Appendix_TDEC_NPDES_NOI.pdf

TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION

Division of Water Pollution Control

William R. Snodgrass Tennessee Tower, 312 Rosa L. Parks Avenue, 11th Floor, Nashville, Tennessee 37243

1-888-891-8332 (TDEC)

Notice of Intent (NOI) for General NPDES Permit for Stormwater Discharges from Construction Activities (TNR100000)

Site or Project Name:

NPDES Tracking Number: TNR

Street Address or Location:

Construction Start Date:

Estimated End Date:

Site Description:

Latitude (dd.dddd):

Longitude (-dd.dddd):

County(ies): MS4 Jurisdiction (if applicable):

Acres Disturbed:

Total Acres:

WetlandsCheck the appropriate box(s) if there are streams and/or wetlands on or adjacent to the construction site: Streams If wetlands are located on-site and may be impacted, attach wetlands delineation report.

If an Aquatic Resource Alteration Permit (ARAP) has been obtained for this site, what is the permit number?

Receiving waters:

Attach the SWPPP with the NOI: SWPPP Attached Attach a site location map: Map Attached

Site Owner/Developer Entity (Primary Permittee): (person, company, or legal entity that has operational or design control over construction plans and specifications):

For corporate entities only, provide the Tennessee Secretary of State (SOS) Control Number:

Site Owner or Developer Contact Name: (individual responsible for site) Title or Position: (the party who signs the certification below):

Mailing Address: City: State: Zip:

Phone: ( ) Fax: ( ) E-mail:

Optional Contact: Title or Position:

Mailing Address: City: State: Zip:

Phone: ( ) Fax: ( ) E-mail:

Owner or Developer Certification: (must be signed by president, vice-president or equivalent, or ranking elected official) (Primary Permittee) I certify under penalty of law that this document and all attachments were prepared by me, or under my direction or supervision. The submitted information 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. As specified in Tennessee Code Annotated Section 39-16-702(a)(4), this declaration is made under penalty of perjury..

Owner or Developer Name: (print or type) Signature: Date:

Contractor(s) Certification: (must be signed by president, vice-president or equivalent, or ranking elected official) (Secondary Permittee) I certify under penalty of law that I have reviewed this document, any attachments, and the SWPPP referenced above. Based on my inquiry of the construction site owner/developer identified above and/or my inquiry of the person directly responsible for assembling this NOI and SWPPP, I believe the information submitted is accurate. I am aware that this NOI, if approved, makes the above-described construction activity subject to NPDES permit number TNR100000, and that certain of my activities on-site are thereby regulated. I am aware that there are significant penalties, including the possibility of fine and imprisonment for knowing violations, and for failure to comply with these permit requirements. As specified in Tennessee Code Annotated Section 39-16- 702(a)(4), this declaration is made under penalty of perjury.

Contractor name, address, and SOS control number (if applicable): Signature: Date:

Contractor name, address, and SOS control number (if applicable): Signature: Date:

OFFICIAL STATE USE ONLY

Received Date: Reviewer: Field Office: Permit Number:

TNR

Exceptional TN Water:

Fee(s): T & E Aquatic Flora/Fauna: SOS Corporate Status: Waters with Unavailable Parameters: Notice of Coverage Date:

CN-0940 (Rev. 6-16) (Instructions on reverse) RDA 2366

CONSTRUCTION GENERAL PERMIT - NOTICE OF INTENT (NOI) - INSTRUCTIONS

A completed NOI must be submitted to obtain coverage under the CGP. Requesting coverage under this permit means that an applicant has obtained and examined a copy of this permit, and thereby acknowledges applicant’s claim of ability to be in compliance with permit terms and conditions. CGP coverage is required for stormwater (SW) discharge(s) from construction activities including clearing, grading, filling and excavating (including borrow pits) of one or more acres of land. This form should be submitted at least 30 days prior to the commencement of land disturbing activities, or no later than 48 hours prior to when a new operator assumes operational control over site specifications or commences work at the site.

The application fee must accompany the NOI and is based on total acreage to be disturbed by an entire project, including any associated construction support activities (e.g., equipment staging yards, material storage areas, excavated material disposal areas, borrow or waste sites, etc.). A separate annual maintenance fee is also required for activities that exceed 1 year under CGP coverage. See TN Rules, Chapter 0400-40-11-.02(b)(12)).

Acres Disturbed

= or > 150 acres

= or > 50 < 150 acres

= or > 20 < 50 acres

= or > 5 < 20 acres

= or > 1 < 5 acres

Subsequent coverage

Fee $10,000 $6,000 $3,000 $1,000 $250 $100

Who must submit the NOI form? All site operators must submit an NOI form. “Operator” for the purpose of this permit and in the context of SW associated with construction activity means any person associated with a construction project who meets either or both of the following two criteria: (1) The person has operational or design control over construction plans and specifications, including the ability to make modifications to those plans and specifications. This person is typically the owner or developer of the project or a portion of the project (e.g., subsequent builder), or the person that is the current land owner of the construction site, and is considered the primary permittee; or (2) The person has day-to-day operational control of those activities at a project which are necessary to ensure compliance with a SWPPP for the site or other permit conditions. This person is typically a contractor or a commercial builder who is hired by the primary permittee, and is considered a secondary permittee.

Owners, developers and all contractors that meet the definition of the operator in subsection 2.2 of the permit shall apply for permit coverage on the same NOI, insofar as possible. After permit coverage has been granted to the primary permittee, any subsequent NOI submittals must include the site’s previously assigned permit tracking number and the project name. The comprehensive site-specific SWPPP shall be prepared in accordance with the requirements of part 3 of the permit and must be submitted with the NOI unless the NOI being submitted is to only add a contractor (secondary permittee) to an existing coverage. Artificial entities (e.g., corporations or partnerships) must submit the Tennessee Secretary of State, Division of Business Services, control number. The division reserves the right to deny coverage to artificial entities that are not properly registered and in good standing with the Tennessee Secretary of State.

Notice of Coverage: The division will review the NOI for completeness and accuracy and prepare a notice of coverage (NOC).

SW discharge from the construction site is authorized as of the effective date of the NOC.

Complete the form: Type or print clearly. Answer each item or enter “NA,” for not applicable. If you need additional space, attach a separate piece of paper to the NOI form. The NOI will be considered incomplete without a permit fee, a map, and the SWPPP.

Describe and locate the project: Use the legal or official name of the construction site. If a construction site lacks street name or route number, give the most accurate information available to describe the location (reference to adjacent highways, roads and structures; e.g., intersection of state highways 70 and 100). Latitude and longitude (in decimal degrees) can be found at numerous other web sites. Attach a copy of a map, showing location of site, with boundaries at least one mile outside the site boundaries. Provide estimated starting date of clearing activities and completion date of the project, and an estimate of the number of acres of the site on which soil will be disturbed, including borrow areas, fill areas, stockpiles and the total acres. For linear projects, give location at each end of the construction area.

Name of the receiving waters: Trace the route of SW runoff from the site and determine the name of the water course(s) into which the stormwater runoff drains. Note that the receiving water course may or may not be located on the construction site. If the first water body receiving construction site runoff is unnamed (“unnamed tributary”), determine the name of the water body that the unnamed tributary enters.

An ARAP may be required: If your work will disturb or cause alterations of a stream or wetland, you must obtain an appropriate Aquatic Resource Alteration Permit (ARAP). If you have a question about the ARAP program, contact your local Field Office (EFO).

Submitting the form and obtaining more information: Note that this form must be signed by the company President, Vice- President, or a ranking elected official in the case of a municipality, for details see subpart 2.5. For more information, contact your local EFO at the toll-free number 1-888-891-8332 (TDEC). Submit the completed NOI form (keep a copy for your records) to the appropriate EFO for the county(ies) where the construction activity is located, addressed to Attention: Stormwater NOI Processing.

EFO Street Address Zip Code EFO Street Address Zip Code Memphis 8383 Wolf Lake Drive, Bartlett 38133-4119 Cookeville 1221 South Willow Ave. 38506

Jackson 1625 Hollywood Drive 38305-4316 Chattanooga 1301 Riverfront Parkway, Suite 206 37402

Nashville 711 R S Gass Boulevard 37243 Knoxville 3711 Middlebrook Pike 37921

Columbia 1421 Hampshire Pike 38401 Johnson City 2305 Silverdale Road 37601

CN-0940 (Rev. 6-16) (Page 2) RDA 2366 http://share.tn.gov/sos/rules/0400/0400-40/0400-40-11.20140911.pdf