6._GA_EPD_NOI_StormWater_Primary_Permitee_Y2008.pdf

For Official Use Only

NOTICE OF INTENT

VERSION 2008

State of Georgia Department of Natural Resources Environmental Protection Division

For Coverage Under the 2008 Re-Issuance of the NPDES General Permits

To Discharge Storm Water Associated With Construction Activity

PRIMARY PERMITTEE

NOTICE OF INTENT (Check Only One):

Initial Notification (New Facility/Construction Site)

Re-Issuance Notification (Existing Facility/Construction Site)

Change of Information (Applicable only if the NOI was submitted after August 1, 2008)

COVERAGE DESIRED (Check Only One):

GAR100001 - Stand Alone GAR100002 - Infrastructure GAR100003 - Common Development

I. SITE/OWNER/OPERATOR INFORMATION

Project Construction Site Name: Basewide Storm Drainage Improvements

GPS Location of Construction Exit (degrees/minutes/seconds):

See Attachment

Construction Site Street Address:

City (applicable if the site is located within the jurisdictional boundaries of the municipality): ____________

County: Cobb___________________________________________________

Common Development Name (applicable only to General NPDES Permit No. GAR100003):

Owner’s Name: Dobbins ARB (Patrina Sheffield) Phone: _(678) 655-5778________

Address: 884 Industrial Drive City: Dobbins ARB State: GA Zip Code: 30069-4210

Duly Authorized Representative (optional): Phone:

Operator’s Name (optional): Phone:

Address: City: State: Zip Code:

Facility/Construction Site Contact: Phone:

II. CONSTRUCTION SITE ACTIVITY INFORMATION

Start Date (month/date/year): _____ / _____ / _____ Completion Date (month/date/year): _____ / _____ / _____

Estimated Disturbed Acreage (acres, to the nearest tenth (1/10 th ) acre): See Attachment__________________

Does the Erosion, Sedimentation and Pollution Control Plan (Plan) provide for disturbing more than 50 acres at any one time for each individual permittee (i.e., primary, secondary or tertiary permittees), or more than 50 contiguous acres total at any one time ? (Check Only One):

YES

NO

N/A - if the Plan was submitted prior to the effective date of the General NPDES Permit No. GAR100001 and No. GAR100003 for Stand Alone and Common Development construction activities.

N/A – if construction activities are covered under the General NPDES Permit No. GAR100002 for Infrastructure construction projects.

Construction Activity Type: Commercial Industrial Municipal

Linear Utility Residential

Number of Secondary Permittees (applicable only to General NPDES Permit No. GAR100003): N/A ________

III. RECEIVING WATER INFORMATION

A. Name of Initial Receiving Water(s): Rottenwood Creek

Trout Stream Warm Water Fisheries Stream

B. Name of MS4 Owner/Operator (if applicable): ______________________

Name of Receiving Water(s):

Trout Stream Warm Water Fisheries Stream

C. Sampling of Receiving Stream(s): Trout Stream Warm Water Fisheries Stream

D. Sampling of Outfall(s): Trout Stream Warm Water Fisheries Stream

Number of Sampling Outfalls: _____ Construction Site Size (acres): _________________________

Appendix B NTU Value: ______________ Surface Water Drainage Area (square miles): _

E. Does the facility/construction site discharge storm water into an Impaired Stream Segment, or within one (1) linear mile upstream of and within the same watershed as, any portion of an Impaired Stream Segment identified as “not supporting” its designated use(s), as shown on Georgia’s 2008 and subsequent “305(b)/303(d) List Documents (Final)” listed for the criteria violated, “Bio F” (Impaired Fish Community) and/or “Bio M” (Impaired Macroinvertebrate Community), within Category 4a, 4b or 5, and the potential cause is either “NP” (nonpoint source) or “UR” (urban runoff) ? (Check Only One):

YES, Name of Impaired Stream Segment(s): __Bio M_____________________________________________

N/A – if the NOI was submitted within 90 days after the effective date of the General NPDES Permit No.

GAR100001 and No. GAR100003 for Stand Alone and Common Development construction activities.

N/A – if the NOI was submitted prior to January 1, 2009 for the General NPDES Permit No. GAR100002 for Infrastructure construction activities.

F. Does the facility/construction site discharge storm water into an Impaired Stream Segment where a Total

Maximum Daily Load (TMDL) Implementation Plan for “sediment” was finalized at least six (6) months prior to the submittal of the NOI ? (Check Only One):

YES, Name of Impaired Stream Segment(s): Rottenwood Creek–Headwaters to Chattahoochee River__

N/A – if the NOI was submitted within 90 days after the effective date of the General NPDES Permit No.

GAR100001 and No. GAR100003 for Stand Alone and Common Development construction activities.

N/A – if the NOI was submitted prior to January 1, 2009 for the General NPDES Permit No. GAR100002 for Infrastructure construction activities.

IV. ATTACHMENTS (Applicable Only to New Facilities/Construction Sites)

Indicate if the items listed below are attached to this Notice of Intent:

X Location map identifying the receiving water(s), outfall(s) or combination thereof to be monitored.

Erosion, Sedimentation and Pollution Control Plan (if the project is greater than 50 acres regardless of the existence of a certified Local Issuing Authority in the jurisdiction OR if the project is in a jurisdiction where there is no certified Local Issuing Authority regulating that project regardless of acreage).

Written authorization from the appropriate EPD District Office if the Plan disturbs more than 50 acres at any one time for each individual permittee (i.e., primary, secondary or tertiary permittees), or more than 50 contiguous acres total at any one time (applicable only to General NPDES Permits No.

GAR100001 and No. GAR100003).

List of known secondary permittees (applicable only to General NPDES Permit No. GAR100003).

Schedule for the timing of the major construction activities.

V. CERTIFICATIONS (Owner or Operator or Both to Initial as Applicable)

I certify that the receiving water(s) or the outfall(s) or a combination of receiving water(s) and outfall(s) will be monitored in accordance with the Erosion, Sedimentation and Pollution Control Plan.

I certify that the Erosion, Sedimentation and Pollution Control Plan (Plan) has been prepared in accordance with Part IV of the General NPDES Permit No. GAR100001, No. GAR100002 or No. GAR100003, the Plan will be implemented, and that such Plan will provide for compliance with this permit.

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 certified personnel properly gather and evaluate the information submitted. Based upon 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 fines and imprisonment for knowing violations.

Owner’s Printed Name: Title:

Signature: Date:

Operator’s Printed Name: Title:

Signature: Date:

ATTACHMENT

GPS LOCATION OF CONSTRUCTION:

Site A:

Latitude ___33__º __55___′ _25.7826_″ Longitude __-084__ º __30___′ _50.2354_ ″

Site B:

Latitude ___33__º __55___′ _20.6669_″ Longitude __-084__ º __30___′ _02.3958_ ″

Site C:

Latitude ___33__º __55___′ _16.4522_″ Longitude __-084__ º __30___′ _55.2792_ ″

Site D:

Latitude ___33__º __55___′ _37.6906_″ Longitude __-084__ º __30___′ _46.4110_ ″

ESTIMATED DISTRUBED ACREAGE:

Site A:

Total Disturbed Acreage = 0.80 Acres

Site B:

Total Disturbed Acreage = 0.63 Acres

Site C:

Total Disturbed Acreage = 0.50 Acres

Site D:

Total Disturbed Acreage = 0.55 Acres

INSTRUCTIONS

NOTICE OF INTENT - PRIMARY PERMITTEE

For Coverage Under the 2008 Re-Issuance of the NPDES General Permits To Discharge Storm Water Associated With Construction Activity

Please print or type the Notice of Intent (NOI) form.. Any NOI that contains illegible or incomplete information will not be accepted, will be returned and the construction site will not be granted Permit coverage. All information requested on the NOI must be submitted in order for the NOI to be valid. Any information requested on the NOI that is not applicable to the primary permittee or to the construction site must be marked “N/A.” Please do not leave any sections blank in the NOI.

Who must file a Notice of Intent Form - The Owner and/or Operator of a facility/construction site that has a discharge of storm water where construction activities occur must apply for a National Pollutant Discharge Elimination System (NPDES) Permit. The Georgia Environmental Protection Division (EPD) re-issued the General NPDES Permits for Storm Water Discharges Associated with Construction Activity on August 1, 2008. The Permits are available for review at the EPD District Offices and on the EPD website, www.gaepd.org. It is highly recommended that the permittees read and understand the terms and conditions of the Permits prior to submitting a NOI. Please contact the appropriate EPD District Office as listed on the following pages for assistance in completing the NOI.

Where to file a Notice of Intent Form - The NOI and the attachments, as applicable, must be submitted to the appropriate EPD District Office as listed on the following pages. Please submit only the first three pages of this document with the applicable attachments.

Section I - Site/Owner/Operator Information

The construction site name and location information (i.e., GPS location of construction exit, street address, city, county) must be sufficient to accurately locate the construction site. If the construction site does not have a street address, please provide sufficient information to accurately locate the construction site. If additional space is needed, attach the location information to the NOI.

A duly authorized representative may be either a named individual or any individual occupying a named position that the primary permittee has authorized to sign all reports, certification statements, or other information requested by EPD.

The facility/construction site contact is the person who the primary permittee has assigned the responsibility for the daily on-site operational control.

Please do not leave any blanks in this section. Any information requested on the NOI that is not applicable to the primary permittee or to the construction site must be mark “N/A.”

Section II – Construction Site Activity Information

For construction activities that began prior to the effective date of the Permits, the start date (month/date/year) must be the actual start date of construction activities.

Estimated disturbed acreage is the total number of acres, to the nearest tenth (1/10 th ) acre, that will be disturbed by the primary permittee and all secondary permittees.

Please do not leave any blanks in this section. Any information requested on the NOI that is not applicable to the primary

Section III - Receiving Water Information

If the facility/construction site discharges storm water directly or indirectly to the receiving water(s), and not through a municipal separate storm sewer system (MS4), enter the name of the receiving water(s) and indicate whether the water(s) is a trout stream or a warm water fisheries stream. Attach a written description and location map identifying the receiving water(s).

If the facility/construction site discharges storm water to a municipal separate storm sewer system (MS4), enter the name of the owner/operator of the MS4 (e.g., city name or county name) and the name of the receiving water(s) at the point of discharge from the MS4. A MS4 is defined as a conveyance or system of conveyances (including roads with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels or storm drains) that is owned and/or operated by a city or county which is designed or used for collecting or conveying storm water. It may be necessary to contact the city or county that owns and/or operates the MS4 to determine the name of the receiving water(s). Indicate whether the receiving water(s) is a trout stream or a warm water fisheries stream. Attach a written description and location map identifying the receiving water(s).

Any permittee who intends to obtain coverage under the Permits for storm water discharges associated with construction activity into an Impaired Stream Segment, or within one (1) linear mile upstream of and within the same watershed as, any portion of an Impaired Stream Segment identified as “not supporting” its designated use(s), as shown on Georgia’s 2008 and subsequent “305(b)/303(d) List Documents (Final)” at the time of NOI submittal, must satisfy the requirements of Part III.C. of the Permits if the Impaired Stream Segment has been listed for criteria violated, “Bio F” (Impaired Fish Community) and/or “Bio M” (Impaired Macroinvertebrate Community), within Category 4a, 4b or 5, and the potential cause is either “NP” (nonpoint source) or “UR” (urban runoff). Those discharges that are located within one (1) linear mile of an Impaired Stream Segment, but are not located within the watershed of any portion of that stream segment, are excluded from this requirement. Georgia’s 2008 and subsequent 305(b)/303(d) List Documents (Final)” can be viewed on the EPD website, www.gaepd.org/Documents/305b.html.

If a Total Maximum Daily Load (TMDL) Implementation Plan for sediment has been finalized at least six (6) months prior to the permittee’s submittal of the NOI, the Erosion, Sedimentation and Pollution Control Plan (Plan) must address any site-specific conditions or requirements included in the TMDL Implementation Plan that are applicable to the permittee’s discharge(s) to the Impaired Stream Segment within the timeframe specified in the TMDL Implementation Plan. If the TMDL Implementation Plan establishes a specific numeric wasteload allocation that applies to an permittee’s discharge(s) to the Impaired Stream Segment, then the permittee must incorporate that allocation into the Erosion, Sedimentation and Pollution Control Plan and implement all necessary measures to meet that allocation. A list of TMDL Implementation Plans can be viewed on the EPD website, www.gaepd.org.

Please do not leave any blanks in this section. Any information requested on the NOI that is not applicable to the primary

Section V – Certifications

The owner and/or operator must sign the Notice of Intent and initial the certification statements on the lines provided.

Federal and State statutes provide specific requirements as to who is authorized to sign the Notice of Intent forms. A Notice of Intent form signed by an unauthorized person will not be valid. Please be aware that Federal and State statutes provide for severe penalties for submitting false information on this Notice of Intent form. Federal and State regulations require that the Notice of Intent form be signed as follows:

▪ For a corporation, by a responsible corporate officer;

▪ For a partnership or sole proprietorship, by a general partner or the proprietor; and

▪ For a municipality, State, Federal or other public facility, by either a principal executive officer or ranking elected official.

GEORGIA EPD DISTRICT OFFICES

All required correspondence, including but not limited to Notices of Intent, Notices of Termination, Erosion, Sedimentation and Pollution Control Plans, certifications and any other reports shall be sent to the following EPD District Offices:

A. For facilities/construction sites located in the following counties: Bibb, Bleckley, Chattahoochee, Crawford, Dooly, Harris, Houston, Jones, Lamar, Macon, Marion, Meriwether, Monroe, Muscogee, Peach, Pike, Pulaski, Schley, Talbot, Taylor, Troup, Twiggs, Upson

Information shall be submitted to: West Central District Office

Georgia Environmental Protection Division 2640 Shurling Drive Macon, GA 31211-3576

(478) 751-6612

B. For facilities/construction sites located in the following counties: Burke, Columbia, Emanuel, Glascock, Jefferson, Jenkins, Johnson, Laurens, McDuffie, Montgomery, Richmond, Screven, Treutlen, Warren, Washington, Wheeler, Wilkinson

Information shall be submitted to: East Central District Office Georgia Environmental Protection Division 1885-A Tobacco Road Augusta, GA 30906-8825

(706) 792-7744

C. For facilities/construction sites located in the following counties: Baldwin, Banks, Barrow, Butts, Clarke, Elbert, Franklin, Greene, Hall, Hancock, Hart, Jackson, Jasper, Lincoln, Madison, Morgan, Newton, Oconee, Oglethorpe, Putnam, Stephens, Taliaferro, Walton, Wilkes

Information shall be submitted to: Northeast District Office

Georgia Environmental Protection Division 745 Gaines School Road Athens, GA 30605-3129

(706) 369-6376

D. For facilities/construction sites located in the following counties: Carroll, Clayton, Coweta, DeKalb, Douglas, Fayette, Fulton, Gwinnett, Heard, Henry, Rockdale, Spalding

Information shall be submitted to: Mountain District - Atlanta Satellite

Georgia Environmental Protection Division 4244 International Parkway, Suite 114 Atlanta, GA 30354-3906

(404) 362-2671

E. For facilities/construction sites located in the following counties: Bartow, Catoosa, Chattooga, Cherokee, Cobb, Dade, Dawson, Fannin, Floyd, Forsyth, Gilmer, Gordon, Habersham, Haralson, Lumpkin, Murray, Paulding, Pickens, Polk, Rabun, Towns, Union, Walker, White, Whitfield

Information shall be submitted to: Mountain District - Cartersville Office Georgia Environmental Protection Division P.O. Box 3250 Cartersville, GA 30120-1705

(770) 387-4900

F. For facilities/construction sites located in the following counties: Appling, Atkinson, Bacon, Brantley, Bryan, Bulloch, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Pierce, Tattnall, Toombs, Ware, Wayne

Information shall be submitted to: Coastal District - Brunswick Office

Georgia Environmental Protection Division One Conservation Way Brunswick, GA 31520-8687

(912) 264-7284

G. For facilities/construction sites located in the following counties: Baker, Ben Hill, Berrien, Brooks, Calhoun, Clay, Colquitt, Cook, Crisp, Decatur, Dodge, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Quitman, Randolph, Seminole, Stewart, Sumter, Telfair, Terrell, Thomas, Tift, Turner, Webster, Wilcox, Worth

Information shall be submitted to: Southwest District Office

Georgia Environmental Protection Division 2024 Newton Road Albany, GA 31701-3576

(229) 430-4144