HomeMy WebLinkAboutWPO202000038 Correspondence 2020-12-06VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY FOR OFFICE USE ONLY
GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM ID Number:
CONSTRUCTION ACTIVITIES (VAR10) Technical Criteria: 11B ❑ IIC ❑
REGISTRATION STATEMENT 2019
NEW ISSUANCE 191
MODIFICATION WITH ACREAGE INCREASE ❑
Existing Permit Coverage Number (if applicable,
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 A. (per Part III. K. of the VAR10 Permit).
Construction Activity
Operator Name: SOUTHEASTERN RETAIL DEVELOPMENT, LLC
Contact person:
Address:
City, State, Zip Code:
Phone Number:
Primary Email:
CC Email:
CIRCLE HWY 30A WEST BLDG M-1. UNIT 231
SANTA ROSA BEACH, FL 32459
850-660-1917
jr-kevef Q 5erj4c.. Caw,
i n,:�.�.. 1� 3QG �1�• npw.
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 M NO ❑
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CONSTRUCTION GENERAL PERMIT IVAR301 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:
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):
SLEEP NUMBER
1425 SEMINOLE TRAIL
CHARLOTTESVILLE, VA 22901
38.075857,-78.478819
38.075857.-78.478819
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: SLEEP NUMBER (ENTRANCE IMPROVEMENTS)
Address: 1425 SEMINOLE TRAIL
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.
38.075857,-78.478819
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
0.93 AC
Management Plan):
Primary estimated area to be disturbed (portions with
1.14 AC
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):
B. Estimated Project Dates
(MM/DD/YYYY)
Start date:
09/15/2020
Completion date:
11/01/2021
FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE
COMMERCIAL
E. Municipal Separate Storm Sewer System (MS4)
name (if discharging to a M54): ALBEMARLE COUNTY
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CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019
F. Is this construction activity part of a common plan of development or sale? YES ❑ NO KI
G. 6te Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Attach a separate list if needed.
HUC RECEIVING WATERBODY(S)
020802040401 MEADOW CREEK
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 ❑ NO
Erosion and Sediment Control Plan Approval Date (for estimated area to be disturbed).:
C. Has land disturbance has commenced? YES ❑ NO
D. If this project is using approved Annual Standards and Specifications (AS&S), attach the completed AS&S Entity
Form. AS&S Entity Name (if different from the Operator identified in Section IL A.):
SEE THE FOLLOWING PAGE FOR SIGNATURE
AND CERTIFICATION REQUIREMENTS AND INFORMATION
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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: N certify under penalty of law that 1 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: Q9. lt-i- `;-ago
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 Authorityplease send to:
Department of Environmental Quality
Office of Stormwater Management Suite 1400
PO Box 1105
Richmond VA 23218
constructionHq(ddea. Vi rginia.HOV
If the locality is the VSMP Authority, please send to:
oaaress
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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 anew 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. VAR1O####)
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 parry 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 activitysubject 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 (if) 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 (M54s), 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 lows 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 after 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]. 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.
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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 underthe
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 9VAC25-870-50. Definitions.
Le. a subdivision, commercial development, business park, etc.
G. 6'h Order Hydrologic Unit Code (HUC) and associated Receiving Water Name(s). Provide all 6'h 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
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CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019INSTRUCTIONS
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.
IL 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 462.1-44.15:24. 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:
(1) 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) Asenior executive officer having responsibilityfor 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 maybe 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 liWPAuthority for mvorofect? 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.dea.virminiogov/Programs/Water/5tormwaterManaee t/VSMPPermts/C st ctio Generale it aspx
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