F?Es $IfI .h F (ni VALVOLINE INSTANT OIL CHANGE ($n 5' 3 m ■ § OANDER DRIVE CHARLOTTESVILLE, VA 22901 d�.E$� 4 i 9HI m @ja= $g g 7y e 3 $ gg$ N pia ¢ @gs Ifl p s w ¢¢ ¢¢ s � ;4ee 88® TIN €3's F?Es g _ jW,4 ■§ - DANDER DRNE CHARLOTTESVILLE, VA 22901 10 d .ESA Section 5. Stormwater Management Plan (Provide a reduced 11 x 17 copy of the latest stormwater management plan. Do not reference only.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County 0 & mG g mG g mG 0 m � = mo floi n odd12g F 5$3 55g$3 55i n E € ;n� y w gad gad f al ry ry A 1911.E €l 1 @as Ell m 5 c $ 5 ga ¢€ g@ $ F k`1w M 5 F i iof !� £ _cpg WE a €� s wa 9 i• a € ei g if �eSS&�?�58pt et jigIf S I 5a f.�.��sa i l` A�gg�A�e� j9Bp G b c G,4 k 4 I o �g a' p£as�E� s55s A t a § I €g Pal id ; EEE65i=E k G e e3 [3 gg 1 ag� �@R 19 G&EE'" De v c 33 S6�EE; m �._ $$$ 6 ; E G j S VALVOLINE INSTANT OIL CHANGE {M $& ¢` GANDER DRIVE CHARLOTTESVILLE, VA 22K1 � :AS n�5 SB 59i 92 48 �9� a � p Section 6. Pollution Prevention Plan. (reference County Code 17-404 and State Regulation 9VAC25-880-70 part II section AA) A. Plan showing pollution activities and prevention practices (Provide a reduced I W7 copy of a site plan on which all of the following activity locations are clearly marked. Keep this plan up-to-date with ongoing site changes and inspections.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County 4 i 9HI m @ja= $g g 7y e 3 $ gg$ N pia ¢ @gs Ifl p s w ¢¢ ¢¢ s � ;4ee 88® TIN €3's F?Es g _ jW,4 ■§ - DANDER DRNE CHARLOTTESVILLE, VA 22901 10 d .ESA B. Sources of Pollutants, locations, and urevention uractices Pollutant, or Pollutant Location on site Prevention Practices, Generating Activity Control Measures C. Sources of Pollutants, continued. Common activities and minimum control and prevention ractices Pollutant, or Pollutant Location on site Prevention Practices, Generating Activity Control Measures Follow Erosion and Sediment Control Clearing, grading, excavating, and on- Land disturbance area Plan. Dispose of clearing debris at stabilized areas acceptable disposal sites. Seed and mulch, or sod within 7 days of land clearing Cover storm drain inlets and use drip Paving operations Roads and driveways pans and absorbent/oil dry for all paving machines to limit leaks ands ills Direct concrete wash water into a leak - Concrete washout Current location and detail shown proof container or leak -proof settling and cement waste on plan basin that is designed so that no overflows can occur Enclose or cover material storage areas. Mix paint indoors in a containment area or Structure construction, stucco, Structures in a flat unpaved area. Prevent the painting, and cleaning discharge of soaps, solvents, detergents and wash water, paint, form release oils and curing compounds. Water shall be filtered, settled or similarly Dewatering operations Dewatering sites shown on plan treated prior to discharge as shown on Plan. Designated areas for material delivery Material delivery and storage Designated area shown on plan and storage. Placed near construction entrances, away from waterways and drainage paths Follow manufacturer's instructions Material use during building process Building areas . MSDS's attached. waste collection area will not receive a substantial amount of runoff from upland Solid waste disposal Current designated container areas areas and does not drain directly to a on plan waterway. Containers have lids covered before periods of rain, or are in a covered area. Scheduled collection to prevent Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Pollutant, or Pollutant Location on site Prevention Practices, Generating Activity Control Measures overfilling. MATERIALS NOT TO BE BURIED ON -SITE Convenient and well -maintained portable sanitary facilities will be Sanitary waste Current locations shown on plan provided, and located away from waterways or inlets. Such facilities shall be regularly maintained. Apply fertilizers in accordance with Landscaping operations Landscape areas shown on plan manufacturer's recommendations and not during rainfall events To be treated in a sediment basin or better control as specified on plan. Wash Waters Wash areas shown on plan Minimize the discharge of pollutants from a ui ment and vehicle washing Designated areas and details shown on Provide containment and filtering for all Vehicle and equipment washing plan wash waters per the plan Minimization of exposure to precipitation and stormwater. Minimize the exposure of building materials, building products, construction wastes, trash, landscape materials, fertilizers, pesticides, herbicides, detergents, sanitary waste, and other materials present on the site to precipitation and to stormwater. (Identify all non-stormwater discharges to occur on your site. Keep this plan up-to-date with ongoing site changes and inspections. See CGP, 9VAC25-880-70 section E for examples of non-stormwater discharges.) D. Non-stormwater dischar es Discharge7 :F_ Pollutants or Pollutant Location on Site Constituents Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County E. Persons responsible for pollution prevention practices (Provide the names and contact information for all persons responsible for prevention practices as listed above.) F. Response and reporting practices Minimize discharges from spills and leaks. Minimize the discharge of pollutants from spills and leaks and implement chemical spill and leak prevention and response procedures as follows. Respond to all spills, leaks and discharges as follows; Report all spills, leaks and discharges as follows; (Provide detailed response and reporting practices according to 9VAC25-880-70, Part II, section AA.e.) G. Pollution Prevention Awareness (Describe training and procedures to provide awareness and compliance for all measures in this document; waste management, wash waters, prevention measures, etc.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 7. Discharges to impaired waters, surface waters within an applicable TMDL wasteload allocation, and exceptional waters. (Provide detailed measures for any applicable TMDL) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 8. Qualified personnel The following personnel are responsible for inspections; (Provide the name, telephone number, and qualifications of the qualified personnel conducting inspections.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 9. Signed Certification (Provide certification according to 9VAC25-870-370) "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate 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." Operator Name: Garland Watkins Company: Vavoline LLC Title: Project Manager Signature: 6a kVi Watkiks Date: 09-29-20 Issued—10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 10. Delegation of authority. (Provide the persons or positions with authority to sign inspection reports or to modify the stormwater pollution prevention plan. A formal, signed delegation of authority is needed.) Delegation of Authority I, (name), hereby designate the person or specifically described position below to be a duly authorized representative for the purpose of overseeing compliance with environmental requirements, including the Construction General Permit, at the construction site. The designee is authorized to sign any reports, stormwater pollution prevention plans and all other documents required by the permit. (name of person or position) (company) (address) (city, state, zip) (phone) By signing this authorization, I confirm that I meet the requirements to make such a designation as set forth in the Construction General Permit (CGP), and that the designee above meets the definition of a "duly authorized representative". Operator Name: Company: Title: Signature: Date: Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 11. General permit copy (Provide a copy of the construction general permit, 9VAC25-880) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 12. Inspection logs (Provide templates for your inspections. Requirements are listed in 9VAC25-880-70, Part H, section B and F.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County 3/2/2021 Independence Construction Mail-(no subject) IIV I Carrie Watkins <cwatkins@icvgc.com> iEPENDESOCE CON`,TRU-CTIO t (no subject) 1 message Carrie Watkins <cwatkins@icvgc.com> Tue, Mar 2, 2021 at 2:06 PM To: Carrie Watkins <cwatkins@icvgc.com> VSMPNESCP Contact Information Project Name: Valvoline Instant Oil Change- ProjectJWPO WPO-2020-00035 VSMP Number: Tax Map/Parcel 45-111 C/04500-00-00-111 CO DEQ Permit Number VAR10P111 (if applicable): Valvoline-John Culley, Land Handley Excavation & Owner/contact construction manager 859-221- Site Operator/phone Development/434-806-8895 8641 Qualified Jack Kay, ICV project manager Principle Carrie Watkins/757-490- Personnel/phone 757-679-8096 contact/phone 1500 Contact E-Mail: cwatkins@icvgc.com RLD name & number Rick Trites-757-402-2243/ contact info rtrites@icvgc.com Inspector: Jonney Otto/434.981.5154 Nutrients Credits Disturbed Acreage: 1.14 acres Carrie W. Watkins Vice President of Business Development Independence Construction Co. of VA 3oi Cleveland Place,Suite io3 Virginia Beach,VA 23462 757-470-5531 direct 757-552-0768 fax www.icvgc.com https://mail.google.com/mail/u/0?ik=e326f7fadd&view=pt&search=all&permthid=thread-a%3Ar-552547549312069296&si mpl=msg-a%3Ar-188205295... 1/2 April 1,2017 < ;Y A i DDT Virginia Department of Transportation Land Use Permit Application(LUP-A) APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below.Said activity(s)will be done under and in accordance with the rules and regulations of the Commonwealth Transportation Board of Virginia,in so far as said rules are applicable thereto and any agreement between the parties herein before referred to. Where applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to maintain work in a manner as approved upon its completion.Applicant also hereby agrees and is bound and held responsible to the owner for any and all damages to any other installations already in place as a result of work covered by resulting permit.Applicants to whom permits are issued shall at all times indemnify and save harmless the Commonwealth Transportation Board members of the Board,the Commonwealth and all Commonwealth employees,agents,and offices,from responsibility, damage,or liability arising from the exercise of the privileges granted in such permit to the extent allowed by law.In consideration of the Issuance of a permit the applicant agrees to waive for itself,successors in interest or assigns any entitlements it may otherwise have or have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the Department or its successor,chooses to exercise its acknowledged right to demand or cause the removal of any or all fixtures, personality of whatever kind or description that may hereafter be located,should this application be approved. Applicant information: Driver's License or Tax ID No. 61-1782197 Contact Name Garland Watkins Owner Name Valvoline LLC E-mail Address garland.watkins@valvoline.com Address 100 Valvoline Way Telephone Number (804)840-1992 City Lexington State KY Zip Code 40509 Emergency Telephone Number (859)357-7189 Fax Number Agent information: Driver's License or Tax ID No. 54-1364524 Contact Name CARRIE WATKINS Owner Name INDEPENDENCE CONSTRUCTION CO.OF VA. E-mail Address CWATKINS@ICVGC.COM Address 301 CLEVELAND PLACE, SUITE 103 Telephone Number(757)490-1500 City VIRGINIA BEACH Slate VA Zip Code23462 Emergency Telephone Number(757)470-5531 Fax Number(757)552-0768 365 days 110.00 Permit Term Requested yFees Enclosed$ Check Number Money Order Estimated cost of work to be performed on VDOT Right of Way$ Surety Information: Surety Posted by: ❑✓ Owner n Agent _County Resolution n Waived If cashlcheck surety is posted,please complete Bonding Company Name Bond# Commonwealth of Virginia's Substitute Form W9. Irrevocable Letter of Credit - Bank Name Irrevocable Letter of Credit# Surety paid by Check- Check Number Amount of Surety$ 2500.00 Obligation Amount$ Request permission to perform the following activity(s): Construct a public sidewalk within the ROW(VDOT) as per attached plans. Location: 6/ County❑Town laity of Albemarle Route No. 29 Street Name Seminole Trail Between Route No. Street Name Gander Dr and Route No. Street Name Woodbrook Dr Latitude Longitude Tax Map Number 04500-00-00-111C0 Applicant Job No. Applicant shall provide proof of registration as an operator with the appropriate notification center In accordance as defined In§2.2-1151.1 of the Code of Virginia&must provide a notarized affidavit,slating that the utility owner has notified the commercial and residential developer,owner of commercial or multifamily real estate,or local government entities with a property Interest in any parcel of land located adjacent to the property over which the land use Is being requested,that application for the permit has been made. 'DIE APPLICABLE,I AGREE TO PAY THE FULL SALARY AND EXPENSES OF A STATE ASSIGNED INSPECTOR IN CONJUNCTION WITH ACTIVITIES AUTHORIZED UNDER THE AUSPICES OF A VDOT LAND USE PERMIT. By signing below,I acknowledge that I am fully cognizant of all the LUP-SPG requirements associated with the Issuance of a VDOT Land Use Permit. Signature of Applicant: Title PM Date 2-18-21 Signature of Agent: L.'+t-- kJ.), W h, Title V r Date 1.-- 0 I 't..o zt All applicable Items on this form must be completed to avoid delay In processing the issuance of a VDOT Land Use Permit. Prepayment required with remittance payable to Treasurer of Virginia. VDOT USE ONLY Receipt is hereby acknowledged for: CHECK No.: MONEY ORDER No.: In the Amount of$ for PERMIT FEE$ CASH SURETY$ Authorized VDOT Signature: Date: 'Agent mean:Applicant contractor's or a person or business authorized to act on another's behalf. COMMONWEALTH OF VIRGINIA State Water Control Board 1111 East Main Street, Richmond, Virginia 23219 RESPONSIBLE LAND DISTURBER Richard Trites • 0I ',+, CERTIFICATE NUMBER iN „ ' 1 I RLD11610 �� ``• . -0t�{ql 1 ®. / VIRGINIA DEPARTMENT OF : �4—.�•► EXPIRATION DATE ENVIRONMENTAL QUALITY """` 2/11/2022 'his certificate is for your records and should be kept in a safe location. Please detach the above certificate and the two wallet size cards below. It is your responsibility to ensure that your certification is kept current and that you meet the requirements for re-certification before the expiration date. COMMONWEALTH OF VIRGINIA COMMONWEALTH OF VIRGINIA State Water Control Board State Water Control Board 1111 East Main Street,Richmond,Virginia 23219 1111 East Main Street,Richmond,Virginia 23219 RESPONSIBLE LAND DISTURBER RESPONSIBLE LAND DISTURBER Richard Trites Richard Trites 4---c,„, Certificate Number Expiration Date Certificate Number 4.0 Expiration Date RLD11610 2/11/2022 RLD11610 2/11/2022