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Home My WebLink AboutWPO201800027 VSMP - SWPPP 2018-07-31® COLLINS ENGINEFP NG TRANSMITTAL 200 GARRETT ST. SUITE K CHARLOTTESVILLE VA 22902 434.293.3719 PH 434.293.2913 FX w Wxollin"ngineering.wm ❑ FAX ❑ MAIL N DELIVERY TO: FROM: SCOTT COLLINS COMPANY: DATE: ALBEMARLE COUNTY 8/1/2018 FAX: TOTAL NO. OF PAGES INCLUDING COVER: PHONE NUMBER: SENDER'S PHONE NUMBER: 434.293.3719 PROJECT/SUBJECT: PLEASE FIND ENCLOSED: NO. COPIES 1 NOTES/ COMMENTS: RECEIVED BY: MARTHA JEFFERSON APARTMENTS WP02O18-00027 DATE DESCRIPTION SWPPP FORMS SIGNATURE DATE Registration Statement General VPDES Permit for Discharges of Stormwater from Construction Activities (VAR10) (Please Type or Print All Information) 1. Construction Activity Operator: (General permit coverage will be issued to this operator. The Certification in Item #12 must be signed by the appropriate person associated with this operator.) Name: RIVERSEND DEVELOPMENT Contact: ALAN TAYLOR Mailing Address: 455 SECOND STREET SE SUITE 400 City. CHARLOTTESVILLE State: VA Zip: 22902 Phone: 434-245-4970 Email address (If available): alan@riverbenddev.com Indicated DIED may transmit general permit correspondence electronically: Yes Q No ❑ 2. Existing General Permit Registration Number (for renewals only): __ 3. Name and Location of the Construction Activity: _ Name: MARTHA JEFFERSON HOSPITAL APARTMENTS Address (if available): PETER JEFFERSON PARKWAY City: CHARLOTTESVILLE State: VA Zip: 22911 County (if not located within a City): Latitude (decimal degrees): 38.020721 Longitude (decimal degrees):-78.447276 Name and Location of all Off -site Support Activities to be covered under the general permit: Address (if available): City: --- -_ State:_- _---- Zip:___ County (if not located within a City): Latitude (decimal degrees): Longitude (decimal degrees): 4. Status of the Construction Activity (check only one): Federal ❑ State ❑ Public ❑ Private 5. Nature of the Construction Activity (e.g., commercial, Industrial, residential, agricultural, oil and gas, etc.): RESIDENTIAL S. Name of the Receiving Water(a) and Hydrologic Unit Code (HUC): Name: RIVANNA RIVER - MEADOW CREEK Name: RIVANNA RIVER - CARROLL CREEK HUC: 020802040401(11114) HUC:020802040404(1R17) 7. If the discharge is through a Municipal Separate Storm Sewer System (MS4), the name of the M84 operator: 8. Estimated Project Start and Completion Date: Start Date (mm/dd/yyyy):_ 9/1f2018 ___ Completion Date (mm/dd/yyyy): 9L1/2020 9. Total Land Area of Development (to the nearest one -hundredth acre):. 26.98 AC Estimated Area to be Disturbed (to the nearest one hundredth acre): 16.4 AC 10. Is the area to be disturbed part of a larger common plan of development or sale? Yes ❑ No 1C 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 We, accurate, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment for knovypgv(lations." Printed Name: 1 Title: pv'J Signature:_ Date: '1 (3 -,- u ( D (Please sign in INK. his CsrtllM'catlon must be signed by the appropriate person associated with tie operator Identified In Item #1.) 07/2014 Page 1 of 1 Instructions for Completing the'Ragiasua'tion 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 Storwater from Construction Activities (VAR10). 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 permirs effective date of July 1, 2014. C. To Apply for Permit Coverage. 1. New 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 lend 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 2008, 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 Sormwater Management, 10s 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 Sormwater 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 -today 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 entitles 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 reapplication only, provide the existing general permit registration number for the construction activity. This hem does not need to be completed for new construction activities applying for general permit coverage. Item 3: Name and Location of the Construction Aetivlty Information. Provide the official name, street address (h 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 -she Support Activity Information. This general permit also authorizes stomvxater 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 (1) 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; (ill) the support activity time not operate beyond the completion of the construction activity it supports; (w) 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 state, 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 off -site support activities to be covered under this general permit- Also, provide the latitude and longitude In decimal dogmas of the approximate center of the off -site support activities (e.g., N 37.6000, W 77.WM). Also, it 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 oft -site support activity need to be Included in Item rig. Item 4: Status of the Construction ActtWty. Indicate the appropriate status (Federal, State, Public, or Private) of the conviction activity. Rom 5: Nature of the Construction Activity. Provide a brief description of the conviction activity, such as commercial, residential, agricultural, oil and gas, etc. This list Is not all Inclusive. Item 6: Receiving Watem%s) and HUC Information. Provide the name of the receiving waters) and corresponding HUC for all stormwater discharges including arty 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 S'" order national watershed boundary daoset 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 (Le_ the total acreage of the larger common plan of development or sate). Include the total acreage of any off -she 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, etc., or physical demarcation such as boundary signs, lot stakes, or surveyor markings Indicating that construction activities may occur. Item 11; Stomnvater 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 Stornwater from Construction Activities (VAR10) prior to submitting this Registration Statement. By signing this Registration Statement the operator is certifying that the SWPPP has been prepared. Item 12: Certification A property 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 impilclt duty of making major capital Investment recommendations, and Initialing 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 solo proprietorship: by a general partner or the proprietor, respectively. c. For a municipality, state, 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: (1) 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 Section 9 - Signed Certification CERTIFICATION "I 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 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." Operator Name: ALAN TAYLOR Company: RIVERBEND DEVELOPMENT Title: PRESIDENT Signature: (— — Date: � ' At 12ot0 Section 10 - Delegation of Authority Delegation of Authority I, ALAN TAYLOR (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 MARTHA JEFFERSON HOSPITAL APARTMENTS 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: _ ALAN TAYLOR Company: RIVERBEND DEVELOPMENT Title: PRESIDENT ` Signature: Date: