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HomeMy WebLinkAboutWPO201400041 Plan - Stormwater 2014-05-06 yr 5ALZED. AND ASSOCIATES INC REFLECTING TOMORROW Storm Water Pollution Prevention Plan In compliance with: Storm Water Construction General Permit No. VAR10 Virginia Stormwater Management Plan (VSMP) Goodwill - Mill Creek Drive Mill Creek Drive & Avon Street Phone: 540-885-5181 Contact: Peter Wray SWPPP and Construction Plans Prepared by Balzer & Associates, Inc. 1561 Commerce Rd., Suite 401 Verona, VA 24482 (540) 248-3220 06/06/2014 1...i �✓ Goodwill - Mill Creek Drive Albemarle County, Virginia Storm Water Pollution Prevention Plan (SWPPP) In compliance with: Storm Water Construction General Permit No. VAR10 Virginia Stormwater Management Plan (VSMP) S 0' 'P so •inator: Pf-41. 11144 1 (Name of Person) /(-Title) Tr;M9+i .S4_SU;Gt5 (Company) StJo 51581 (Phone#) "I certify under penalty of law that I have read and understand this document and that this document and all attachments were prepared in accordance with a system designed to assure that 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." "I certify that the SWPPP coordinator named above is my duly authorized representative for this P Date: --2J1 I " [Authorized Representative per rt III K 1 of the Permit, Appendix A] Name: Title: Legal Entity: Goodwill - Mill Creek Drive Storm Water Pollution Prevention Plan I INTRODUCTION 1 A) Plan Purpose 1 B) Background-Construction General Permit No. VAR10 1 II PLAN REQUIREMENTS 1 A) General Requirements 1 1) Deadlines 1 2) Incorporation of Other Plans 2 3) Plan Administration 2 4) Plan Updates 2 5) Potential Construction Site Storm Water Pollutants 2 B) Specific Requirements 3 1) Site and Activity Description 3 2) Controls and Measures 4 a) Erosion and Sediment Control 5 b) SWM/BMP's 5 c) Fuels and Oils 6 d) Solid Waste 6 e) Fertilizer 6 f) Paint and other Chemicals 6 g) Concrete 7 h) Water Testing 7 i) Sanitary Waste 7 j) Grading and E& S Activities 7 3) Spills 7 4) Maintenance 8 5) Inspections 8 6) Non-Storm Water Discharges 10 C) Contractor Certification 11 REFERENCES 12 Appendix A Storm Water Construction General Permit No. VAR10 Appendix B Forms;Notice of Registration and Notice of Termination Appendix C Record of Land Disturbance Appendix D Record of Inspections Appendix E Record of Contractor Certification Appendix F Construction drawings +Ise *toe I Introduction A)Plan Purpose This Storm Water Pollution Prevention Plan (Plan) has been developed as a requirement of the Virginia Stormwater Management Plan (VSMP) General Permit for Discharges of Storm Water from Construction Activities (Permit), as defined in 9 VAC 25-180-10 et seq. The purpose of this plan is to: 1) Identify potential sources of pollution that may reasonably be expected to affect the quality of storm water discharges from the construction site, and, 2) To describe and ensure the implementation of practices that will be used to reduce pollutants in storm water discharges from the construction site and to assure compliance with the conditions of the Permit. Implementation of the components of this plan is required as a condition of the Permit (Appendix A). The Department of Conservation and Recreation (Department) has been granted authority to administer the VPDES program and is therefore the regulatory authority overseeing the implementation of this plan. B)Background- Construction General Permit No. VAR10 The Permit has a fixed term of 5 years from the effective date of August 05, 2010 and is required for all projects that will disturb 1 or more acres of total land area. To obtain a Permit, operators must submit a Registration Statement (Appendix B) at least 2 days prior to the commencement of construction activities (clearing, grading, or other activities that result in soil disturbance). The Permit authorizes the discharge of storm water from construction activities until the Permit's expiration date. The Permit also authorizes the discharge of storm water from offsite support activities, provided that certain conditions are met as outlined in the Permit (Part I A. 2.). Certain non-storm water discharges are also authorized by the Permit, provided the conditions contained in the Permit (Part I D. 2.) are met. Upon final stabilization of the site, a Notice of Termination (Appendix B) must be submitted to the Department. Coverage under the Permit will be deemed terminated 2 days after submittal of the Notice of Termination. II Plan Requirements A) General Requirements 1) Deadlines Storm Water Pollution Prevention Plan Page 1 Albemarle County, Virginia Goodwill-Mill Creek Drive New '4.000 The plan shall be prepared prior to the submittal of the Registration Statement and shall provide for compliance with the terms and schedule of the Permit beginning with the initiation of construction activities. 2) Incorporation of Other Plans The plan requirements of the Permit are satisfied by incorporating by reference other plans developed for this construction activity,provided that the other plans meet or exceed the requirements of Part HD. of the Permit. The construction plans developed for this project, Goodwill - Mill Creek Drive, have been approved by the Albemarle County. The construction plans meet current Albemarle County requirements regarding erosion and sediment control and storm water management, and also comply with State regulatory requirements as presented in the Virginia Erosion and Sediment Control Handbook, Third Edition. All plans incorporated by reference into the plan are enforceable under the Permit. 3) Plan Administration The plan shall be certified in accordance with the Permit (the certification statement is presented in the beginning of this plan). Copies of the plan shall be kept on-site and be made available to the Department, or other regulatory agencies having authority, upon request. The plan must also be available to all operators identified as having responsibilities to carry out provisions contained in the plan. 4) Plan Updates The plan shall be amended whenever there is a change in design, construction, operation, or maintenance of the construction site that has a significant effect on the potential for the discharge of pollutants to surface waters and that has not been addressed in the normal implementation of the plan. The plan shall also be updated whenever it is found to be ineffective in meeting the requirements of the Permit. In the event the Department notifies the permittee that the plan does not meet one or more of the provisions of the Permit, within a period of 7 days the permittee must make the required changes to the plan and submit a certification to the Department stating that the required changes have been made. 5) Potential Construction Site Storm Water Pollutants The plan is focused upon limiting the pollution potential from the following: Table 1 Storm Water Pollution Prevention Plan Page 2 Albemarle County, Virginia Goodwill-Mill Creek Drive Potential Construction Site Storm Water Pollutants Trade Name Chemical/Physical Description Storm Water Pollutants Material Pesticides(insecticides,fungicides, Various colored to colorless liquid, Chlorinated hydrocarbons, herbicides,rodenticides) powder,pellets,or grains organophosphates,carbamates, arsenic Fertilizer Liquid or solid grains Nitrogen,phosphorous Plaster White granules or powder Calcium sulphate,calcium carbonate,sulfuric acid Cleaning solvents Colorless,blue,or yellow-green Perchloroethylene,methylene liquid chloride,trichloroethylene, petroleum distillates Asphalt Black solid Oil,petroleum distillates Concrete White solid Limestone,sand Glue,adhesives White or yellow liquid Polymers,epoxies Paints Various colored liquid Metal oxides,Stoddard solvent, talc,calcium carbonate,arsenic Curing compounds Creamy white liquid Naphtha Wastewater from construction Water Soil,oil&grease,solids equipment washing Wood preservatives Clear amber or dark brown liquid Stoddard solvent,petroleum distillates,arsenic,copper, chromium Hydraulic oil/fluids Brown oily petroleum hydrocarbon Mineral oil Gasoline Colorless,pale brown or pink Benzene,ethyl benzene,toluene, petroleum hydrocarbon xylene,MTBE Diesel Fuel Clear,blue-green to yellow liquid Petroleum distillate,oil &grease, naphthalene,xylenes Kerosene Pale yellow liquid petroleum Coal oil,petroleum distillates Hydrocarbon Antifreeze/coolant Clear green/yellow liquid Ethylene glycol,propylene glycol, heavy metals(copper, lead,zinc) Erosion Solid Particles Soil, Sediment B) Specific Requirements 1) Site and Activity Description The owner is proposing the construction of a 10,400 sq. ft. building with associated utility extensions and parking amenities. Necessary grading and erosion control will be performed. Storm Water Pollution Prevention Plan Page 3 Albemarle County, Virginia Goodwill-Mill Creek Drive ti✓ 4..r+ The items required by the Permit regarding the site description (Part II D.1., Appendix A) can be found in the project design plans, Goodwill - Mill Creek Drive, which are incorporated by reference into this plan. A summary of the required elements is provided in Table 2, with a reference to the sheet number in the design plans where the required element can be located: Table 2. Site Description Elements Please refer to the referenced location (i.e. Plan Sheet#) in Goodwill - Mill Creek Drive or as referenced elsewhere Permit Part Location' II D. 1.... Required Element a. Description of construction sequence of soil disturbing activities C2&C4 b. Site area estimates,including limits of soil disturbance C2&C4 c. Pre and post-construction runoff areas C2&C4 d. Existing vegetation at the site C2 e. Description of other potential pollution sources,including vehicle fueling,chemical N/A storage areas,sanitary waste facilities,construction debris,litter,etc. f. Receiving water location,resource protection areas and the extent of wetlands and N/A wetlands buffers g. Site map,to include locations of the following: g•(l) -Drainage patterns,pre and post-construction C2&C4 g.(2) -Limits of clearing C2&C4 g.(3) -Major structural and non-structural controls C2&C4 g.(4) -Stabilization areas,including types of vegetative cover C4 g.(5) -Surface waters,including wetlands N/A g.(6) -Storm water discharge points,with an outline of the associated drainage areas N/A g.(7) -Existing and planned:buildings,paved areas,stockpiles C2&C4 g.(8) -Permanent storm water management facilities N/A g.(9) -Offsite material,waste,borrow,or equipment areas covered by the Plan N/A g(10) -Other potential pollution sources(as described in f above) N/A h. Description of support activities covered by the Permit,including any dedicated concrete N/A and asphalt plants _ ti Attach to this Plan any required elements that are not found in the design plans.] 2) Controls and Measures The Permit requires the implementation of various types of controls and measures that are implemented to control pollutants in storm water discharges from the project site. The Permit specifically requires the implementation of erosion and sediment control practices (both structural and non-structural), storm water management practices, and specific other controls to reduce pollutants. All E & S and SWM/BMP controls employed in this project were selected to meet and/or exceed State and local requirements and are detailed in the referenced design plans. Storm Water Pollution Prevention Plan Page 4 Albemarle County, Virginia Goodwill-Mill Creek Drive Several requirements of the Permit relating to controls (Part II.D.2., Appendix A) are not included in the referenced design plans. A description of all the required items (including E&S and SWM/BMP) is presented below, along with how they are addressed in this Plan: a) Erosion and Sediment Control The design plans for this project, Goodwill - Mill Creek Drive, contain detailed information regarding erosion and sediment controls used in this project. Specifically E & S control measures can be found on sheets C2&C4. Stabilization measures shall be initiated as soon as practicable in portions of the site where construction activities have temporarily or permanently ceased, but in no case more than seven days after the construction activity in that portion of the site has temporarily or permanently ceased. Where construction activity on a portion of the site is temporarily ceased, and earth disturbing activities will be resumed within 30 days, temporary stabilization measures do no have to be initiated on that portion of the site. In drought-stricken areas where initiating perennial vegetative stabilization measures is not possible within seven days after construction activity has temporarily or permanently ceased, final vegetative stabilization measures shall be initiated as soon as practicable All control measures must be properly selected, installed and maintained in accordance with manufacturer specifications and good engineering practices. If periodic inspections or other information indicates a control has been used inappropriately, or incorrectly, the permittee must replace or modify the control for site situations as soon as practicable. If sediment escapes the construction site, off-site accumulations of sediment must be removed at a frequency sufficient to minimize off-site impacts. Litter, construction debris, and construction chemicals exposed to storm water shall be prevented from becoming a pollutant source in storm water discharges. No solid materials, including building materials, garbage, and debris shall be discharged to surface waters of the state, except as authorized a Clean Water Permit Section 404 permit. b) SWM/BMP's Storm Water Pollution Prevention Plan Page 5 Albemarle County, Virginia Goodwill-Mill Creek Drive The design plans for this project, Goodwill - Mill Creek Drive, contain detailed information regarding SWM/BMP controls used in this project. Specifically Stormwater Management Control Measures can be found on sheet C5. c) Fuels and Oils (i) On-site vehicle refueling will be conducted in a dedicated location away from access to surface waters. Since the location of fueling activities will periodically move during construction, the design plans do not contain a specific location. For each phase of work a location will be determined in the field and noted in the Site Inspection Log (Appendix D). Containment berms will be located adjacent to the refueling area that will contain any inadvertent spills until they can be cleaned up. Any on-site storage tanks will have a means of secondary containment. In the event of a spill, it will be cleaned up immediately and the material, including any contaminated soil, will be disposed of according to all federal, state, and local regulations. (ii) All vehicles on site will be monitored for leaks and receive regular preventive maintenance to reduce the chance of leakage. (iii) Petroleum products will be stored in tightly sealed containers which are clearly labeled. (iv) Spill kits will be included with all fueling sources and maintenance activities. (v) Any asphalt substances used onsite will be applied according to the manufacturer's recommendation. d) Solid Waste No solid materials shall be discharged to surface water. Solid materials, including building materials, garbage, and debris shall be cleaned up daily and deposited into dumpsters, which will be periodically removed from the site and deposited into a landfill. e) Fertilizer (i) Fertilizers will be applied only in the minimum amounts recommenced by the manufacturer. (ii) Fertilizers will be worked into the soil to limit exposure to storm water. (iii) Fertilizers will be stored in a covered shed and partially used bags will be transferred to a sealable bin to avoid spills. f) Paint and other Chemicals Storm Water Pollution Prevention Plan Page 6 Albemarle County, Virginia Goodwill-Mill Creek Drive Nip" 'Imre (i) All paint containers and curing compounds will be tightly sealed and stored when not required for use. Excess paint will not be discharged to the storm sewers, but will be properly disposed according to the manufacturer's instructions. (ii) Spray guns will be cleaned on a removable tarp. (iii) Chemicals used on-site are kept in small quantities and stored in closed containers undercover and kept out of direct contact with storm water. As with fuels and oils, any inadvertent spills will be cleaned up immediately and disposed of according to federal, state, and local regulations. g) Concrete (i) Concrete trucks will not be allowed to wash out or discharge surplus concrete or drum wash water on the site, except in a specially designated concrete disposal area. (ii) Form release oil used for decorative stone work will be applied over a pallet covered with an absorbent material to collect excess fluid. The absorbent material will be replaced and disposed of properly when saturated. h) Water Testing When testing/cleaning of water supply lines, the discharge from the tested pipe will be collected and conveyed to a completed storm water pipe system for ultimate discharge into a sedimentation basin or SWM/BMP facility. i) Sanitary Waste Portable lavatories are located on-site and are serviced on a regular basis by a contractor. They will be located in upland areas away from direct contact with surface waters. Any spills occurring during servicing will be cleaned up immediately, including any contaminated soils, and disposed of according to all federal, state, and local regulations. j) Grading and E & S Activities A record of the dates when major grading activities occur, when construction activities temporarily or permanently cease on a portion of the site, and when stabilization measures are initiated shall be maintained and included in Appendix C of this plan or in another acceptable location onsite. 3) Spills Storm Water Pollution Prevention Plan Page 7 Albemarle County, Virginia Goodwill-Mill Creek Drive \tow Nevi Oil, chemical or other hazardous substance spills in excess of reportable quantities, in accordance with Part I E. of the Permit (Appendix A), will be reported to the Department in accordance with Part III G. of the Permit as soon as the discharge is discovered, but no later than 24 hours. A reportable quantity of oil is defined as a discharge to a surface water that causes a sheen, discoloration, and/or an emulsion. Reports will be made to the following: DEQ Valley Regional Office Phone: (540) 574-7800 Fax: (540)574-7878 For reports outside normal working hours, leave a message. Virginia Department of Emergency Management Emergency Operations Center (EOC) Phone: 1-(800) 468-8892 Materials and equipment necessary for oil or chemical spill cleanup will be kept in the temporary material storage trailer onsite. Equipment will include, but not be limited to, brooms, dust pans, mops, rags, gloves, goggles, kitty litter, sand, saw dust, and plastic and metal trash containers. All oil or other chemical spills will be cleaned up immediately upon discovery. Spills large enough to reach the storm sewers will be reported to the National Response Center at 1-800-424-8802. 4) Maintenance Maintenance of the erosion and sediment controls and the storm water management/BMP facilities incorporated into this project must be maintained on a regular basis to assure their continued effectiveness. This includes repairs to all erosion and sediment controls, including cleanout of all sediment basins and storm water management facilities at the required intervals. Those controls found to be ineffective during routine inspections (as described in the following section) shall be repaired before the next anticipated storm event or as soon as practicable. A more detailed description of the maintenance procedures is contained in the design plans, Goodwill - Mill Creek Drive, on sheet C5, and is incorporated in this plan by reference. 5) Inspections Inspections by qualified personnel shall be conducted of all areas of the site disturbed by construction activity, and areas used for storage of materials that are exposed to storm water. "Qualified personnel" means a licensed professional engineer, responsible land disturber (RLD), or other knowledgeable person who (i) holds a certificate of competence from the board in the area of project inspection; or (ii) is Storm Water Pollution Prevention Plan Page 8 Albemarle County, Virginia Goodwill-Mill Creek Drive '`r►` 'gin/ enrolled in the board's training program for project inspection or combined administrator and successfully completes such program within one year of enrollment. Inspections shall include the review of all disturbed areas, structural and non-structural control measures, material storage areas, and vehicular access points. Inspections are to be performed at least once every 14 calendar days and within 48 hours after a storm event totaling 0.5 inches or more. Areas that already have been stabilized or where runoff is unlikely due to frozen or snow covered ground shall be inspected at least on a monthly basis. Inspections are intended to identify areas where the pollutant control measures at the site are ineffective and are allowing pollutants to enter surface waters. Receiving waters shall be inspected to ascertain whether control measures are effective in preventing significant impacts. Locations where vehicles enter or exit the site shall be inspected for evidence of offsite sediment tracking. If as a result of the inspection, the site conditions and/or control measures are found to have changed, the plan shall be updated within a period of 7 calendar days. If control measures need to be modified to assure effectiveness or if additional measures are determined to be necessary, implementation shall be completed prior to the next anticipated storm event or as soon as practicable. A report summarizing the inspections and the subsequent maintenance activities must be completed and maintained as part of the plan. The sample inspection forms are included in Appendix D. Required elements include major observations (including information on control measure performance and incidents of non-compliance), and information on the inspecting personnel. If an inspection does not identify any incidents of non-compliance, then the certification statement contained in the inspection form will apply. Utility line installation, pipeline construction, and other examples of long, narrow, linear construction activities may limit the access of inspection personnel to the areas described in Section D 4 b. Inspection of these areas could require that vehicles compromise temporarily or even permanently stabilized areas, cause additional disturbance of soils, and increase the potential for erosion. In these circumstances, controls must be inspected on the same frequencies as other construction projects, but representative inspections may be performed. For representative inspections, personnel must inspect controls along the construction site for 0.25 miles above and below each access point where a roadway, undisturbed right-of-way, or other similar feature intersects the construction site and allows access to the areas described above. The conditions of the controls, along each inspected 0.25-mile segment may be considered as representative of the condition of controls along that reach extending from the end of the 0.25-mile segment to either the end of the next 0.25-mile segment, or to the end of the project, whichever comes first. Inspection locations must be listed in the report required by Section II D 4 d. Storm Water Pollution Prevention Plan Page 9 Albemarle County, Virginia Goodwill-Mill Creek Drive 6) Non-Storm Water Discharges With the exception of flows from fire fighting activities, allowable sources of non- storm water discharges (Part I D.2. of the Permit, Appendix A) must be identified in the plan. Appropriate measures must be taken to ensure that pollution prevention measures for the non-storm water component of the discharge are implemented. The non-storm water discharges associated with this project identified at this time are: a) Testing of Water as discussed under II, B, 2, h. Other permitted discharges include: a) Discharges from fire fighting activities; b) Fire hydrant flushings; c) Waters used to wash vehicles where detergents are not used; d) Potable water sources, including waterline flushings; e) Water used to control dust; f) Water used for hydrostatic testing of new pipeline construction; g) Routine external building wash down which does not use detergents; h) Pavement washwaters where spills or leaks of toxic or hazardous materials have not occurred (unless all spilled material has been removed) and where detergents are not used; i) Uncontaminated air conditioning or compressor condensate; j) Uncontaminated ground water or spring water; k) Foundation or footing drains where flows are not contaminated with process materials such as solvents; 1) Uncontaminated excavation dewatering, and m) Landscape irrigation. 7) Total maximum daily loads a) A total maximum daily load (TMDL) approved by the State Water Control Board may include a wasteload allocation to the regulated construction activity that identifies the pollutant for which stormwater control measures are necessary for the surface waters to meet water quality standards. The pollutant identified in a wasteload allocation as of the effective date of this permit must be specified in the SWPPP. The SWPPP shall include strategies and control measures to ensure consistency with the assumptions and requirements of the TMDL WLA that apply to the operator's discharge. In a situation where a TMDL has specified a general wasteload allocation applicable to construction stormwater discharges, but no specific requirements for construction sites have been identified in the TMDL, the operator shall consult with the state or federal TMDL authority to confirm that meeting permit requirements will be consistent with the approved TMDL. If the TMDL specifically precludes such discharges, the operator is not eligible for coverage under the general permit. Loads & Implementation Plans can be found at the following links: http://www.deq.state.va.us/Resources/ReportsandData.aspx & Storm Water Pollution Prevention Plan Page 10 Albemarle County, Virginia Goodwill-Mill Creek Drive l http://www.deq.state.va.us/Programs/Water/WaterQualitylnformationTMDLs/TM DL/TMDLImplementation/TMDLImplementationPlans.aspx At this time the receiving waters from Goodwill—Mill Creek Drive have no general wasteload allocation applicable to construction stormwater discharges. 8) Impaired waters a) In accordance with Section I H, control measures shall be protective of water quality standards for impaired waters identified as having impairments for pollutants that may be discharged from the construction activity in the 2012 § 305(b)/303(d) Water Quality Assessment Integrated Report which can be found at the following link: http://www.deq.state.va.us/Programs/Water/WaterQualitylnformationTMDLs/Wat erQualityAssessments/201 2305b303dIntegratedReport.aspx - factsheets An integrated map can be found at the following link: http://www.deq.virginia.gov/mapper ext/default.aspx?service=public/2012 adb a nyuse Currently Moores Creek is listed as impaired by bacteria from municipal, wildlife, non-point source, and agriculture.No activities associated with this land disturbance will generate additional Bacteria. C) Contractor Certification All contractors and/or sub-contractors who have responsibility for implementing and maintaining the controls identified in this plan must sign the certification statement contained in Appendix E. The person signing the certification must meet the signatory requirements, as presented in Part III K of the Permit (Appendix A). The certifications must be maintained as part of the plan. Storm Water Pollution Prevention Plan Page 11 Albemarle County, Virginia Goodwill-Mill Creek Drive REFERENCES Virginia Department of Conservation and Recreation. 1992.Virginia Erosion and Sediment Control Handbook. Third Edition. Division of Soil and Water Conservation, Virginia Department of Conservation and Recreation. Title of Regulation: 4VAC50-60. Virginia Stormwater Management Program (VSMP) Permit Regulations (amending 4VAC50-60-10, 4VAC50-60-1100 through 4VAC50-60-1190; adding 4VAC50-60-1182, 4VAC50-60-1184, 4VAC50-60-1186, 4VAC50-60-1188). Storm Water Pollution Prevention Plan Page 12 Albemarle County, Virginia Goodwill-Mill Creek Drive APPENDIX A Storm Water Construction General Permit No. VAR10 APPENDIX B Forms: (DEQ 199-213) Department of Conservation and Recreation Permit Fee Form (DEQ 199-146) VSMP General Permit for Discharges of Stormwater from Construction Activities (DEQ 199-147) VSM General Permit Notice of Termination Noe um lie General Permit for Discharges of Stormwater from Construction Activities (VAR10) Registration Statement (Please Type or Print All Information) 1. Construction Activity Operator(The permit will be issued to this operator, and the Certification in Item#13 must be signed by the appropriate person associated with this operator[see the instructions]}: Name: TRIANGLE SERVICES - PETER WRAY Mailing Address: 2903 N.AUGUSTA STREET City: STAUNTON State: VA Zip: 24401 Phone: 540-885-5181 Email address(if available):P�,�f`i`�( )-r, Indicate if DEQ may transmit the perm ele tronically: Yes No 2. (Must be included for renewals of coverage only)Existing Permit Coverage#: 3. Location of Construction Activity: Name: GOODWILL MILL CREEK DR Address: MILL CREEK DRIVE AND AVON STREET City: CHARLOTTESVILLE State: VA Zip: County: DMS to the nearest 15 seconds: Latitude 38°0'2.67"N Longitude 78°29'49.71"W Location of all Offsite Support Activities to be Covered Under the Permit: Name: Address: City: State: Zip: County: If street address unavailable: Latitude Longitude 4. Status of Activity:Federal❑ State❑ Public❑ Private Ni (Check one only) 5. The Nature of the Construction Activity(e.g.,commercial,industrial,residential,agricultural,oil and gas,etc.): COMMERCIAL 6. Name of the Receiving Water(s): Moores Creek Hydrologic Unit Code(HUC): HUC 12—020802040402 VAHU6 —JR15 (Receiving waters identified as impaired on the 2008 305(b)/303(d)Water Quality Assessment Integrated Report or for which a TMDL WLA has been established for stormwater discharges from a construction site shall be noted in an attached list.) 7. If the discharge is through a Municipal Separate Storm Sewer System(MS4),the name of the municipal operator of the storm sewer: 8. Estimated Project Start Date(mmlddlyyyy): 06/02/2014 Estimated Project Completion Date(mmiddlyyyy): 06/01/2015 9. Total Land Area of Development(to the nearest one-tenth acre): 0.8 Estimated Area to be Disturbed(to the nearest one-tenth acre): 0.8 10. Is the area to be disturbed by the construction activity part of a larger common plan of development or sale?Yes I4 No❑ 11. Are nutrient offsets intended to be acquired for this activity?Yes© No❑ Under consideration❑ 12. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General 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. 13. 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 tine and imprisonm r . IL t for knowing lati vio ns." Print Name: (.� v Title: Signature: t Date: —4 -VA (Please sign in I K.The pe signing this form must be associated with the operator identified in Item#1 above.) Mail to: Department of Environmental Quality, Office of Stormwater Management, 10th Floor, P.O. Box 1105, Richmond,VA 23218 (DEQ 199-146)(08113) 2009 DEPARTMENT OF ENVIRONMENTAL QUALITY CONSTRUCTION ACTIVITY OPERATOR PERMIT FEE FORM (Please Type or Print All Information) Instructions: Applicants for a Construction Activity Individual Permit are required to pay permit application fees. Fees are also required for registration for coverage under a Construction Activity General Permit. Fees must be paid when applications for state permit issuance or modification are submitted. Applications will be considered incomplete if the proper fee is not paid and will not be processed until the fee is received. The fee schedule for state permits is included with this form. Fees for state permit issuance, reissuance, modification, maintenance, and reinspection are included. Once you have determined the fee for the type of application you are submitting, complete this form. The original copy of the form and your check or money order payable to"Treasurer of Virginia"should be mailed to: Department of Environmental Quality Receipts Control P.O. Box 1104 Richmond,VA 23218 A copy of this form and a copy of your check or money order should accompany the permit application (or registration statement). You should retain a copy for your records. Construction Activity Operator: Name: TRIANGLE SERVICES - PETER WRAY FIN: Mailing Address: 2903 N. AUGUSTA STREET City: STAUNTON State: VA Zip: 24401 Phone: 540-885-5181 Name and Location Construction Activity: Name: GOODWILL MILL CREEK DR City: CHARLOTTESVILLE State: VA Zip: County: (Lat: 38°0'2.67"N Long: 78°29'49.71"W) Type of State Permit: ❑ Construction Activity Individual Permit © Construction Activity General Permit (from Fee Schedule) Type of Action: © New Issuance ❑ Reissuance ❑ Modification ❑ Maintenance ❑ Reinspection Amount of Fee Submitted (from Fee Schedule): $200 Existing Permit Number(if applicable): FOR DEQ USE ONLY Date: DC#: (DEQ 199-213)(08/13) err' CONSTRUCTION ACTIVITY PERMIT FEE SCHEDULE A. Individual Permits. Applications for issuance of new Construction Activity individual permits, and for permittee initiated major modifications that occur (and become effective) before the specified state permit expiration date. (NOTE: Individual Construction Activity permittees pay an Annual State Permit Maintenance Fee instead of a reapplication fee. The permittee is billed separately by DEQ for the State Annual Permit Maintenance Fee.) TYPE OF STATE PERMIT ISSUANCE MODIFICATION Construction Stormwater Individual $15,000 $0 B. Registration Statements for Construction Activity General Permit Coverage. The fee for filing a state permit application (registration statement)for coverage under a Construction Activity general permit issued by the Board is as follows: TYPE OF STATE PERMIT ISSUANCE Construction General/Stormwater Management—Phase I Land Clearing ("Large" Construction Activity—Sites or common plans of development or sale equal to or greater $750 than 5 acres) Construction General/Stormwater Management—Phase II Land Clearing ("Small" Construction Activity—Sites or common plans of development or sale equal to or greater $450 than 1 acre and less than 5 acres) Construction General/Stormwater Management—Small Construction Activity/Land Clearing (Sites within designated areas of Chesapeake Bay Act localities with land $200 disturbance acreage equal to or greater than 2,500 square feet and less than 1 acre) (Fee valid until July 1, 2014) C. Permit Maintenance Fees. The annual permit maintenance fees apply to each state permit identified below, including expired permits that have been administratively continued. TYPE OF STATE PERMIT MAINTENANCE Construction General/Stormwater Management—Phase I Land Clearing ("Large" Construction Activity—Sites or common plans of development or sale equal to or greater $0 than 5 acres) Construction General/Stormwater Management—Phase II Land Clearing ("Small" Construction Activity—Sites or common plans of development or sale equal to or greater $0 than 1 acre and less than 5 acres) Construction General/Stormwater Management—Small Construction Activity/Land Clearing (Sites within designated areas of Chesapeake Bay Act localities with land $0 disturbance acreage equal to or greater than 2,500 square feet and less than 1 acre) Individual Permit for Discharges from Construction Activities $3,000 D. Reinspection Fee. The reinspection fee is required to be paid when the Department is required conduct a follow-up inspection based upon the findings of a previous inspection. TYPE OF FEE REINSPECTION Construction Activity Reinspection $125 (DEQ 199-213)(08/13) • 2014 DEPARTMENT OF ENVIRONMENTAL QUALITY CONSTRUCTION ACTIVITY OPERATOR PERMIT FEE FORM (Please Type or Print All Information) Instructions: Applicants for a Construction Activity Individual Permit are required to pay permit application fees. Fees are also required for registration for coverage under a Construction Activity General Permit. Fees must be paid when applications for state permit issuance or modification are submitted. Applications will be considered incomplete if the proper fee is not paid and will not be processed until the fee is received. The fee schedule for state permits is included with this form. Fees for state permit issuance, reissuance, modification, maintenance, and reinspection are included. Once you have determined the fee for the type of application you are submitting, complete this form. The original copy of the form and your check or money order payable to"Treasurer of Virginia"should be mailed to: Department of Environmental Quality Receipts Control P.O. Box 1104 Richmond,VA 23218 A copy of this form and a copy of your check or money order should accompany the permit application (or registration statement). You should retain a copy for your records. Construction Activity Operator: Name: TRIANGLE SERVICES - PETER WRAY FIN: Mailing Address: 2903 N. AUGUSTA STREET City: STAUNTON State: VA Zip: 24401 Phone: 540-885-5181 Name and Location Construction Activity: Name: GOODWILL MILL CREEK DR City: CHARLOTTESVILLE State: VA Zip: County: (Lat: 38°0'2.67"N Long: 78°29'49.71"W) Type of State Permit: ❑ Construction Activity Individual Permit © Construction Activity General Permit (from Fee Schedule) Type of Action: ❑ New Issuance © Reissuance ❑ Modification ❑ Maintenance ❑ Reinspection Amount of Fee Submitted (from Fee Schedule): $290 Existing Permit Number(if applicable): FOR DEQ USE ONLY Date: DC#: (DEQ 199-213)(08/13) • Now CDFW-PROJECT ACCT. 1058 Payee: n/a SWPPP FEE GOODWILL MILL CREEK DR 05/12/14 *******200.00 THE FACE OF TIES DOCUMENT HAS A COLORED BACKGROUND ON:WHITEPAPER AND ORIGINAL DOCUMENT SECURITY SCREEN-ON BACK WITH P'ADLOCKSECURITY ICON.. - CDFW-PROJECT ACCT. STELLARONE 1058 2903 N AUGUSTA ST. www.steCarone,com:. STAUNTON;:VA'24401 541}885-5181 li 88222/514 . : ,. ************Two Hundred & 00/100 Dollars DATE AMOUNT 05/12/14 *******200.00 - PAY TREASURER OF VIRGINIA _ TO THE ORDER OF: AL fr6lon, G.AMR. <`n • CDFW-PROJECT ACCT. 1048 Payee: n/a 05/09/14 *******290.00 THE PACE OF Tills DOCUMENT'HAS A COLORED BACKGROUND ON AYHI tE PAPER AND.ORIOINAL DOCUMENT SECURITY SCREEN ON BACK YJITJt PADLOCK SECURITY ICON. CDPA4 PROJECT ACCT STELtARONE 1048 2903 N.AUGUSTA ST.:.`: www.stellarone coon STAUNTON;:VA 24401: 540 885-5181 ***********Two Hundred Ninety& 00/100 Dollars DATE AMOUNT 05/09/14 *******290.00 PAY TREASURER.OF VIRGINIA TO THE ORDER DEPT OF ENVIRONMENTAL QUALITY OF: PO BOX 1104 Richmond, VA 23218 UTW)r Z JGN:''TtRE. ) APPENDIX C Record of Land Disturbance o m •2...1 N O O • rti O Q O a a 41 C O O C.) O C m O V L co U) J w-. O s- 0 V G� C V APPENDIX D Record of Site Inspections ' . 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Site: Goodwill- Mill Creek Drive Contractor# Name: Title: Firm: Name: Address: Telephone: Date: Signature: Contractor# Name: Title: Firm: Name: Address: Telephone: Date: Signature: Albemarle County, Virginia Goodwill-Mill Creek Drive APPENDIX F Construction Drawings %i NO RECEIVED itl' 1 ;-; COMMUNITY :DEVELOPMENT