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Home My WebLink AboutWPO202300013 Other 2023-02-27 (2)VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT#: GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM PLAN/ID #: CONSTRUCTION ACTIVITIES (VAR10) TECHNICAL CRITERIA: 116 ❑ IIC ❑ REGISTRATION STATEMENT 2019 Application type. VNEW PERMIT ISSUANCE (CHOOSE ONE) ❑ MODIFICATION WITH ACREAGE INCREASE ❑ MODIFICATION WITHOUT ACREAGE INCREASE ❑ EXISTING PERMIT RE -ISSUANCE Section I. Operator/Permittee Information. A. Construction Activity Operator (Permittee). The person or entity that is applying for permit coverage and will have operational control over construction activities to ensure compliance with the general permit. A person with signatory authority for this operator must sign the certification in Section V. (per Part III. K. of the VAR10 Permit). Operator Name: S Contact person: "j LA j Address: 3-3$ 1q 7Qc>&j City, State and Zip Code: h)arjo ', O) Phone Number: j+_ aQa • 03(44' Primary and CC Email: 1 Wj( icVhdCy @ j. om -1 t )4- 5. Co m B. Electronic correspondence. To receiv an mailed cove age letter or to pay by credit c rd, you must choose YES and include a valid email. May we transmit correspondence electronically? YES 4 NO ❑ Section II. Construction Activity Information. A. Include a site map showing the location of the existing or proposed land -disturbing activities, the limits of land disturbance, construction entrances and all waterbodies receiving stormwater discharges from the site. B. Project site location information. Construction Activity Name: (yy� YYl pha^i 5-ate Address: qL��;O� L'Ar+ City and/or County and Zip Code: j ue Oa Construction Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Latitude and Longitude (6-digit, decimal degrees format): J7Gq i i l I.3 ) _ —7 � U-7cja g J `I �� C. Acreage totals for all land -disturbing activities to be included under this permit coverage. Report to the nearest one -hundredth of an acre. Total land area of development (include entire area to be disturbed as approved in the Stormwater Management Plan): �( Primary estimated area to be disturbed (include portions with Erosion and Sediment Control Plan approval only): a RC Off -site estimated area to be disturbed (if applicable): D. Property Owner Status: FEDERAL ❑ STATE ❑ PUBLIC ❑ PRIVATE E. Nature of the Construction Activity Description (i.e. commercial, industrial, residential, agricultural, environmental, utility): F. Municipal Separate Storm Sewer System (MS4) name(s) (if the site is discharging to a MS4): G. Estimated Project Dates (MM/DD/YYYY). Start Date: 12°J Completion Date: I W Ia H. Is this construction activity part of a larger common plan of development or sale? YES NO ❑ Rev 11/2020 PAGE 1 1 6 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 I. 61h Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Include additional areas on a separate page. HUC NAME(S) OF RECEIVING WATERBODY Section III. Off -site Support Activity Location Information. List all off -site support activities and excavated material disposal areas being utilized for this project. Include additional areas on a separate page. Off -site Activity Name: Address: City or County: Off -site Activity Entrance Location (description, street address and/or latitude/longitude in decimal degrees): Latitude and Longitude (6-digit, decimal degrees format): Is this off -site activity an excavated material disposal area? YES ❑ NO ❑ If this off -site activity is an excavated material disposal area, list the contents of the excavated fill material: Will a separate VPDES permit cover this off -site activity? YES ❑ NO ❑ Section IV. Other Information. A. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the General VPDES Permit for Discharges of Stormwaterfrom Construction Activities prior to submittingthe Registration Statement. By signing the Registration Statement, the operator is certifying that the SWPPP has been prepared. B. Has an Erosion and Sediment Control Plan been submitted to the VESC Authority for review? YES 121' NO ❑ Erosion and Sediment Control Plan Approval Date (for the estimated area to be disturbed MM/DD/YYYY): C. Has land -disturbance commenced? YES NO ❑ D. Annual Standards and Specifications. If this project is utilizing approved Annual Standards and Specifications (AS&S), attached the completed AS&S Entity Form. AS&S Entity Name (if different from the Operator identified in Section 1): E. Billing information (leave blank if same as the Operator identified in Section I. above). This entity will receive Annual Permit Maintenance and Permit Modification Fee invoices (if applicable). Billing Name: Contact Name: Address: City, State and Zip Code: Phone Number: Primary and CC Email: Rev 11/2020 PAGE 2 16 CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 Section V. Certification. A person representing the operator as identified in Section I. A. and meeting the requirements of 9VAC25-880-70. Part III. K must physically sign this certification. A typed signature is not acceptable. Please note that operator is defined in 9VAC25-870-10 as follows: "Operator" means the owner or operator of any facility or activity subject to the Act and this chapter. 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 (H) 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). In the context of stormwater discharges from Municipal Separate Storm Sewer Systems (MS4s), operator means the operator of the regulated MS4 system. 9VAC25-880-70. Part III. K. Signatory Requirements. Registration Statement. All Registration Statements shall be signed as follows: a. For a corporation: by a responsible corporate officer. For the purpose of this chapter, 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 -making or decision -making functions far the corporation; or (H) 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 state 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 orsole proprietorship: by a general partner or the proprietor, respectively; or c. For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this chapter, a principal executive officer of a public agency includes: (1) the chief executive officer of the agency or (i)) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency. Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this document and all attachments were prepared in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment for knowing violations." Printed Name: V N I I I) Q VY/1 V, u'(.11Q Signature (signed In ink): Z-- � Date Signed: ,l[ac) 113 Section VI. Submittal Instructions. Submit this form to the VSMP Authority. If the locality is the VSMP Authority, please send your Registration Statement submittal directly to the locality; do NOT send this form to DEC. A list of local VSMP Authorities is available here: VSMP Authorities. If DEQ is the VSMP Authority, please send to: If the locality is the VSMP Authority, please send to: Department of Environmental Quality Office of Stormwater Management Suite 1400 PO Box 1105 Richmond VA 23218 constructiongp@deq.virginia.gov Rev 11/2020 PAGE 3 16