EPA_Form_3510-9.pdf

This Form Replaces Form 3510-9 (8-98) Form Approved OMB Nos. 2040-0188 and 2040-0211 Refer to the Following Pages for Instructions

NPDES

Form

United States Environmental Protection Agency Washington, DC 20460

Notice of Intent (NOI) for Storm Water Discharges Associated with Construction Activity Under an NPDES General Permit

Submission of this Notice of Intent (NOI) constitutes notice that the party identified in Section II of this form requests authorization to discharge pursuant to the NPDES Construction General Permit (CGP) permit number identified in Section I of this form. Submission of this NOI also constitutes notice that the party identified in Section II of this form meets the eligibility requirements of the CGP for the project identified in Section III of this form. Permit coverage is required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in the CGP. To obtain authorization, you must submit a complete and accurate NOI form.

Refer to the instructions at the end of this form.

I. Permit Number

II. Operator Information

Name:

IRS Employer Identification Number (EIN): -

Mailing Address:

Street:

City: State: Zip Code: -

Phone: - - Fax (optional): - -

E-mail (optional):

III. Project/Site Information

Project/Site Name:

Project Street/Location:

City: State: Zip Code: -

County or similar government subdivision:

Latitude/Longitude (Use one of three possible formats, and specify method)

Latitude 1. _ _ο _ _´ _ _´´ N (degrees, minutes, seconds) Longitude 1. _ _ _ο _ _´ _ _´´ W (degrees, minutes, seconds)

2. _ _ο _ _ . _ _´ N (degrees, minutes, decimal) 2. _ _ _ο _ _ . _ _´ W (degrees, minutes, decimal)

3. _ _ . _ _ _ _ο N (decimal) 3. _ _ _ . _ _ _ _ο W (decimal)

Method: U.S.G.S. topographic map EPA web site GPS Other:

• If you used a U.S.G.S. topographic map, what was the scale:

Project Located in Indian country? Yes No If so, name of Reservation or if not part of a Reservation, put “Not Applicable”:

Estimated Project Start Date: / / Estimated Project Completion Date: / / Month Date Year Month Date Year

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

EPA Form 3510-9 (Rev. 6/03)

IV. SWPPP Information

Has the SWPPP been prepared in advance of filing this NOI? Yes No

Location of SWPPP for viewing: Address in Section II Address in Section III Other If Other:

SWPPP Street:

City:

State: Zip Code: -

SWPPP Contact Information (if different than that in Section II):

Name:

Phone: - - Fax (optional): - -

E-mail (optional):

V. Discharge Information

Identify the name(s) of waterbodies to which you discharge.

Is this discharge consistent with the assumptions and requirements of applicable EPA approved or established TMDL(s)?

Yes No

VI. Endangered Species Information Under which criterion of the permit have you satisfied your ESA eligibility obligations?

A B C D E F

• If you select criterion F, provide permit tracking number of operator under which you are certifying eligibility:

VII. Certification Information 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 am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Print Name:

Print Title:

Signature:

Date:

EPA Form 3510-9 (Rev. 6/03)

Instructions for Com pleting EPA Form 3510-9

Notice of Intent (NOI) for Storm W ater Discharges Associated with

Construction Activity Under an NPDES General Permit

NPDES Form This Form Replaces Form 3510-9 (8/98) Form Approved OMB Nos. 2040-0188 and 2040-0211

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 storm water 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.

Operator(s) 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 submit an NOI to obtain coverage under an NPDES general permit. Each person, firm, public organization, or any other entity that meets either of the following criteria must file this 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 SW PPP requirements or other permit conditions. If you have questions about whether you need an NPDES storm water permit, or if you need information to determine whether EPA or your state agency is the permitting authority, refer to www.epa.gov/npdes/stormwater/cgp or telephone the Storm Water Notice Processing Center at (866)

352-7755.

Where to File NOI Form

See the applicable CGP for information on where to send your completed NOI form.

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, refer to www.epa.gov/npdes/stormwater/cgp or telephone the Storm W ater Notice Processing Center at (866)

352-7755. Please submit original document with signature in ink � do not send a photocopied signature.

Section I. Permit Number

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

Section II. Operator Information

Provide the legal name of the person, firm, public organization, or any other entity that operates the project described in this application. An operator of a project is a legal entity that controls at least a portion of site operations and is not necessarily the site manager. Provide the employer identification number (EIN from the Internal Revenue Service;

IRS), also commonly referred to as your taxpayer ID. If the applicant does not have an EIN enter “NA” in the space provided. Also provide the operator’s mailing address, telephone number, fax number (optional) and e-mail address (if you would like to be notified via e-mail of NOI approval when available). Correspondence for the NOI will be sent to this address.

Section III. 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.

The applicant must also provide the latitude and longitude of the facility either in degrees, minutes, seconds; degrees, minutes, decimal; or decimal 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 EPA’s web-based siting t o o l s , a m o n g o t h e r s . R e f e r t o www.epa.gov/npdes/stormwater/cgp for further guidance on the use of these methodologies. For consistency, EPA requests that measurements be taken from the approximate center of the construction site. Applicants must specify which method they used to determine latitude and longitude. If a

U.S.G.S. topographic map is used, applicants are required to specify the scale of the map used.

Indicate whether the project is in Indian country, and if so, provide the name of the Reservation. If the project is in Indian Country Lands that are not part of a Reservation, indicate “not applicable” in the space provided.

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 quarter acre. Note: 1 acre

= 43,560 sq. ft.

Section IV. SWPPP Information

Indicate whether or not the SWPPP was prepared in advance of filing the NOI form. Check the appropriate box for the location where the SWPPP may be viewed. Provide the name, Instructions for Completing EPA Form 3510-9

Notice of Intent (NOI) for Storm W ater Discharges Associated with

Construction Activity Under an NPDES General Permit

NPDES Form This Form Replaces Form 3510-9 (8/98) Form Approved OMB Nos. 2040-0188 and 2040-0211 fax number (optional), and e-mail address (optional) of the contact person if different than that listed in Section II of the

NOI form.

Section V. Discharge Information

Enter the name(s) of receiving waterbodies to which the project’s storm water will discharge. These should be the first bodies of water that the discharge will reach. (Note: If you discharge to more than one waterbody, please indicate all such waters in the space provided and attach a separate sheet if necessary.) For example, if the discharge leaves your site and travels through a roadside swale or a storm sewer and then enters a stream that flows to a river, the stream would be the receiving waterbody. Waters of the U.S. include lakes, streams, creeks, rivers, wetlands, impoundments, estuaries, bays, oceans, and other surface bodies of water within the confines of the U.S. and U.S. coastal waters.

Waters of the U.S. do not include man-made structures created solely for the purpose of wastewater treatment. U.S.

Geological Survey topographical maps may be used to make this determination. If the map does not provide a name, use a format such as “unnamed tributary to Cross Creek”. If you discharge into a municipal separate storm sewer system (MS4), you must identify the waterbody into which that portion of the storm sewer discharges. That information should be readily available from the operator of the MS4.

Indicate whether your storm water discharges from construction activities will be consistent with the assumptions and requirements of applicable EPA approved or established

T MDL(s). To answe r th is quest ion, re fer t o www.epa.gov/npdes/stormwater/cgp for state- and regional-specific TMDL information related to the construction general permit. You may also have to contact your EPA regional office or state agency. If there are no applicable TMDLs or no related requirements, please check the “yes” box in the NOI form.

Section VI. Endangered Species Information

Indicate for which criterion (i.e., A, B, C, D, E, or F) of the permit the applicant is eligible with regard to protection of federally listed endangered and threatened species, and designated critical habitat. See Part 1.3.C.6 and Appendix C of the permit. If you select criterion F, provide the permit tracking number of the operator under which you are certifying eligibility. The permit tracking number is the number assigned to the operator by the Storm Water Notice Processing Center after EPA acceptance of a complete NOI.

Section VII. Certification Information

All applications, including NOIs, 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.

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: Chief, Information Policy Branch 2136, U.S. Environmental

Protection, Agency, 1200 Pennsylvania Avenue, NW , Washington, D.C. 20460. Include the OMB control number on any correspondence. Do not send the completed form to this address. Visit this website for mailing instructions:

http://cfpub.epa.gov/npdes/stormwater/application_coverage.

cfm#mail http://www.epa.gov/npdes/stormwater/cgp http://cfpub.epa.gov/npdes/stormwater/application_coverage.cfm#mail

Check Box1: Off