HomeMy WebLinkAboutWPO201700050 Permit 2017-06-26 Registration Statement
General VPDES Permit for Discharges of Stormwater from Construction Activities(VAR10)
(Please Type or Print All Information)
1. Construction Activity Operator: (General permit coverage will be issued to this operator. The Certification in Item#12 must be
signed by the appropriate person associated with this operator.)
Name:Crutchfield Corporation
Contact:Bill Crutchfield 1
Mailing Address:1 Crutchfield Park
City: Charlottesville State:Virginia Zip:22911 Phone:(434)817-1000
Email address(if available):
Indicate if DEQ may transmit general permit correspondence electronically: Yes 0 No 0
2. Existing General Permit Registration Number(for renewals only):
3. Name and Location of the Construction Activity:
Name:Crutchfield Corporation
Address (if available): 1540 Quiet Acres Ln.
City: Charlottesville State:Virginia Zip:22911
County (if not located within a City):Albemarle County
Latitude(decimal degrees):38.143695 Longitude(decimal degrees):-78.445644
Name and Location of all Off-site Support Activities to be covered under the general permit:
Name:
Address(if 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 ❑ State 0 Public 0`Private 0
5. Nature of the Construction Activity(e.g.,commercial,industrial,residential,agricultural,oil and gas,etc.):
Building addition,select utilities,and earthwork for an industrial building
6. Name of the Receiving Water(s)and Hydrologic Unit Code(HUC):
Name:Rivanna River Name:
HUC:02080204 HUC:
7. If the discharge is through a Municipal Separate Storm Sewer System(MS4),the name of the MS4 operator:
n/a
8. Estimated Project Start and Completion Date:
Start Date(mm/dd/yyyy):08/01/2017 Completion Date(mm/dd/yyyy): 10/31/2017
9. Total Land Area of Development(to the nearest one-hundredth acre):13.16
Estimated Area to be Disturbed(to the nearest one-hundredth acre):4.90
10. Is the area to be disturbed part of a larger common plan of development or sale? Yes 0 No IA
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 prior to 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 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 pe alties for submitting false information induding the possibility of
fine and impriso ment for Wowing violati , r�
Printed Name: �� �� , S��L � ,,I^'Title: C
Signature: Date: C ' Z \ to
(Please sign in INK. This Certification must be signed by the appropriate person associated with the operator identified in
Item#1.)
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