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HomeMy WebLinkAboutWPO202200048 VSMP - SWPPP 2022-11-22A COUNTY OF ALBEMARLE Department of Community Development 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: Broadway Street Water Main Replacement Address: Broadway Street, Charlottesville, VA 22902 Tax Map 77-40N Prepared by: Name: Whitman, Requardt & Associates LLP Prepared for: Name: (Contractor to Be Determined) SWPPP Preparation Date: (This document is to be made publicly available according to 9VAC25-880-70, Part 11, section D) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County CONTENTS: (from Albemarle County Code Sec. 17405) 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 Registration Statement General VPDES Permit for Discharges of Stormwaterfrorn 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.) N,,r,,, Albemarle County Service Authority contact Richard Nelson Mailing Address 168 Spotnap Road city: Charlottesville State: VA zip: 22911 Phone (434) 977-4511, Ext. 113 Email address (if available): Indicate if DEQ may transmit general permit correspondence electronically: YesF&—/]NoF—1 2. Existing General Permit Registration Number (for renewals only): 3. Name and Location of the Construction Activity: Name Broadway Street Water Main Replacement Address (if available): Broadway Street city: Charlottesville State VA zip: 22902 County (if not located within a city): Albemarle County Latitude (decimal degrees): N 38.021162 — Longitude (decimal degrees): W 78.459505 Name and Location of all Off -site Support Activities to be covered under the general permit: Name Address (if available): County (if not located within a City): Latitude (decimal degrees): Longitude (decimal degrees): 4. Status of the Construction Activity (check only one): FederalE StateE]Public rV_1 PrivateF] S. Nature of the Construction Activity (e.g., commercial, industrial, residential, agricultural, oil and gas, etc.): Municipal 6. Name of the Receiving Water(s) and Hydrologic Unit Code (HUC): Name Rivanna River/Moores Creek Name HUC 020802040402 HUC 7. If the discharge is through a Municipal Separate Storm Sewer System (MS4), the name of the MS4 operator: Albemarle County 8. Estimated Project Start and Completion Date: Start Date (mm/dd/yyyy): January 1, 2023 Completion Date (mm/dd/yyyy): December 31, 2023 9. Total Land Area of Development (to the nearest one -hundredth acre): 1 -31 acres Estimated Area to be Disturbed (to the nearest one -hundredth acre): 0.12 acres 10. Is the area to be disturbed part of a larger common plan of development or sale? YeSF—INoF&—/] 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 penalties for submitting false information including the possibility of fine and imprisonment for knowing violations." Printed Name Title Signature Date (Please sign in INK. This Certification must be signed by the appropriate person associated with the operator identified in Item #11.) 07/2014 Page 1 of 1 Instructions for Completing the Registration Statement General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10) GENERAL A. Coverage Under this General Permit. Any operator applying for coverage under this general permit who is required to submit a Registration Statement (see Section B below) must submit a complete Registration Statement to the Department. The Registration Statement serves as a Notice of Intent for coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR1 0). B. Single-family Detached Residential Structures. Operators with an existing stormwater discharge or proposing a new stormwater discharge associated with the construction of a single- family detached residential structure are not required to submit a Registration Statement or the Department of Environmental Quality (DEQ) portion of the general permit fee. Operators of these types of discharges are authorized to discharge under this general permit immediately upon the general permit's effective date of July 1, 2014. C. To Apply for Permit Coverage. 1. Now Construction Activities. Any operator proposing a new stormwater discharge from construction activities shall submit a complete Registration Statement to the Department prior to the commencement of land disturbance, unless exempted by Section B above. Any operator proposing a new stormwater discharge from construction activities in response to a public emergency where the related work requires immediate authorization to avoid imminent endangerment to human health or the environment is immediately authorized to discharge under this general permit and must submit a complete Registration Statement to the Department no later than 30 days after commencing land disturbance; documentation to substantiate the occurrence of the public emergency must accompany the Registration Statement. 2. Existing Construction Activities. Any operator that was authorized to discharge under the general permit issued in 2009, and who intends to continue coverage under this general permit, shall submit a complete Registration Statement to the Department on or before June 1, 2014, unless exempted by Section B above. D. Where to Submit Registration Statements. All Registration Statements should be submitted to: Department of Environmental Quality Office of Stormwater Management 1 O� Floor P.O. Box 1105 Richmond, VA 23218 LINE -BY-LINE INSTRUCTIONS Item 1: Construction Activity Operator Information. "Operator" means the owner or operator of any facility or activity subject to the Stormwater Management Act and regulations. 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). The entities that are considered operators will commonly consist of the owner or developer of a project (the party with control of project plans and specifications) or the general contractor (the party with day to day operational control of the activities at the project site which are necessary to ensure compliance with the general permit). Provide the legal name (do not use a colloquial name), contact, mailing address, telephone number, and email address (if available) of the construction activity operator; general permit coverage will be issued to this operator. Indicate if the Department may transmit general permit correspondence electronically. Item 2: Existing General Permit Registration Number For reapplications only, provide the existing general permit registration number for the construction activity. This item does not need to be completed for new construction activities applying for general permit coverage. Item 3: Name and Location of the Construction Activity Information. Provide the official name, street address (if available), city or county (if not located within a City) of the construction activity. Also, provide the latitude and longitude in decimal degrees of the approximate center of the construction activity (e.g., N 37.5000, W 77.5000). Name and Location of Off -site Support Activity Information This general permit also authorizes sto"water 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 slate, federal, and local approvals are obtained for the support activity. Provide the official name, street address (if available), City and County (if not located within a City) of all aff-site support activities to be covered under this general permit. Also, provide the latitude and longitude in decimal degrees of the approximate center of the off -site support activities (e.g., N 37.5000, W 77.5000). AJso, if an off -site support activity is going to be covered under this general permit the total land area of the off -site support activity and the estimated area to be disturbed by the off -site support activity need to be included in Item #9. Item 4: Status of the Construction Activity. Indicate the appropriate status (Federal, Stale, Public, or Private) of the construction activity. Item 5: Nature of the Construction Activity. Provide a brief description of the construction activity, such as commercial, residential, agricultural, oil and gas, e1c. This list is not all inclusive. Item 6: Receiving Waters(s) and HUC Information. Provide the name of the receiving water(s) and corresponding HUC for all stormwater discharges including any stormwater discharges from off -site support activities to be covered under this general permit. Hydrologic Unit Code or HUC is a watershed unit established in the most recent version of Virginia's 60 order national watershed boundary dataset. 07/2014 Page 1 of 2 Item 7: MS4 Information If stormwater is discharged through a municipal separate storm sewer system (MS4), provide the name of the MS4 operator. The name of the MS4 operator is generally the Town, City, County, Institute or Federal facility where the construction activity is located. Item 8: Construction Activity Start and Completion Date Information. Provide the estimated start date (month/day/year) of the construction activity. Provide the estimated completion date (month/day/year) of the construction activity. Item 9: Construction Activity Area Information. Provide the total area (to the nearest one -hundredth acre) of the development (i.e... the total acreage of the larger common plan of development or sale). Include the total acreage of any off -site support activity to be covered under this general permit. Provide the estimated area (to the nearest one -hundredth acre) to be disturbed by the construction activity. Include the estimated area of land disturbance that will occur at any off -site support activity to be covered under this general permit. Item 10: Common Plan of Development or Sale Information Indicate if the area to be disturbed by the construction activity is part of a larger common plan of development or sale. Larger common plan of development or sale is defined as a contiguous area where separate and distinct construction may be taking place at different times on different schedules. Plan is broadly defined as any announcement or documentation, including a sign, public notice or hearing, sales pitch, advertisement, drawing, permit application, zoning request, e1c., or physical demarcation such as boundary signs, lot stakes, or surveyor markings indicating that construction activities may occur. Item 11: Stomwater Pollution Prevention Plan (SWPPP). 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 (VAR1 0) prior to submitting this Registration Statement. By signing this Registraton Statement the operator is certifying that the SWPPP has been prepared. Item 12: Certification A properly authorized individual associated with the operator identified in Item 1 of the Registration Statement is responsible for certifying and signing the Registration Statement. Please sign the Registration Statement in INK. 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: a. For a corporation: by a responsible corporate officer. For the purpose of this part, 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 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, stale, 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) A senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency. 07/2014 Page 2 of 2 VSMP Application Requirements Land Disturbance, -greater than 2,500sq.ft to less than 1AC: Single Family Development F-I City of Fairfax VSMP Permit Application F-I Plans F-I VSIVIP Checklist F-I BIVIP Agreement (if applicable) F-I $290 fee check All Other Non-SFD LDAs (Commercial, Common Plan of Development, Etc.) F-I City of Fairfax VSIVIP Permit Application F-I Plans F-I Site Plan Checklist F� BIVIP Agreement (if applicable) F-I SWPPP F-I $290 fee check Chesapeake Bay Preservation Act Land -Disturbing Activity. $290 Land Disturbance = 2500sq.ft to less than 1 acre Areas within common plans of development or sale (except for single family detached homes) $290 Land Disturbance = 2500sq.ft to less than 1 acre Land Disturbance, 1AC or more: All LDAs, 1AC or More F-I D EQ VAR 10 Registration Statement F-I DEQ VAR 10 Notice of Termination F� Plans F-I Site Plan Checklist F-I BIVIP Agreement (if applicable) F-I SWPPP F-I Fee per schedule below Small Single Family Detached Home Construction Land Disturbance = 1 acre to less than 5 acres $209 Land Disturbance = 1 acre to less than 5 acres $2,700 Land Disturbance = 5 acres to less than 10 acres $3,400 Land Disturbance = 10 acres to less than 50 acres $4,500 Land Disturbance = 50 acres to less than 100 acres $6,100 Land Disturbance= greater than 100 acres $9,600 NOTE: All VSMP application fees are to be submitted on a separate check. Revenue Account: 340-313350 Virginia Stormwater Management Program WSMP) Checklist STORMWATER MANAGEMENT PLAN PAGE(S): YES � NO � NTA[DESCRIPTION PAGE # Narrative: 0 F-1 F-1 Contact information including the name, address and telephone number of the owner and the tax reference number and parcel number of the property or properties affected -[T-EF-ET Description of current site conditions and final site conditions -ET=-[71- Information on type and location of stormwater discharges F-1 Information on the features to which stormwater is being discharged, including water bodies classified as impaired on the Virginia DEQ 303(d) list -0-=TT Information on any additional control measures to be implemented to address a local TMDL -EF== A general description of the proposed stormwater management facilities and the mechanism through which the facilities will be operated and maintained after construction is complete Site Information: L-1 L-1 H Existing drainage facilities and creeks and channels, including all streams, ponds, culverts, ditches, wetlands, other water bodies and floodplains H H Soil types, geologic formations if karst features are present in the area, forest cover and other vegetative areas =-E] H Current land use including existing structures, roads and locations of known utilities and easements -ET== Sufficient information on adjoining parcels to assess the impacts of stormwater from the site on these parcels -ET=TT The limits of clearing and grading and the proposed drainage patterns on the site F-1 Proposed buildings, roads, parking areas, utilities and stormwater management facilities F-1 0= Proposed land use with tabulation of the percentage of surface area to be adapted to various uses, including but not limited to, planned locations of utilities, roads and easements Virginia Stormwater Management Program (VSMP) CheckliSt Hydrologic Analysis: LIH H * Pre -development and post -development contributing drainage areas L-1 H H Pre -development and post -development runoff rates, volumes and velocities, and methodologies used TT—ITTI Pollution load and reduction requirements and calculations Hydraulic Analysis: H�H Sizing calculations for stormwater control measures H H Existing and proposed structural elevations (pipe inverts, manholes, etc.) TTTIH Stage -storage or outlet rating curves and inflow and outflow hydrographs for storage facilities -0-7 F-I Design water surface elevations _ET_ETTT Analysis of potential downstream impacts/effects of the project -IT-ET-IT Location and elevation of the lowest floor in all proposed and existing buildings adjacent to the floodplain _ET_ETTT Dam safety and breach analysis Best Management Practices (BMPs): H H Type of facilities proposed (use BIVIP Clearinghouse names) ITF—I Location, including geographic coordinates (Lat/Long) -IT-ETIT Total acres treated -7-F-D-17F Acres impervious treated _7F_EF_D_ Acres pervious treated _EF F-I Documentation and calculations verifying compliance with water quality and quantity requirements EFTTApplicable supporting documents and studies (e.g. infiltration tests, geotechnical investigations) —a—IT IT Landscaping plan for any BIVIPs or site reforestation *Denotes items that are required in digital format "dxf'for purpose of updating the City's GIS data. Virginia Stormwater Management Program (VSMP) CheckflSt Piped Systems: YES NO N/A DESCRIPTION PAGE # F-1 -ET F-1 Analyzed and designed for 2/1 0-yr/25-yr/l 00-yr Storm Primary road crossings designed for 25-yr flows and 1 O-yr under secondary roads and other locations -ET-ET-0- Culverts checked for the effects of 1 00-yr Storm No flooding of building Structures shall result from 1 00-yr design Energy dissipater calculations Capacity of receiving channel downstream of channel or pipe system Gutter spread limited to 1 Off from the face of the curb E F-1 F-1 Hydraulic grade lines show 11ft below inlets Open Channel Systems: YES NO N/A DESCRIPTION PAGE # TT—UTT Proposed channel capacity analyzed and designed for pre 1 O-yr Storm -ET F-1 F-1 Channel designed for a 2-yr Storm without erosion and 1 O-yr for bank fill (liner design) -D-17TT Velocity Check (liners provided, if needed) Provide channel velocities 0 F-1 F-1 Overlot grading plan El—ITTT Provide 1 00-yr overland relief assuming pipe system failure Virginia Stormwater Management Program (VSMP) CheckliSt CHESAPEAKE BAY REGULATIONS PLAN PAGE(S): YES NO N/A DESCRIPTION PAGE # TITT-IT For any property depicted on the City's Chesapeake Bay preservation area map as a resource protection area (RPA), the applicant shall determine and show on the plan the site -specific boundaries of the RPA components per code section 110-86(c). The applicant shall also submit a RPA site -specific study application available at the Zoning Division or at: httr)://www.fairfaxva.gov/cdo/docs/RPASiteSi)ecificStudvAi)i)licati on.1)d TTETTUSACE T jurisdictional determination or verification letter for RPA boundaries Water quality impact assessment (WQIA) is required for any proposed development or redevelopment unless the requirement is waived by the Zoning Administrator Application/waiver form is available at the Zoning Division or at: htti)://www.fairfaxva.gov/cdi)/docsANQIAAi)i)lication.l)df Tree management plan per code section 11 0-86(d) TT-0-TT I Stormwater management plan _ET_E1__ET BMP maintenance plan, including inspection schedule TT —ET El BMP maintenance agreement (available at the Zoning Division) 1::F_E1_TT Copies of any required wetland permits Performance Standards of Chesapeake Bay Regulations: YES NO N/A DESCRIPTION PAGE # TT-EI-1:1- Maximize rainwater infiltration TT—E]--EF Reduce the land application of nutrients and toxics TT—EI-1:1— Minimize erosion and sedimentation potential -EFTT Limit land disturbance and preserve indigenous vegetation to the maximum extent practicable, consistent with the use or development proposed Virginia Stormwater Management Program WSMP) Checklist Stormwater Pollution Prevention Plan (SWPPP) Contents: YES NO N/A DESCRIPTION PAGE # -E--EFTI SWPPP package complete 11 El 0 An erosion and sediment control plan consistent with the requirements of the Virginia Erosion and Sediment Control Law and regulations must be designed and implemented during construction activities. Prior to land disturbance, this plan must be approved by either the VESCP authority or the department in accordance with the Virginia Erosion and Sediment Control Law and attendant regulations. A stormwater management plan consistent with the requirements of the Virginia Stormwater Management Act and regulations must be designed and implemented during construction activities. Prior to land disturbance, this plan must be approved by the City of Fairfax. ]::F-E]-]::F A pollution prevention plan that identifies potential sources of pollutants that may reasonably be expected to affect the quality of stormwater discharges from the construction site and describe control measures that will be used to minimize pollutants in stormwater discharges from the construction site must be developed before land disturbance commences. ]::F El F If a specific wasteload allocation (WLA) for a pollutant has been established in an approved TMDL and is assigned to stormwater discharges from a construction activity, additional control measures must be identified and implemented by the operator so that discharges are consistent with the assumptions and requirements of the WLA. NOTE: The SWPPP shall be amended whenever there is a change in design, construction, operation or maintenance that has a significant effect on the discharge of pollutants to state waters and that has not been previously addressed in the SWPPP. The SWPPP must be maintained at a central location onsite. If an onsite location is unavailable, notice of the SWPPP's location must be posted near the main entrance at the construction site. Virginia Stormwater Management Program (VSMP) CheckliSt Pollution Prevention Plan (PPP) Contents: YES NO N/A DESCRIPTION PAGE # -ITTT A pollution prevention plan, as required by 9VAC25-870-56, shall be developed, implemented and updated as necessary and must detail the design, installation, implementation and maintenance of effective pollution prevention measures to minimize the discharge of pollutants. Minimize the discharge of pollutants from equipment and vehicle washing, wheel wash water and other wash waters Wash waters must be treated in a sediment basin or alternative control that provides equivalent or better treatment prior to discharge. 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 -11-ET-EF The pollution prevention plan shall include effective best management practices to prohibit the following discharges: (a) Wastewater from washout of concrete, unless managed by an appropriate control (b) Wastewater from washout and cleanout of stucco, paint, form release oils, curing compounds and other construction materials (c) Fuels, oils or other pollutants used in vehicle and equipment operation and maintenance (d) Soaps or solvents used in vehicle and equipment washing NOTE: Discharges from dewatering activities, including discharges from dewatering of trenches and excavations, are prohibited unless managed by appropriate controls. General Permit for Discharges of Stormwater from Construction Activities (VAR1 0) Notice of Termination 1. Construction Activity Operator: Mailing (Please Type or Print All Information) State:_ Zip: Phone: Email address (if available): 2. Location of Construction Activity (As listed on registration statement): County: If street address unavailable: Latitude Longitude 3. Stormwater General Permit Number: 4. The Reason for Terminating Coverage Under the General Permit (The construction activity operator may only submit a Notice of Termination after one or more of the conditions below have been met): ElA. Necessary post -construction control measures included in the SWPPP for the site are in place and functioning effectively and final stabilization has been achieved on all portions of the site for which the operator is responsible; ElB. Another operator has assumed control over all areas of the site that have not been finally stabilized and obtained coverage for the ongoing discharge; F1C. Coverage under an altemative VPDES or State permit has been obtained; or D. For residential construction only, temporary stabilization has been completed and the residence has been transferred to the homeowner. The Notice of Termination must be submitted within 30 days of one of the above conditions being met Authorization to discharge terminates at midnight on the date that the Notice of Termination is submitted for conditions B through D above. Authorization to discharge terminates upon notification from the Department or 60 days after the submittal of the Notice of Termination (whichever occurs first) for condition A above. 5. Permanent Control Measures Installed: Attach a list of permanent control measures (both structural and non-structural) that were installed at the construction site. For each control measure, include the following information: (a) Type of control measure installed and the date that it became functional as a permanent control measure; (b) Geographic location (county or city and Hydrologic Unit Code) (latitude and longitude may additionally be included if available); (c) Waterbody the control measure discharges into; and, (d) Number of acres that will be treated (to the nearest one -tenth of an acre). If no permanent control measures were installed please check this box F� 6. Participation in a ReClional Stormwater Management Plan: Where applicable, attach the following information related to participation in a regional stormwater management plan: (a) Type of regional facility to which the site discharges; (b) Geographic location of any regional facility to which the site discharges (county or city and Hydrologic Unit Code); (c) Geographic location of the site (county or city and Hydrologic Unit Code) (latitude and longitude may additionally be included if available); and (d) Number of acres treated by a regional facility. 7. Nutrient Offsets: Where applicable, attach the following information related to nutrient offsets that were acquired in accordance with §62.1-44.15:35 of the Code of Virginia: (a) Name of the broker from which offsets were acquired; (b) Geographic location (county or city and Hydrologic Unit Code) of the brokers offset generating facility; (c) Number of nutrient offsets acquired (lbs. per acre per year); and (d) Nutrient reductions achieved on site (lbs. per acre per year). 8. Certification: "I certify under penalty of law that I have read and understand this notice of termination 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." Print Name: Title: Signature: Date: (Please sign In INK. The person signing this form must be associated with the operator identified in Item #1 above.) Mail to: Devartment of Environmental Quality, Office of Stormwater Management, 1 oth Floor, P.O. Box 1105, Richmond, VA 23218 (DEC 199-147) (08/13) INSTRUCTIONS for FORM DEQ 199-147 General Permit Notice of Termination - Construction Activity Stormwater Discharges General A Notice of Termination must be submitted when an operator no longer wishes to be covered under the General Permit for Stormwater Discharges from Construction Activities. Mail to: Department of Environmental Quality Office of Stormwater Management, 1 (Yh Floor P.O. Box 1105 Richmond, VA 23218 Section 1 Activity Operator Information Give the legal name of the person, firm, public organization, or any other entity that was issued the general permit for the site described in this Notice of Termination. Do not use a colloquial name. Enter the complete address and phone number of the operator. Section 2 Activity Location Information Enter the activity's official name and complete street address, including city (or town), county (if not located within a City), state and ZIP code. If the site lacks a street address, enter the city (or town), county (if not located within a City) and the latitude and longitude in degrees, minutes, seconds (DMS). Section 3 Permit Information Enter the existing Stormwater General Permit Number assigned to the activity or site identified in Section 1 that the operator wishes to be terminated. Section 4 Reason for Termination Check the appropriate statement indicating the reason for submitting this Notice of Termination. The Notice of Termination may only be submitted after one or more of the following conditions have been met: A. Necessary post -construction control measures included in the SWPPP for the site are in place and functioning and final stabilization has been achieved on all portions of the site for which the operator is responsible; B. Another operator has assumed control over all areas of the site that have not been finally stabilized; C. Coverage under an alternative VPDES or State permit has been obtained; or D. For residential construction only, temporary stabilization has been completed and the residence has been transferred to the homeowner. The Notice of Termination must be submitted within 30 days of one of the above conditions being met. Section 5 Permanent Control Measures Installed Attach a list of the permanent control measures (both structural and non-structural) that were installed at the construction site. For each control measure, include the following information: (a) Type of control measure installed; (b) Geographic location (county or city and Hydrologic Unit Code); (c) Waterbody the control measure discharges into; and, (d) Number of acres that will be treated (to the nearest one -tenth of an acre). If no permanent control measures were installed, please check the box at the end of this section. Section 6 Participation in a Regional Stormwater Management Plan Where applicable, attach the following information related to participation in a regional stormwater management plan: (a) Type of regional facility to which the site discharges; (b) Geographic location of any regional facility to which the site discharges (county or city and Hydrologic Unit Code); (c) Geographic location of the site (county or city and Hydrologic Unit Code) (latitude and longitude may additionally be included if available); and, (d) Number of acres treated by a regional facility. Section 7 Nutrient Offsets Where applicable, attach the following information related to nutrient offsets that were acquired in accordance with §62.1-44.15:35 of the Code of Virginia: (a) Name of the broker from which offsets were acquired; (b) Geographic location (county or city and Hydrologic Unit Code) of the brokers offset generating facility; (c) Number of nutrient offsets acquired (lbs. per acre per year); and (d) Nutrient reductions achieved on site (lbs. per acre per year). Section 8 Certification State statutes provide for severe penalties for submitting false information on this Notice of Termination. State regulations require this Notice of Termination to be signed as follows: For a corporation: by a responsible corporate officer. For the purpose of this section, 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- or decision -making functions for the corporation, or (2) the manager of one or more manufacturing, production, or operating facilities provided the manager is authorized to make management decisions which 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 environmental 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. For a partnership or sole proprietorship: by a general partner or the proprietor. For a municipality, state, federal, or other public agency: by either a principal executive officer or a ranking elected official. The Department of Environmental Quality reserves the riqht to request additional information not directly addressed by th registration statement if, in its discretion, a facility or operation poses a potential impact on water quality, (DEQ 199-147) (08/13) Section 2. Notice of general permit coverage (This notice is to be posted near the main entrance according to 9VAC25-880-70, Part 11, 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.) Construction Activities I . Fumish and install 8", 6", and 4" Ductile Iron water main. 2. Fumish and install 8" tapping sleeve and valve with valve box 3. Fumish and install 6" and 4" gate valves. 4. Furnish and install fire hydrants, air release valves, and blow offs. 5. Locate and connect to existing water mains. 6. Restoration of all easements, yards, parking lot. 7. Place asphalt pavement according to VDOT specifications. 8. Test all pipe and all appurtenances. 9. Disinfection of water main. 10. Any incidental work to complete project. Anticipated Schedule: Start Construction: January 1, 2023 End Construction: December 31, 2023 Sequence of Construction I . Notify the Albemarle County Service Authority (ACSA) inspector in writing seven days prior to commencing construction of this project. The inspector will notify the ACSA to arrange an on -site preconstruction meeting at least 48 hours prior to the issuance of a Land Disturbance Permit. 2. Install all erosion and sediment control measures. 3. Notify the ACSA inspectors when initial erosion control measures are in place. 4. Locate all existing utilities and construct all water main improvements and water service connections. Place and compact approved backfill materials as trenching and installations proceed. 5. Test water mains, connect new water service connections, and overlay existing roads and gravel drives. 6. No stockpile is anticipated for this project. 7. Upon completion of work, apply permanent seeding to all disturbed areas. 8. When disturbed area are stabilized to the satisfaction of the inspectors and the engineer, remove all temporary erosion and sediment control devices. 9. Notify the ACSA inspectors when all work is complete. Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 4. Erosion and Sediment Control Plan. (Provide a reduced, I W7 copy of the latest Erosion and Sediment Control Plan. Do not reference only.) (To be inserted into SWPPP following final review and approval.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 5. Stormwater Management Plan (Provide a reduced I I x 17 copy of the latest stormwater management plan. Do not reference only.) (Not required.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 6. Pollution Prevention Plan. (reference County Code 17-404 and State Regulation 9VAC25-880-70 pan 11 section A.4) 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.) (To be inserted into SWPPP` following final review and approval.) Issued — 10/2014 Storrawater Pollution Prevention Plan (SWPPP) Albemarle County B. z5ources oi it-onutams. iocanons. anu Pollutant, or Pollutant Location on site Prevention Practices, Generating A Control N No additional activities — N/A C. Sources of Pollutants continued. Common activities and minimum control and prevention practices Pollutant, or Pollutant Location on site Prevention Practices, Generating Activity Control Measures Follow Erosion and Sediment Control Clearing, grading, excavating, and un- Land disturbance area Plan. Dispose of clearing debris at stabil ized areas acceptable disposal sites. Seed and mulch, or sod within 7 days of land clearing Cover storin drain inlets and use drip pans Paving operations Roads and driveways and absorberit/od dry for all paving machines to limit leaks and spills Direct concrete wash water into a leak - Concrete washout and Current location and detail shown on proof container or leak -proof settling basin cement waste plan that is designed so that no overflows can occur Enclose or cover material storage areas. Mix paint indoors in a contairanent 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 and Material delivery and storage Designated area shown on plan storage Placed near construction entrances, away from waterways and drainage paths Material use during building process Building areas Follow manufacturer's instructions. MSDS's attached. Waste collection area will not receive a substantial amount of runoff from upland areas and does not drain directly to a Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Pollutant, or Pollutant Location on site Prevention Practices, Generating Activity Control Measures Current designated container areas on waterway. Containers have lids covered Solid waste disposal plan before periods of rain, or are in a covered area. Schedidedcollectiontoprevent overfilling. MATERIALS NOT TO BE BURIED ON -SITE Convenient and well -maintained portable sanitary facilities mill be provided, and Sarmary waste Current locations shown on plan 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 Wash Waters Wash areas shown on plan control as specified on plan. Minimize the discharge of pollutants from equipment and vehicle washing Vehicle and equipment washing Designated areas and details shown on Provide containment and filtering for all plan wash waters per the plan Minimization ofexposure topreciphation 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 discharees Discharge Pollutants or Pollutant Location on Site Constituents None anticipated N/A N/A 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.) (To be provided by contractor.) F. Response and reporting practices Minimize dischargesfrom 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 11, section AA.e.) (To be provided by contractor.) 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.) (To be provided by contractor.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 7. Discharges to impaired waters, surface waters within an applicable TNIDL wasteload allocation, and exceptional waters. (Provide detailed measures for any applicable T�ML) (Not required — N/A) 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.) (To be provided by contractor.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Section 9. Signed Certification (Provide certification according to 9VAC25-870-370. For purposes of plan review and approvals, this certification should be the owner of the property, the same signature as appears on the bonds and applications. Another operator can be designated on the delegation of authority form to follow.) CERTIFICATION 1 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 infonnation 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 infonnation, including the possibility of fine and imprisonment for knowing violations." Owner/Operator Name: Company: Title: Signature: Date: 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 1, (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: (To be provided by contractor.) 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) (To be inserted upon receipt.) 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 11, section B and F.) (To be provided by contractor.) Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County Issued — 10/2014 Stormwater Pollution Prevention Plan (SWPPP) Albemarle County