Attachment 30 Example NOI Form.pdf

Appendix H - Notice of Intent (NOI) Form and Instructions

Part 1.4.1 requires you to use the NPDES eReporting Tool, or “NeT” system, to prepare and submit your

NOI electronically. However, if the EPA Regional Office grants you a waiver to use a paper NOI form, and you elect to use it, you must complete and submit the following form.

EPA Form 3510-9 Page 1

NPDES

Form

3510-9

U.S. Environmental Protection Agency

Washington, DC 20460

Notice of Intent for the 2022 NPDES Construction General Permit

OMB No.

2040-0305 Exp. Date

01/31/2025

Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section III of this form requests authorization to discharge pursuant to the NPDES Construction General Permit (CGP) permit number identified in Section II of this form. Submission of this NOI also constitutes notice that the operator identified in Section III of this form meets the eligibility requirements of Part 1.1 CGP for the project identified in Section IV of this form.

Permit coverage is required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in Part 8 of the CGP.

To obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for permit coverage. Refer to the instructions at the end of this form.

SECTION I. APPROVAL TO USE PAPER NOI FORM

P a p e r N

O I

Fo rm

Have you been granted a waiver from electronic reporting from the Regional Office*? Yes No

If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:

Waiver granted:

The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as under-served for broadband Internet access in the most recent report from the Federal Communications

Commission.

The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that granted the waiver Date approval obtained (MM/DD/YYYY)

* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you must file this form electronically using the NPDES eReporting Tool (NeT).

SECTION II. PERMIT INFORMATION

P e rm it NPDES ID (EPA Use Only) Master Permit Number (see Appendix B of the CGP for the list of eligible permit numbers)

SECTION III. OPERATOR INFORMATION

O p e ra to r

In fo rm a ti o n

Operator Name

Are you requesting coverage under this NOI as a “Federal Operator” or for a “Federal Facility” as defined in

Appendix A?

Yes No

Mailing Address

Street

City State ZIP Code

County or Similar Government Division

Operator Point of Contact Information:

First Name Middle Initial Last Name

Title

Phone Number Email Address

LJohnson Highlight

EPA Form 3510-9 Page 2

N O

I P re p a re r Complete if NOI was prepared by someone other than the certifier:

First Name Middle Initial Last Name

Organization

Phone number Email address

SECTION IV. PROJECT/SITE INFORMATION

P ro je c t/ S it e

A d d re ss

Project/Site Name

Street/Location

City State ZIP Code

County or Similar Government Division:

For the project/site you are seeking permit coverage, provide the following information:

Latitude (in decimal degrees to four decimal places): Longitude (in decimal degrees to four decimal places):

° N ° W

Latitude/Longitude Data Source: Map GPS Other (Specify):

Horizontal Reference Datum: NAD 27 NAD 83 WGS 84

S it e

I n fo rm a ti

Is your site located in Indian country lands, or on a property of religious or cultural significance to an Indian Tribe? Yes No

If yes, provide the name of the Indian Tribe associated with the area of Indian country (including name of Indian reservation, if applicable), or if not in Indian country, provide the name of the Indian Tribe associated with the property:

P ro je c t In fo rm a ti

Estimated Project Start Date (MM/DD/YYYY) Estimated Project Completion Date (MM/DD/YYYY)

Estimated Area to be Disturbed (to the nearest quarter acre):

Type of Construction Site

(check all that apply):

Single-Family Residential Multi-Family Residential Commercial

Industrial Institutional Highway or Road

Utility Other (Specify):

Was the pre-development land use used for agriculture (see Appendix A for definition of “agricultural land”)?

Yes No

Have earth-disturbing activities commenced on your project/site? Yes No

If yes, is your project an “emergency-related project” (see Appendix A)? Yes No

EPA Form 3510-9 Page 3

P ro je c t In fo rm a ti

Have stormwater discharges from your project/site been covered previously under an NPDES permit? Yes No

If yes, provide the NPDES ID (if you had coverage under EPA’s 2017 CGP) or the NPDES permit number (if you had coverage under an EPA individual permit): ______________________

Are there other operators that are covered under this permit for the same project site? Yes No

If yes, provide the NPDES ID number for all other operators at the site who have coverage under this permit: ______________________

Will there be demolition of any structure built or renovated before January 1, 1980?

Yes No

If yes, do any of the structures being demolished have at least 10,000 square feet of floor space? Yes No

Will you be discharging dewatering water from your site?

Yes No

If yes, will you be discharging dewatering water from a current or former Federal or State remediation site? Yes No

SECTION V. DISCHARGE INFORMATION

P ro je c t In fo rm a ti

By indicating “Yes,” I confirm that I understand that the CGP only authorizes the allowable stormwater discharges in Part 1.2.1 and the allowable non-stormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA section 402(k) by disclosure to EPA, State, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by the permit, the Stormwater Pollution Prevention Plan

(SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must be covered under another NPDES permit.

Yes

Does your project/site discharge stormwater into a Municipal Separate Storm Sewer System (MS4)? Yes No

Are there any waters of the U.S. within 50 feet of your project’s earth disturbances? Yes No

R e c e iv in g W a te rs I n fo rm a ti

For each point of discharge, provide the following receiving water information. (Attach a separate list if necessary)

Point of Discharge ID Provide the name of the first water of the U.S. that receives stormwater directly from the point of discharge and/or from the MS4 that the point of discharge discharges to:

If the receiving water is impaired

(on the CWA 303(d) list), list the pollutants that are causing the impairment:

If a TMDL been completed for this receiving waterbody, providing the following information:

TMDL Name and ID:

Pollutant(s) for which there is a TMDL:

TMDL Name and ID:

Pollutant(s) for which there is a TMDL:

EPA Form 3510-9 Page 4

R e c e iv in g W a te rs I n fo rm a ti

For each point of discharge, provide the following receiving water information. (Attach a separate list if necessary)

Point of Discharge ID Provide the name of the first water of the U.S. that receives stormwater directly from the point of discharge and/or from the MS4 that the point of discharge discharges to:

If the receiving water is impaired

(on the CWA 303(d) list), list the pollutants that are causing the impairment:

If a TMDL been completed for this receiving waterbody, providing the following information:

Are any of the waters of the U.S. to which you discharge designated by the State or Tribal authority under its antidegradation policy as a Tier 2 (or Tier 2.5) water (water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water) or as a Tier 3 water (Outstanding

National Resource Water)? (See Appendix F).

Yes No

If yes, name(s) of receiving water(s) and its designation (Tier 2, Tier 2.5 or Tier 3):

EPA Form 3510-9 Page 5

SECTION VI. CHEMICAL TREATMENT INFORMATION

C h e m ic a l Tr e a tm e n t

Will you use polymers, flocculants, or other treatment chemicals at your construction site? Yes No

If yes, will you use cationic treatment chemicals at your construction site*? Yes No

If yes, have you been authorized to use cationic treatment chemicals by your applicable EPA

Regional Office in advance of filing your NOI*?

If you have been authorized to use cationic treatment chemicals by your applicable EPA Regional Office, attach a copy of your authorization letter and include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards.

Please indicate the treatment chemicals that you will use:

* Note: You are ineligible for coverage under this permit unless you notify your applicable EPA Regional Office in advance and the EPA office authorizes coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards.

SECTION VII. STORMWATER POLLUTION PREVENTION PLAN (SWPPP) AND PERSONNEL TRAINING INFORMATION

S W

P P

P Has the SWPPP been prepared in advance of filing this NOI, as required? Yes No

By indicating “Yes,” I confirm that all required personnel, including those conducting inspections at your site, will meet the training requirements in Part 6 of this permit.

Yes

S W

P P

P C o n ta c t

In fo rm a ti

First Name Middle Initial Last Name

Professional Title

Phone number Email address

SECTION VIII. ENDANGERED SPECIES PROTECTION

E n d a n g e re d S p e c ie s P ro te c ti o n In accordance with Part 1.1.5, if the EPA Regional Office grants you a waiver from electronic reporting, you must complete the worksheet in

Appendix D to select your eligibility criteria with respect to the protection of Federally listed threatened or endangered species and Federally designated “critical habitat” under the Endangered Species Act (ESA) [hereinafter “ESA-listed species and designated critical habitat(s)”] from discharges and discharge-related activities authorized under this permit.

You must submit the ESA worksheet and all required supporting documentation with this NOI. If you do not submit the worksheet and the required supporting documentation with your NOI, your NOI will be considered incomplete. After you submit your NOI and before your NOI is authorized, EPA may notify you if any additional controls are necessary to ensure your discharges are not likely to result in any short- or long-term adverse effects on ESA-listed species and critical habitat.

By indicating “Yes,” I confirm that you have included the completed ESA worksheet from Appendix D and all required supporting information for your criterion selection with the submission of this NOI.

Yes

EPA Form 3510-9 Page 6

SECTION IX. HISTORIC PRESERVATION

H is to ri c

P re se rv a ti

Are you installing any stormwater controls as described in Appendix E that require subsurface earth disturbance? (Appendix E, Step 1)

If yes, have prior surveys or evaluations conducted on the site have already determined historic properties do not exist, or that prior disturbances have precluded the existence of historic properties?

(Appendix E, Step 2)

If no, have you determined that your installation of subsurface earth-disturbing stormwater controls will have no effect on historic properties? (Appendix E, Step 3)

If no, did the SHPO, THPO, or other Tribal representative (whichever applies) respond to you within the 15 calendar days to indicate whether the subsurface earth disturbances caused by the installation of stormwater controls affect historic properties? (Appendix E, Step 4)

If yes, describe the nature of their response:

Written indication that no historic properties will be affected by the installation of stormwater controls.

Written indication that adverse effects to historic properties from the installation of stormwater controls can be mitigated by agreed upon actions.

No agreement has been reached regarding measures to mitigate effects to historic properties from the installation of stormwater controls.

Other (Specify):

SECTION X. CERTIFICATION INFORMATION

C e rt if ic a ti o n I n fo rm a ti

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 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 have no personal knowledge that the information submitted is other than 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.

First Name Middle Initial Last Name

Title

Signature Date (MM/DD/YYYY)

Email Address

EPA Form 3510-9 Page 7

Instructions for Completing EPA Form 3510-9

Notice of Intent for the 2022 NPDES Construction General Permit

NPDES Form Date (02/22) This Form Replaces Form 3510-9 (02/17) Form Approved OMB No. 2040-0305

General Instructions

Who Must File an NOI Form?

Under the provisions of the Clean Water Act, as amended (33

U.S.C. 1251 et. seq.; the Act), Federal law prohibits stormwater discharges from certain construction activities to waters of the U.S. unless that discharge is covered under a National

Pollutant Discharge Elimination System (NPDES) permit.

Operators of construction sites where one 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 one acre, or any other site specifically designated by the Director, must obtain coverage under an

NPDES general permit. For coverage under the 2022 CGP, each person, firm, public organization, or any other entity that meets either of the following criteria must file a Notice of

Intent form: (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 day-to-day operational control of those activities at the project necessary to ensure compliance with the permit conditions. If you have questions about whether you need a NPDES stormwater permit, or if you need information to determine whether EPA or your State agency is the permitting authority, contact your EPA Regional Office.

Completing the Form

Obtain and read a copy of the 2022 CGP, viewable at https://www.epa.gov/npdes/stormwater-discharges-construction-activities#cgp. To complete this form, type or print 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, telephone EPA’s NOI Processing Center at (866) 352-7755.

Please submit the original document with signature in ink - do not send a photocopied signature.

Section I. Approval to Use Paper NOI Form

You must indicate whether you have been granted a waiver from electronic reporting from the EPA Regional Office. Note that you are not authorized to use this paper NOI form unless the EPA Regional Office has approved its use. Where you have obtained approval to use this form, indicate the waiver that you have been granted, the name of the EPA staff person who granted the waiver, and the date that approval was provided.

See https://www.epa.gov/npdes/contact-us-stormwater#regional for a list of EPA Regional Office contacts.

Section II. Permit Information

Provide the master permit number of the permit under which you are applying for coverage (see Appendix B of the general permit for the list of eligible master permit numbers)

Section III. Operator Information

Provide the legal name of the person, firm, public organization, or any other entity that operates the project described in this NOI. Refer to Appendix A of the permit for the definition of “operator”.

Indicate whether you are seeking coverage under this permit as a “Federal Operator” or “Federal Facility” as defined in

Appendix A.

Also provide a point of contact, the operator’s mailing address, county, telephone number, and e-mail address (to be notified via e-mail of NOI approval when available).

Correspondence for the NOI will be sent to this address.

If the NOI was prepared by someone other than the certifier

(for example, if the NOI was prepared by the facility SWPPP contact or a consultant for the certifier’s signature), include the full name, organization, phone number, and email address of the NOI preparer.

Section IV. Project/Site Information

Enter the official or legal name and complete street address, including city, State, ZIP code, and county or similar government subdivision of the project or site. If the project or site lacks a street address, indicate the general 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.

Provide the latitude and longitude of your facility in decimal degrees format. The latitude and longitude of your facility can be determined in several different ways, including through the use of global positioning system (GPS) receivers, U.S. Geological Survey (U.S.G.S.) topographic or quadrangle maps, and web-based siting tools, among others. For consistency, EPA requests that measurements be taken from the approximate center of the construction site. For linear construction sites, the measurement should be taken midpoint of the site. If known, enter the horizontal reference datum for your latitude and longitude. The horizontal reference datum is shown on the bottom left corner of USGS topographic maps; it is also available for GPS receivers.

Indicate whether the project is in Indian country lands or located on a property of religious or cultural significance to an Indian Tribe, and if so, provide the name of the Indian Tribe associated with the area of Indian country (including name of Indian reservation, if applicable), or if not in Indian country, provide the name of the Indian Tribe associated with the property.

Enter the estimated construction start and completion dates using four digits for the year (i.e., 10/06/2012). Indicate to the nearest quarter acre the estimated area to be disturbed.

Indicate the type of construction site.

Indicate whether the pre-development land use of the site was used for agriculture Appendix A defines “agricultural land” as cropland, grassland, rangeland, pasture, and other agricultural land, on which agricultural and forest-related products or livestock are produced and resource concerns may be addressed. Agricultural lands include cropped woodland, marshes, incidental areas included in the agricultural operation, and other types of agricultural land used for the production of livestock.

Indicate whether earth-disturbing activities have already commenced on your project/site. If earth-disturbing activities have commenced on your site because stormwater discharges from the site have been previously covered under a NPDES permit, you must provide the 2017 CGP NPDES ID or

EPA Form 3510-9 Page 8 the NPDES permit number if coverage was under an individual permit.

Indicate if demolition is occurring, and if so, if the structure has at least 10,000 square feet of floor space.

Indicate if there are other operators covered under this permit for the same project site. If there are multiple operators, provide the NPDES ID number for the other operators at the site who have coverage under this permit.

Indicate whether you will be discharging dewatering water, as defined in Appendix A, during the course of the project. If you will be discharging dewatering water, indicate whether the site from which you will be dewatering is located on a current or former Federal or State remediation site. Federal remediation sites include cleanups covered by Superfund

(both National Priorities List (NPL) sites and non-NPL sites), Resource Conservation and Recovery Act (RCRA) corrective actions sites, cleanups at Federal Facilities, and Federal, State, or Tribal brownfields sites. State remediation sites could include, for instance, brownfield site cleanups funded by the

State, State superfund sites, and petroleum tank release sites.

Operators may use online mapping resources, such as EPA’s

Cleanups in My Community Map, to help determine if they are located on a remediation site. The Cleanups in My

Community Map is viewable at:

https://ordspub.epa.gov/ords/cimc/f?p=cimc:map::::71

Section V. Discharge Information

You must confirm that you understand that the CGP only authorizes the allowable stormwater discharges listed in Part

1.2.1 and the allowable non-stormwater discharges listed in

Part 1.2.2. Any discharges not expressly authorized under the

CGP are not covered by the CGP or the permit shield provision of the CWA Section 402(k) and they cannot become authorized or shielded by disclosure to EPA, State, or local authorities via the NOI to be covered by the permit or by any other means (e.g., in the SWPPP or during an inspection). If any discharges requiring NPDES permit coverage other than the allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must either be eliminated or covered under another NPDES permit.

Indicate whether discharges from the site will enter into a municipal separate storm sewer system (MS4), as defined in

Appendix A.

Also, indicate whether any waters of the U.S. exist within 50 feet from your site. Note that if “yes”, you are required to comply with the requirement in Part 2.2.1 of the permit to provide natural buffers or equivalent erosion and sediment controls.

For each unique point of discharge you list, you must specify the name of the first water of the U.S. that receives stormwater directly from the point of discharge and/or from the MS4 that the point of discharge discharges to. You must specify whether any waters of the U.S. that you discharge to are listed as

”impaired” as defined in Appendix A, and the pollutants for which the water is impaired. You must identify any Total

Maximum Daily Loads (TMDL) that have been completed for any of the waters of the U.S. that you discharge to. Operators may find it useful to use EPA’s Discharge Mapping Tool to determine whether the water of the U.S. is impaired, the pollutant causing the impairment, and whether a TMDL exists for the water body. The Discharge Mapping Tool is viewable at https://www.epa.gov/npdes/epas-stormwater-discharge-mapping-tools.

Indicate whether discharges from the site will enter into a water of the U.S. that is designated as a Tier 2, Tier 2.5, or Tier

3 water. A list of Tier 2, 2.5, and 3 waters is provided at https://www.epa.gov/npdes/construction-general-permit-resources-tools-and-templates. If the answer is “yes”, name all waters designated as Tier 2, Tier 2.5, or Tier 3 to which the site will discharge.

Section VI. Chemical Treatment Information

Indicate whether the site will use polymers, flocculants, or other treatment chemicals. Indicate whether the site will employ cationic treatment chemicals. If the answer is “yes” to either question, indicate which chemical(s) you will use.

Note that you are not eligible for coverage under this permit to use cationic treatment chemicals unless you notify your applicable EPA Regional Office in advance and the EPA office authorizes coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. If you have been authorized to use cationic treatment chemicals by your applicable EPA

Regional Office, attach a copy of your authorization letter and include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. Examples of cationic treatment chemicals include, but are not limited to, cationic polyacrylamide (C-PAM), PolyDADMAC (POLY DIALLYL

DIMETHYL AMMONIUM CHLORIDE), and chitosan.

Section VII. Stormwater Pollution Prevention Plan (SWPPP) and Personnel Training Information

All sites eligible for coverage under this permit are required to prepare a SWPPP in advance of filing the NOI, in accordance with Part 7. Indicate whether the SWPPP has been prepared in advance of filing the NOI.

Confirm that all required personnel, including those conducting inspections at your site, will meet the training requirements in Part 6 of this permit.

Indicate the street, city, State, and ZIP code where the SWPPP can be found. Indicate the contact information (name, organization, phone, and email) for the person who developed the SWPPP for this project.

Section VIII. Endangered Species Information

Confirm that you have included the completed ESA worksheet from Appendix D and all required supporting information for your criterion selection with the submission of this NOI.

Section IX. Historic Preservation

Use the instructions in Appendix E to complete the questions on the NOI form regarding historic preservation.

Section X. Certification Information

The NOI must be signed as follows:

For a corporation: By a responsible corporate officer. For the purpose of this Section, 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- 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 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, respectively; or

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

Federal 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 (e.g., Regional Administrator of EPA). Include the name and title of the person signing the form and the date of signing. An unsigned or undated NOI form will not be considered eligible for permit coverage.

Modifying Your NOI

If you have been granted a waiver from your Regional

Office from electronic reporting, and if after submitting your

NOI you need to correct or update any fields on this NOI form, you may do so by indicating changes on this same form.

Paperwork Reduction Act Notice

This collection of information is approved by OMB under the

Paperwork Reduction Act, 44 U.S.C. 3501 et seq.

(OMB Control No. 2040-0305). Responses to this collection of information are mandatory (40 CFR 122.26).

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. The public reporting and recordkeeping burden for this collection of information is estimated to be 3.3 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division

Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.

Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form 3510-9

Submitting Your Form

Submit your NOI form by mail to one of the following addresses:

For Regular U.S. Mail Delivery:

Stormwater Notice Processing Center

Mail Code 4203M, ATTN: 2022 CGP

U.S. EPA

1200 Pennsylvania Avenue, NW

Washington, DC 20460

For Overnight/Express Mail Delivery:

Stormwater Notice Processing Center

William Jefferson Clinton East Building - Room 7420

ATTN: 2022 CGP

U.S. EPA

1201 Constitution Avenue, NW

Washington, DC 20004

Visit this website for instructions on how to submit electronically:

https://www.epa.gov/npdes/stormwater-discharges-construction-activities#ereporting