HomeMy WebLinkAboutWPO201800025 Permit 2019-02-26Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10)
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1. Construction Activity Operator: (General permit coverage will be issued to this operator. The Certifiga#on In Item #12 must be
signed by the appropdate person associated with this operator.)
Name: 00476RL C04STG.usyroa c-mmwv
Contact:.. SM616 It Aa.PER .....
Mailing Address:__._. 0.0 AQ3 Me
City: Sr. Ak4ANs State; ..t.t+/ Tip 2111_1 Phone: 17.%44'L%7
Email address (If available): ja" - en ms 'L 60rurfiot% cow
Indicate if DEG may transmit general permit correspondence electronically, Yes[9 No
2. Existing General Permit Registratlon Number (for renewals only):
8. Narhe and Location of the Construction Activity:
Address (if available):4685 Three blotched Rd
city:: Crozet state; VA
County (If not located within a City): .
Latitude (decimal degrees): 38A87075 Longitude (decimal degrees?: 78,6132
Name and Location of all OHatte Support Activities to be covered under the general permit;
Address (N available);
City State: Zip, .
County (if not located within a City):
Latitude (decimal degrees): Longitude (decimal degrees)';
4. Status of the Construction Activity (check only one): Federal Q State [] Public Private
5. Nature of the construction Activity (e,gā commercial, industrial, residential, agriwkurel; oil and gas, etc:):
Industrup)
6. Name of the Receiving Water(s) and Hydrologic Unit Code (HUC):
Name: Rivanna
Name:
Mo., '0208.0204 HUC:
7, If the discharge is through a Municipal Separate Storm Sewer System (1101134), the name of the M34 operator,
MIA
S. Estitriated Project Stall and Completion Date:
Start Data (mm/dd/yyyq): 10 D9-20.18 Completion bate (mm/dd/yyyy)i 8=01-2018
S. Total Land Area of Development (to the nearest one -hundredth acre): 625 acres
Estimated Area to :be Disturbed (to the nearest one -hundredth acre): 1.78 acres
10. Is the area to be disturbed part of a, larger common plan of development or sale? Yes ā No
11. 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 jdaLLO submitting this Registration statement.
By signing this Registration Statement the operator Is certifying that the SWPPP has been prepared.
12. 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 She 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: Title: Ato,7"r MAUA&EK
Signature: Date:_ zhalre
i
(Please sign In INK. Thi ertificati n must be signed by the appropriate person associated with the operator identified in
Item 01.)
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