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NOI.- THIS FORM REPLACES PREVIOUS FORM 3510-6 (8-98) See Reverse for Instructions 4FOl~g/ 8: L/ Q()ft.J /-cf 1-03 Form Approved. OMB No. 2040-0188 QJ_, NPDES FORM &EPA United States Environmental Protection Agency Washington, DC 20460 Notice of Intent (NOi) for Storm Water Discharges Associated with CONSTRUCTION ACTIVITY Under a NPDES General Permit Submission of this Notice of Intent constitutes notice that the party identified in Section I of this form intends to be authorized by a NP DES permit issued for storm water discharges associated with construction activity in the State/Indian Country Land identified in Section II of this form. Submission of this Notice of Intent also constitutes notice that the party identified in Section I of this form meets the eligibility requirements in Part l.B. of the general permit (including those related to protection of endangered species determined through the procedures in Addendum A of the general permit), understands that continued authorization to discharge is contingent on maintaining permit eligibility, and that implementation of the Storm Water Pollution Prevention Plan required under Part IV of the general permit will begin at the time the permittee commences work on the construction project identified in Secion II below. IN ORDER TO OBTAIN AUTHORIZATION , ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM. I. Owner/Operator (Applicant) Information Name: 1A 51 M1 1Chvr~1h1 101-Pi ,Chr1i 1s1t 1 1Cf17816 1q131qtl-plq Phone: Address: 1I1'1i01I1 H1ar 1V1f1Y1 M1i 1+ich1<;l 1 { 1 r:+>1l 1l 1e 191e1 1.Si+iqjl-1 i P11J 1P ~ 1 '#r 'fr I I Status of !pl Owner/Operator: l!;;J City: State:~ ZipCode: 17171Si41C1 -1 II. Project/Site Information ProjectName: IA 1& 1M 1Ghuriqh 10f1 1Chr1i1s1t1 I I Is the facility located on Indian Country Lands? Yes D No [i?' Project Address/Location:!~ S=H"'--'-1-=6"--'1-=B"-\ID~=-a~s==s._.1=ai..t=i...__..,1R=....i.=a=-1.J=· =n=t==1ri=1-=e"""'e='-...CJ)=-=r""""11=· "'-'1V'""'"1e~1 _.__,__,! city: 1Go11ege 1Stati1an 1 1 state:~ zipcooe:~1 7i~1 7i~1~8_4~5~-~1~~~ Latitude: i 3i 0 3i 71 J, 0 Longitude: I 19161117 b3 19 i County: I B #a 2i Q S Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes [M' No D Optional: Address of location of SWPPP for viewing SWPPP ~Address in Section I above D Address in Section II above D Other address (if known) below: Phone: Address: ~I _.__.___.___,___.~.__._..__...__.__.__,__.__.__.___.___,___.___,.__._..__...__.__.__,__.__.__._--'--'--'--' I I I City: State: l_J_J Zip Code: 1-1 Name of Receiving Water: '-I W_._q....__1 ..... :E-'-1 _.1_B_..1 §__._n-'-_.1_G ...... ri__._1§-'-§ ..... ~__,___,__,___._....__.__,'-L__.__.__. 10~0120031 1010120041 Month Day ")bar Month Day ")bar Estimated Construction Start Date Estimated Completion Date Estimate of area to be disturbed (to nearest acre): ~I ~I ~~~~~1=9~1 Estimate of Likelihood of Discharge (choose only one): 1. D Unlikely 3. D Once per week 5. D Continual 2. E Once per month 4. D Once per day Ill. Certification Based on instruction provided in Addendum A of the permit, are there any listed endangered or threatened species, or designated critical habitat in the project area? Yes D No~ I have satisfied permit eligibility with regard to protection of endangered species through the indicated section of Part l.B.3.e.(2) of the permit (check one or more boxes): (a)~ (bJO (cJD (dl D 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 this system, or those persons directly responsible for gathering the infonnation, 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: ........... _._,e:-o ..... N_,_....._*U_._S_.._S__._~·;_"1;'---'-__.__,__..._1........L__.__.__.__..__.__.__._....._.J.........J__. Signature: EPA Form 3510-9 replaced 3510-6 (8-98) Instructions -EPA Form 3510-9 Form Approved. OMB No. 2040-0188 &EPA Notice of Intent (NOi) for Storm Water Discharges Associated with Construction Activity to be Covered Under a NPDES Permit Who Must File a Notice of Intent Form Under the provisions of the Clean Water Act, as amended, (33 U.S.C. 1251 et.seq.; the Act), except as provided by Part l.B.3 the permit, Federal law prohibits discharges of pollutants in storm water from construction activities without a National Pollutant Discharge Elimination System Permit. Operatorts) of construction sites where 5 or more acres are disturbed, smaller sites that are part of a larger common plan of development or sale where there is a cumulative disturbance of at least 5 acres, or any site designated by the Director, must submit an NOi to obtain coverage under an NPDES Storm Water Construction General Permit. If you have questions about whether you need a permit under the NPDES Storm Water program, or if you need information as to whether a particular program is administered by EPA or a State agency, write to or telephone the Notice of Intent Processing Center at (703) 931-3230. Where to File NOi Form NOls must be sent to the following address: Storm Water Notice of Intent (4203M) US EPA -Ariel Rios Building 1200 Pennsylvania Ave., NW Washington, D.C. 20460 Do not send Storm Water Pollution Prevention Plans (SWPPPs) to the above address. For overnight/express delivery of NOls, please send them to SW NOi, US EPA -ICC Building, 1201 Constitution Ave., NW, Rm. 7329, Washington, DC 20004. NOi Center phone number is 866-352-7755. When to File This form must be filed at least 48 hours before construction begins. Completing the Form OBTAIN AND READ A COPY OF THE APPROPRIATE EPA STORM WATER CONSTRUCTION GENERAL PERMIT FOR YOUR AREA. To complete this form, type or print, using uppercase letters, in the appropriate areas only. Please place each character between the marks (abbreviate if necessary to stay within the number of characters allowed for each item). Use one space for breaks between words, but not for punctuation marks unless they are needed to clarify your response. If you have any questions on this form, call the Notice of Intent Processing Center at (703) 931-3230. Section I. Facility Owner/Operator (Applicant) Information Provide the legal name, mailing address, and telephone number of the person, firm, public organization, or any other entity that meet either of the following two criteria: (1) they have operational control over construction plans and specifications, including the ability to make modifications to those plans and specifications; or (2) they have the day-to-day operational control of those activities at the project necessary to ensure compliance with SWPPP requirements or other permit conditions. Each person that meets either of these criteria must file this form. Do not use a colloquial name. Correspon- dence for the permit will be sent to this address. Enter the appropriate letter to indicate the legal status of the owner/operator of the project: F = Federal; S = State; M = Public (other than federal or state); P = Private. Section II. Project/Site Information Enter the official or legal name and complete street address, including city, county, state, zip code, and phone number of the project or site. If it lacks a street address, indicate with a general statement the location of the site (e.g., Intersection of State Highways 61 and 34). Complete site information must be provided for permit coverage to be granted. The applicant must also provide the latitude and longitude of the facility in degrees, minutes, and seconds to the nearest 15 seconds. The latitude and longitude of your facility can be located on USGS quadrangle maps. Quadrangle maps can be obtained by calling 1-800 USA MAPS. Longitude and latitude may also be obtained at the Census Bureau Internet site: http://www.census.gov/cgi-bin/gazetteer. Latitude and longitude for a facility in decimal form must be converted to degrees, minutes and seconds for proper entry on the NOi form. To convert decimal latitude or longitude to degrees, minutes, and seconds, follow the steps in the following example. Convert decimal latitude 45.1234567 to degrees, minutes, and seconds. 1) The numbers to the left of the decimal point are degrees. 2) To obtain minutes, multiply the first four numbers to the right of the decimal point by 0.006. 1234 x .006 = 7.404. 3) The numbers to the left of the decimal point in the result obtained in step 2 are the minutes: 7'. 4) To obtain seconds, multiply the remaining three numbers to the right of the decimal from the result in step 2 by 0.06: 404 x 0.06 = 24.24. Since the numbers to the right of the decimal point are not used, the result is 24". 5) The conversion for 45.1234 = 45° 7' 24". Indicate whether the project is on Indian Country Lands. Indicate if the Storm Water Pollution Prevention Plan (SWPPP) has been developed. Refer to Part IV of the general permit for information on SWPPPs. To be eligible for coverage, a SWPPP must have been prepared. Optional: Provide the address and phone number where the SWPPP can be viewed if different from addresses previously given. Check appropriate box. Enter the name of the closest water body which receives the project's construction storm water discharge. Enter the estimated construction start and completion dates using four digits for the year (i.e. 05/27/1998). Enter the estimated area to be disturbed including but not limited to: grubbing, excavation, grading, and utilities and infrastructure installation. Indicate to the nearest acre; if less than 1 acre, enter "1." Note: 1 acre = 43,560 sq . ft. Indicate your best estimate of the likelihood of storm water discharges from the project. EPA recognizes that actual discharges may differ from this estimate due to unforeseen or chance circumstances. Indicate if there are any listed endangered or threatened species, or designated critical habitat in the project area. Indicate which Part of the permit that the applicant is eligible with regard to protection of endangered or threatened species, or designated critical habitat. Section Ill. Certification Federal Statutes provide for severe penalties for submitting false information on this application form. Federal regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) 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, or (ii) the manager of one or more manufacturing, production, or operating facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million (in second-quarter 1980 dollars), if 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 of the proprietor, or For a municipality, state, federal, or other public facility: by either a principal executive or ranking elected official. An unsigned or undated NOi form will not be granted permit coverage. Paperwork Reduction Act Notice Public reporting burden for this application is estimated to average 3.7 hours. This estimate includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate, any other aspect of the collection of information, or suggestions for improving this form, including any suggestions which may increase or reduce this burden to: Director, OPPE Regulatory Information Division (2137), U.S. Environmental Protection Agency, 401 M Street, SW, Washington, D.C. 20460. Include the OMB control number on any correspondence. Do not send the completed form to this address.