HomeMy WebLinkAboutWPO202100050 Application 2021-09-20VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT #:
GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM PLAN/ID #:
CONSTRUCTION ACTIVITIES (VAR10) TECHNICAL CRITERIA: 1113 ❑ 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 V. (per Part III. K. of the VAR10 Permit).
Operator Name:
Contact person:
Address:
City, State and Zip Code:
Phone Number:
Primary and CC Email:
B. Electronic correspondence. To receive an emailed coverage letter or to pay by credit card, you must choose YES
and include a valid email. May we transmit correspondence electronically? YES ❑ NO ❑
Section II. Construction Activity 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 waterbodies receiving stormwater discharges from the site.
B.
Project site location information.
Construction Activity Name:
Address:
City and/or County and Zip Code:
Construction Activity Entrance Location
(description, street address and/or
latitude/longitude in decimal degrees):
Latitude and Longitude
(6-digit, decimal degrees format):
C.
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 (include entire area to be
disturbed as approved in the Stormwater Management Plan):
Primary estimated area to be disturbed (include portions with
Erosion and Sediment Control Plan approval only):
Off -site estimated area to be disturbed (if applicable):
D.
Property Owner Status:
FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE ❑
E.
Nature of the Construction Activity Description (i.e. commercial,
industrial, residential, agricultural, environmental, utility):
F.
Municipal Separate Storm Sewer System (MS4) name(s) (if the
site is discharging to a MS4):
G.
Estimated Project Dates (MM/DD/YYYY).
Start Date:
Completion Date:
H.
Is this construction activity part of a larger common plan of
development or sale?
YES ❑ NO ❑
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CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019
1. 6`h Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Include additional areas on a separate page.
HUC T NAME(S) OF RECEIVING WATERBODY
Section III. Off -site Support Activity Location Information.
List all off -site support activities and excavated material disposal areas being utilized for this project. Include additional
areas on a separate page.
Off -site Activity Name:
Address:
City or County:
Off -site Activity Entrance Location (description, street
address and/or latitude/longitude in decimal degrees):
Latitude and Longitude (6-digit, decimal degrees format):
Is this off -site activity an excavated material disposal
area?
YES ❑ NO ❑
If this off -site activity is an excavated material disposal
area, list the contents of the excavated fill material:
Will a separate VPDES permit cover this off -site activity?
YES ❑ NO ❑
Section IV. 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 ❑ NO ❑
Erosion and Sediment Control Plan Approval Date (for
the estimated area to be disturbed MM/DD/YYYY):
C.
Has land -disturbance commenced?
YES ❑ NO ❑
D.
Annual Standards and Specifications. If this project is utilizing approved Annual Standards and Specifications
(AS&S), attached the completed AS&S Entity Form.
AS&S Entity Name (if different from the Operator
identified in Section I):
E.
Billing information (leave blank if same as the Operator identified in Section I. above). This entity will receive
Annual Permit Maintenance and Permit Modification Fee invoices (if applicable).
Billing Name:
Contact Name:
Address:
City, State and Zip Code:
Phone Number:
Primary and CC Email:
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CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT MOMS
Section V_ Certification_ A person representing the operator as identified in Section 1_ 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 c f any foci//ty or activity subject to the Act and this chapter_ /n the context of stormwoter
associated with a large or srrmol/ construction activity, operator means any person associated with o construction project thot meets
either of the fo//owing two criterio: (i) the person has direct operotionco/ control over construction pions and specifications including
the ability to make modifications to those plan cond specifications or (ii) the person has day-to-day opercotion4al contra/ of those
activities cot a project that ore necessary to ensure comp//once with o storrr»woter pollution prevention p/an for the site or other state
permit c r VSMP authority permit conditions (i_ e_, they ore authorized to direct workers cit o site to curry out activities required by the
stormwoter po//ut/on prevention p/on or comply with other permit conditions)_ /n the context of stormwoter discharges from
Municipal Sepcorote Storm Sewer Systems (MS4s), operator means the operator of the regulated MS-4 system.
9VAC25-880-70. Part Ill. K. Signatory Requirements_ Registration Statement_ A// Registration Statements shall be signed os fo//ows:
o_ For or corporation: by o responsible corporate officer_ For the purpose of this chapter o responsible corporate officer
means: (i) o president secretory, treasurer, or vice-president of the corporation in charge of a principal business function or
any other person who performs simi/or po/icy-cooking or decision -cooking functions for the corporotion,; or (ii) the manager
of one or more rrmonufacturing, production, or operating facilities provided the monoger is authorized to make management
decisions that govern the operation of the regu/oted foci/ity including having the explicit or implicit duty cf cooking major
capital investment recommendations and initiot/ng and directing other comprehensive measures to assure long-term
comp/ionce with environmental lows and regu/ations,; the manager con ensure that the necessary systems are established or
actions token to gather complete crud occurote information for state permit opp/icotion requirements, and where authority
to sign documents has been assigned or de%gated to the monoger in accordance with corporate procedures;
b. Fora partnersh/p or sole proprietorship: by o genera/ partner or the proprietor respectively; or
c. For o municipality, state, federal c r other public agency: by either a principal executive officer dzw ranking elected officio/.
For purposes cf th/s chapter, co 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 pr/ncipa/ 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 imprisonment for knowing violations_"
Printed Name:
Signature (signed in ink):
Date Signed:
Section VI_ 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 DECL is the VSMP Authority, please send to: If the locality is the VSMP Authorityplease send to:
Coepartrrsent of Environmental Quality
Office of Stormwater Management Suite M400
PO iBox MHOS
Richmond VA 2323.8
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