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MBD0121BDC2.pdf

ADEMForm4981-03.doc Page 1 of 4

ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM)

FIELD OPERATIONS DIVISION NPDES STORMWATER PROGRAM

NOTICE OF REGISTRATION (NOR)

THIS FORM IS TO BE USED FOR ADEM ADMINISTRATIVE CODE CHAPTER 335-6-12 - NPDES CONSTRUCTION, NONCOAL/NONMETALLIC MINING AND DRY PROCESSING LESS THAN FIVE ACRES, OTHER LAND

DISTURBANCE ACTIVITIES, AND AREAS ASSOCIATED WITH THESE ACTIVITIES

PLEASE READ THE INSTRUCTIONS BEGINNING ON PAGE 3 OF THIS FORM CAREFULLY BEFORE COMPLETING. COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES

WILL DELAY ACCEPTANCE OF REGISTRATION. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. ATTACH CBMPP AND OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN INK.

I. REGISTRANT INFORMATION Registration: Modification: Transfer: Re-Registration: AL_______________________

Registrant Name Facility/Site Name # of Years Coverage Requested:

Responsible Owner/Operator or Official, and Title Site Contact and Title

Mailing Address of Registrant Site Street Address or Location Description

City State Zip City State Zip

Business Phone Number Site Phone Number Fax Number

Responsible Official (RO) Street/Physical Address RO Phone Number Email Address

(If applicable) Registered Agent Name, Address, & Phone Number

II. LEGAL STRUCTURE OF REGISTRANT

Corporation Individual Single Proprietorship Partnership LLC LLP Government Agency Other _______________

Yes No If not an Individual or Single Proprietorship, registrant is properly registered and in good standing with the Alabama Secretary of State’s office. If “No”, please explain:

III. ACTIVITY DESCRIPTION & INFORMATION

County(s) ________________________________ Township(s), Range(s), Section(s) __________________________________________

Directions To Site ____________________________________________________________________________________________________

Yes No Is/will this facility: Yes No

(a) an existing site which currently discharges to State waters? (b) discharge to waters of or be located in the Coastal Zone?

(c) a proposed site which will result in a discharge to State waters? (d) be located on Indian/ historically significant lands?

IV. PROPOSED SCHEDULE - Used to determine potential registration duration & applicable fee amount, considering responses to Item VIII.

Anticipated Activity schedule: Commencement date: __________________________ Completion date: ______________________________

Area of the Registered site: Total site area in acres: ____________________ Total disturbed area in acres: _____________________

V. VIOLATION HISTORY

Identify every Notice of Violation (NOV), Administrative Order, Directive, or Litigation filed by ADEM or EPA during the three year (36 months) period preceding the date on which this form is signed issued to the operator, owner, registrant, partner, parent corporation, subsidiary, LLP, or LLC Member. Indicate the date of issuance, briefly describe alleged violations, list actions (if any) to abate alleged violations, and indicate date of final resolution:

VI. MAP SUBMITTAL

Yes No A 7.5 minute series USGS topographic map(s) or equivalent map(s) is attached according to the instructions beginning on Page

3. If “No”, explain:

ADEMForm4981-03.doc Page 3 of 4

VII. PROPOSED ACTIVITY(S) TO BE CONDUCTED

If Non-Coal, Non-Metallic Mining, Recovery, or Construction Material Management Site: Dirt-Chert Sand-Gravel Shale-Clay

Crushed-Dimension Stone Other ____________________ Other _____________________ Other _____________________

Primary SIC Code _________________ Brief Description Construction, Noncoal Mining, or Materials Management Activity:

VIII. RECEIVING WATERS

List name of receiving water(s), latitude & longitude (decimal or deg,min,sec) of location(s) that run-off enters the receiving water, total number of disturbed acres, the total number of drainage acres which will drain through each treatment system or BMP, and the waterbody classification. If receiving water is designated as ONRW and/or Tier 1 waterbody, attach/submit copy of CBMPP.

Receiving Water Latitude Longitude Disturbed Acres

Drainage

Waterbody Classification

ONRW

Y or N

TIER 1

IX. MODIFICATION & RE-REGISTRATION - CONTINUING EDUCATION & INSPECTION INFORMATION

Yes No Required inspections/monitoring by QCP/QCI have been performed and records retained. If “No”, explain:

List name(s) and designation/certification #s of QCPs/QCIs that performed required inspections/monitoring:

X. QUALIFIED CREDENTIALED PROFESSIONAL (QCP) CERTIFICATION

“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated areas/activities, utilizing effective BMPs from the Alabama Handbook For Erosion Control, Sediment Control, And Stormwater Management On Constructions Sites And Urban Areas, Alabama Soil and Water Conservation Committee, as amended (ASWCC). If the CBMPP is properly implemented and maintained by the registrant, discharges of pollutants in stormwater runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code Chapter 335-6-12. The CBMPP describes the pollution abatement/prevention management and effective structural & nonstructural BMPs that must be fully implemented and regularly maintained as needed at the registered site in accordance with sound sediment and erosion practices to ensure the protection of water quality.”

QCP Designation/Description: _________________________________________________________________________________

Address ____________________________________________________ Registration/Certification ____________________

Name and Title (type or print) __________________________________ Phone Number __________________________

Signature _________________________________________________ Date Signed _____________________________

XI. OPERATOR - RESPONSIBLE OFFICIAL SIGNATURE

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOR must be signed by a Responsible Official of the registrant who is the operator, owner, the sole proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government; or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity. “I certify under penalty of law that this form, the CBMPP, 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 qualified credentialed professional (QCP) and other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”

Name (type or print) _______________________________________ Official Title __________________________________

Signature ____________________________________________________ Date Signed _______________________________

ADEMForm4981-03.doc Page 4 of 4

* DISCARD THIS AND FOLLOWING INFORMATION PAGES PRIOR TO SUBMISSION OF NOR *

Contact ADEM prior to submittal with any questions.

Be advised that you are not authorized to commence regulated activity until a complete and correct NOR is received, including the correct registration fee, and if required, a CBMPP, is received by ADEM.

Alabama Department of Environmental Management (ADEM) - Field Operation Division WebPage: www.adem.state.al.us

Send by Certified Mail, Overnight Mail, or Hand-Deliver NOR, including CBMPP and other attachments if required, and correct registration fee to:

Montgomery MNPS Phone: (334) 394-4311 Fax: (334) 394-4326

PO Box 301463 Montgomery, AL 36130-1463

1400 Coliseum Boulevard Montgomery, AL 36110-2059

Email: mnps@adem.state.al.us

Birmingham Branch Phone: (205) 942-6168 Fax: (205) 941-1603

110 Vulcan Road Birmingham, AL 35209-4702 bhamail@adem.state.al.us

Mobile Branch Phone: (251) 450-3400 Fax: (251) 479-2593

2204 Perimeter Road Mobile, AL 36615-1131 mobilemail@adem.state.al.us

Decatur Branch Phone: (256) 353-1713 Fax: (256) 340-9359

2715 Sandlin Road, S.W.

Decatur, AL 35603-1333 decaturmail@adem.state.al.us

1. Review ADEM Administrative Code Chapter 335-6-12.

2. Attach correct registration fee (check or money-order). Registration may be requested for up to five (5) years. Multiply annual fee amount by the number of years for which coverage is being requested to determine the total fee amount due.

Responses from Item IV and Item VIII are used when determining potential registration duration and applicable fee amount.

3. Review ADEM Administrative Code Rule 335-6-12-.21 for preparation of the required Construction Best Management

Practices Plan (CBMPP). Regular inspections must be performed by a QCP or QCI, or by a qualified person under the direct supervision of a QCP, and all appropriate pollution abatement/prevention management and structural & nonstructural BMPs must be fully implemented prior to and concurrent with commencement of regulated activities and regularly maintained as needed for the site/activity, and associated regulated areas/activities, in accordance with good sediment, erosion, and other pollution control practices to ensure the protection of water quality.

4. While registration under ADEM Administrative Code Chapter 335-6-12 allows for noncoal, nonmetallic mining less than five acres in size, registration does not provide permit coverage for mining activities, associated areas, and material management sites described in ADEM Administrative Code Chapter 335-6-9 that at any time exceed 5 un-reclaimed acres.

Planned/proposed coal/mineral mining/recovery sites, mining sites greater than 5 acres in size, and material recovery/management sites with wet preparation or mineral beneficiation must apply for and obtain coverage under an NPDES Individual Permit prior to commencement of any land disturbance.

5. Hydraulic mining, mineral dredging, instream or between stream-bank mining, wet preparation, metallic ores mining/recovery, fuels mining, coal mining, or mining disturbances greater than five acres are not authorized under Chapter 335-6-12.

Coverage under an Individual NPDES permit must be obtained to conduct these activities.

6. Pursuant to ADEM Administrative Code Rule 335-6-12-.30, a comprehensive Spill Prevention Control & Countermeasures

(SPCC) Plan must be prepared for onsite fuel/chemical use as part of the CBMPP, retained onsite, and be available for review by the Department upon request. You are not required to submit the SPCC plan unless specifically requested by the Department.

7. NPDES construction stormwater registration coverage is not available for regulated disturbance and discharges of stormwater from landfill development, construction, operation, expansion, and closure. Landfill operators/owners are required to obtain permit coverage from ADEM’s Land Division for landfill development, construction, operation, expansion, and closure.

Please contact the Department’s Land Division at (334) 271-7700 or by email at Landmail@adem.state.al.us for additional information.

ADEMForm4981-03.doc Page 5 of 4

8. NPDES General Permit coverage is required for discharges of stormwater from a variety of other industrial facilities/activities associated with construction activities such as asphalt/cement plants, pipeline hydrostatic testing, recycling facilities, etc.

Please contact the Department’s Water Division at (334) 271-7700 or by email at H2omail@adem.state.al.us for additional

9. In recognition that projects are site specific in nature and conditions can change during project implementation, ADEM reserves the right to require the submission of additional information or require additional management measures to be implemented, as necessary on a case-by-case basis, in order to ensure the protection of water quality.

Item I – Registrant Information

Please provide facility/project name which is unique or different from registrant name.

Item II – Legal Structure of Registrant

If the registrant is a company that is not incorporated, please identify registrant as an individual doing business as (dba) the company.

For example: John Smith dba Liberty Building Company.

Item III – Activity description & Information

If the response to (c) is "yes" - the project will result in a discharge to coastal waters or is within the Alabama Coastal Area - the operator may be required to apply for and obtain Coastal Zone Management Certification from the Department’s Mobile Branch.

Please contact the Mobile Branch office listed above.

Item IV – Proposed Schedule – Self-explanatory.

Item V – Violation History – Self-explanatory.

ITEM VI – Map Submittal

Attach to this Registration a 7.5 minute series USGS topographic map(s) or equivalent map(s) no larger than, or folded to a size of 8.5 by 11 inches (several pages may be necessary) of the area extending to at least one-mile beyond property boundaries. The topographic or equivalent map(s) must include a caption indicating the name of the topographic map, name of the registrant, site name, county, and township, range, & section(s) where the facility is located. Unless approved in advance by ADEM, the topographic or equivalent map(s), at a minimum, must show:

(a) an outline of legal boundary of entire property (b) an outline of the facility (c) owners/lease or other boundaries

(d) all existing & proposed disturbed areas (e) location of discharge areas (f) buildings and structures

(g) perennial, intermittent, & ephemeral streams (h) hydro-geologic testing locations (i) all proposed structures

(j) all known facility dirt/improved access/haul roads (k) lakes/springs/wells/wetlands (l) drainage patterns/swales/washes

(m) contour lines, township-range-section lines (n) proposed and existing discharge points

(o) all surrounding unimproved/improved roads (p) high tension power lines & railroad tracks

Item VII – Proposed Activity To Be Conducted

List the federal Standard Industrial Code (SIC) for the project. Describe purpose or ultimate result of project, i.e. highway, subdivision, industrial park, shopping center, pipeline, golf course, etc.

Item VIII – Receiving Waters

List the exact name of the receiving stream(s) as found on the USGS or TVA topographic map. You may use "UT" to designate unnamed tributary of a named creek. List the Latitude & Longitude in degrees, minutes, & seconds of the point where pollutants enter the receiving waters.

Item IX – Modification & Re-Registration – Continuing Education & Inspection Information – Self-explanatory.

Item X – Qualified Credentialed Professional Certification – Self-explanatory.

Item XI – Responsible Official Signature

Please submit the completed NOR with original signatures of a responsible corporate official (RCO) according to ADEM Administrative Code Rule 335-6-6-.09.

MBD0121C371.pdf

PLEASE READ THE INSTRUCTIONS BEGINNING ON PAGE 3 OF THIS FORM CAREFULLY BEFORE COMPLETING. COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES

WILL DELAY ACCEPTANCE OF REGISTRATION. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS

I. REGISTRANT INFORMATION Registration: Modification: Transfer: Re-Registration: AL_______________________

Responsible Owner/Operator or Official, and Title Site Contact and Title

City State Zip City State Zip

Corporation Individual Single Proprietorship Partnership LLC LLP Government Agency Other _______________

Yes No If not an Individual or Single Proprietorship, registrant is properly registered and in good standing with the Alabama Secretary

County(s) ________________________________ Township(s), Range(s), Section(s) __________________________________________

Directions To Site ____________________________________________________________________________________________________

Yes No Is/will this facility: Yes No

(a) an existing site which currently discharges to State waters? (b) discharge to waters of or be located in the Coastal

(c) a proposed site which will result in a discharge to State waters? (d) be located on Indian/ historically significant lands?

IV. PROPOSED SCHEDULE - Used to determine potential registration duration & applicable fee amount, considering responses to Item VIII.

Anticipated Activity schedule: Commencement date: __________________________ Completion date: ______________________________

Area of the Registered site: Total site area in acres: ____________________ Total disturbed area in acres: _____________________

Identify every Notice of Violation (NOV), Administrative Order, Directive, or Litigation filed by ADEM or EPA during the three year (36 months) period preceding the date on which this form is signed issued to the operator, owner, registrant, partner, parent corporation, subsidiary, LLP, or LLC Member. Indicate the date of issuance, briefly describe alleged violations, list actions (if any) to abate alleged violations, and indicate date of final

Yes No A 7.5 minute series USGS topographic map(s) or equivalent map(s) is attached according to the instructions beginning on Page

If Non-Coal, Non-Metallic Mining, Recovery, or Construction Material Management Site: Dirt-Chert Sand-Gravel Shale-Clay

Crushed-Dimension Stone Other ____________________ Other _____________________ Other _____________________

Primary SIC Code _________________ Brief Description Construction, Noncoal Mining, or Materials Management Activity:

List name of receiving water(s), latitude & longitude (decimal or deg,min,sec) of location(s) that run-off enters the receiving water, total number of disturbed acres, the total number of drainage acres which will drain through each treatment system or BMP, and the waterbody classification. If

Yes No Required inspections/monitoring by QCP/QCI have been performed and records retained. If “No”, explain:

List name(s) and designation/certification #s of QCPs/QCIs that performed required inspections/monitoring:

“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated areas/activities, utilizing effective BMPs from the Alabama Handbook For Erosion Control, Sediment Control, And Stormwater Management On Constructions Sites And Urban Areas, Alabama Soil and Water Conservation Committee, as amended (ASWCC). If the CBMPP is properly implemented and maintained by the registrant, discharges of pollutants in stormwater runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code Chapter 335-6-12. The CBMPP describes the pollution abatement/prevention management and effective structural & nonstructural BMPs that must be fully implemented and regularly maintained as needed at the registered site in accordance with sound sediment and erosion practices to ensure the protection of water quality.”

QCP Designation/Description: _________________________________________________________________________________

Address ____________________________________________________ Registration/Certification ____________________

Name and Title (type or print) __________________________________ Phone Number __________________________

Signature _________________________________________________ Date Signed _____________________________

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOR must be signed by a Responsible Official of the registrant who is the operator, owner, the sole proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government; or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity. “I certify under penalty of law that this form, the CBMPP, 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 qualified credentialed professional (QCP) and other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”

Name (type or print) _______________________________________ Official Title __________________________________

Signature ____________________________________________________ Date Signed _______________________________

Be advised that you are not authorized to commence regulated activity until a complete and correct NOR is received, Alabama Department of Environmental Management (ADEM) - Field Operation Division WebPage: www.adem.state.al.us

Send by Certified Mail, Overnight Mail, or Hand-Deliver NOR, including CBMPP and other attachments if

2. Attach correct registration fee (check or money-order). Registration may be requested for up to five (5) years. Multiply annual fee amount by the number of years for which coverage is being requested to determine the total fee amount due.

Responses from Item IV and Item VIII are used when determining potential registration duration and applicable fee amount.

3. Review ADEM Administrative Code Rule 335-6-12-.21 for preparation of the required Construction Best Management

Practices Plan (CBMPP). Regular inspections must be performed by a QCP or QCI, or by a qualified person under the direct supervision of a QCP, and all appropriate pollution abatement/prevention management and structural & nonstructural BMPs must be fully implemented prior to and concurrent with commencement of regulated activities and regularly maintained as needed for the site/activity, and associated regulated areas/activities, in accordance with good sediment, erosion, and other

4. While registration under ADEM Administrative Code Chapter 335-6-12 allows for noncoal, nonmetallic mining less than five acres in size, registration does not provide permit coverage for mining activities, associated areas, and material management sites described in ADEM Administrative Code Chapter 335-6-9 that at any time exceed 5 un-reclaimed acres.

Planned/proposed coal/mineral mining/recovery sites, mining sites greater than 5 acres in size, and material recovery/management sites with wet preparation or mineral beneficiation must apply for and obtain coverage under an NPDES

5. Hydraulic mining, mineral dredging, instream or between stream-bank mining, wet preparation, metallic ores mining/recovery, fuels mining, coal mining, or mining disturbances greater than five acres are not authorized under Chapter 335-6-12.

6. Pursuant to ADEM Administrative Code Rule 335-6-12-.30, a comprehensive Spill Prevention Control & Countermeasures

(SPCC) Plan must be prepared for onsite fuel/chemical use as part of the CBMPP, retained onsite, and be available for review by the Department upon request. You are not required to submit the SPCC plan unless specifically requested by the

7. NPDES construction stormwater registration coverage is not available for regulated disturbance and discharges of stormwater from landfill development, construction, operation, expansion, and closure. Landfill operators/owners are required to obtain permit coverage from ADEM’s Land Division for landfill development, construction, operation, expansion, and closure.

Please contact the Department’s Land Division at (334) 271-7700 or by email at Landmail@adem.state.al.us for additional

8. NPDES General Permit coverage is required for discharges of stormwater from a variety of other industrial facilities/activities associated with construction activities such as asphalt/cement plants, pipeline hydrostatic testing, recycling facilities, etc.

Please contact the Department’s Water Division at (334) 271-7700 or by email at H2omail@adem.state.al.us for additional

9. In recognition that projects are site specific in nature and conditions can change during project implementation, ADEM reserves the right to require the submission of additional information or require additional management measures to be implemented, as necessary on a case-by-case basis, in order to ensure the protection of water quality.

Item II – Legal Structure of Registrant

If the registrant is a company that is not incorporated, please identify registrant as an individual doing business as (dba) the company.

For example: John Smith dba Liberty Building Company.

Item III – Activity description & Information

If the response to (c) is "yes" - the project will result in a discharge to coastal waters or is within the Alabama Coastal Area - the operator may be required to apply for and obtain Coastal Zone Management Certification from the Department’s Mobile Branch.

Please contact the Mobile Branch office listed above.

Item IV – Proposed Schedule – Self-explanatory.

Item V – Violation History – Self-explanatory.

ITEM VI – Map Submittal

Attach to this Registration a 7.5 minute series USGS topographic map(s) or equivalent map(s) no larger than, or folded to a size of 8.5 by 11 inches (several pages may be necessary) of the area extending to at least one-mile beyond property boundaries. The topographic or equivalent map(s) must include a caption indicating the name of the topographic map, name of the registrant, site name, county, and township, range, & section(s) where the facility is located. Unless approved in advance by ADEM, the

(a) an outline of legal boundary of entire property (b) an outline of the facility (c) owners/lease or other boundaries

(d) all existing & proposed disturbed areas (e) location of discharge areas (f) buildings and structures

(g) perennial, intermittent, & ephemeral streams (h) hydro-geologic testing locations (i) all proposed structures

(j) all known facility dirt/improved access/haul roads (k) lakes/springs/wells/wetlands (l) drainage patterns/swales/washes

(m) contour lines, township-range-section lines (n) proposed and existing discharge points

(o) all surrounding unimproved/improved roads (p) high tension power lines & railroad tracks

Item VII – Proposed Activity To Be Conducted

List the federal Standard Industrial Code (SIC) for the project. Describe purpose or ultimate result of project, i.e. highway, subdivision, industrial park, shopping center, pipeline, golf course, etc.

Item VIII – Receiving Waters

List the exact name of the receiving stream(s) as found on the USGS or TVA topographic map. You may use "UT" to designate unnamed tributary of a named creek. List the Latitude & Longitude in degrees, minutes, & seconds of the point where pollutants enter the receiving waters.

Item IX – Modification & Re-Registration – Continuing Education & Inspection Information – Self-explanatory.

Item X – Qualified Credentialed Professional Certification – Self-explanatory.

Item XI – Responsible Official Signature

Please submit the completed NOR with original signatures of a responsible corporate official (RCO) according to ADEM

MBD01219B79.pdf

PLEASE READ THE INSTRUCTIONS BEGINNING ON PAGE 3 OF THIS FORM CAREFULLY BEFORE COMPLETING. COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES

WILL DELAY ACCEPTANCE OF REGISTRATION. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS

I. REGISTRANT INFORMATION Registration: Modification: Transfer: Re-Registration: AL_______________________

Responsible Owner/Operator or Official, and Title Site Contact and Title

City State Zip City State Zip

Corporation Individual Single Proprietorship Partnership LLC LLP Government Agency Other _______________

Yes No If not an Individual or Single Proprietorship, registrant is properly registered and in good standing with the Alabama Secretary

County(s) ________________________________ Township(s), Range(s), Section(s) __________________________________________

Directions To Site ____________________________________________________________________________________________________

Yes No Is/will this facility: Yes No

(a) an existing site which currently discharges to State waters? (b) discharge to waters of or be located in the Coastal

(c) a proposed site which will result in a discharge to State waters? (d) be located on Indian/ historically significant lands?

IV. PROPOSED SCHEDULE - Used to determine potential registration duration & applicable fee amount, considering responses to Item VIII.

Anticipated Activity schedule: Commencement date: __________________________ Completion date: ______________________________

Area of the Registered site: Total site area in acres: ____________________ Total disturbed area in acres: _____________________

Identify every Notice of Violation (NOV), Administrative Order, Directive, or Litigation filed by ADEM or EPA during the three year (36 months) period preceding the date on which this form is signed issued to the operator, owner, registrant, partner, parent corporation, subsidiary, LLP, or LLC Member. Indicate the date of issuance, briefly describe alleged violations, list actions (if any) to abate alleged violations, and indicate date of final

Yes No A 7.5 minute series USGS topographic map(s) or equivalent map(s) is attached according to the instructions beginning on Page

If Non-Coal, Non-Metallic Mining, Recovery, or Construction Material Management Site: Dirt-Chert Sand-Gravel Shale-Clay

Crushed-Dimension Stone Other ____________________ Other _____________________ Other _____________________

Primary SIC Code _________________ Brief Description Construction, Noncoal Mining, or Materials Management Activity:

List name of receiving water(s), latitude & longitude (decimal or deg,min,sec) of location(s) that run-off enters the receiving water, total number of disturbed acres, the total number of drainage acres which will drain through each treatment system or BMP, and the waterbody classification. If

Yes No Required inspections/monitoring by QCP/QCI have been performed and records retained. If “No”, explain:

List name(s) and designation/certification #s of QCPs/QCIs that performed required inspections/monitoring:

“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated areas/activities, utilizing effective BMPs from the Alabama Handbook For Erosion Control, Sediment Control, And Stormwater Management On Constructions Sites And Urban Areas, Alabama Soil and Water Conservation Committee, as amended (ASWCC). If the CBMPP is properly implemented and maintained by the registrant, discharges of pollutants in stormwater runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code Chapter 335-6-12. The CBMPP describes the pollution abatement/prevention management and effective structural & nonstructural BMPs that must be fully implemented and regularly maintained as needed at the registered site in accordance with sound sediment and erosion practices to ensure the protection of water quality.”

QCP Designation/Description: _________________________________________________________________________________

Address ____________________________________________________ Registration/Certification ____________________

Name and Title (type or print) __________________________________ Phone Number __________________________

Signature _________________________________________________ Date Signed _____________________________

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOR must be signed by a Responsible Official of the registrant who is the operator, owner, the sole proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government; or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity. “I certify under penalty of law that this form, the CBMPP, 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 qualified credentialed professional (QCP) and other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”

Name (type or print) _______________________________________ Official Title __________________________________

Signature ____________________________________________________ Date Signed _______________________________

Be advised that you are not authorized to commence regulated activity until a complete and correct NOR is received, Alabama Department of Environmental Management (ADEM) - Field Operation Division WebPage: www.adem.state.al.us

Send by Certified Mail, Overnight Mail, or Hand-Deliver NOR, including CBMPP and other attachments if

2. Attach correct registration fee (check or money-order). Registration may be requested for up to five (5) years. Multiply annual fee amount by the number of years for which coverage is being requested to determine the total fee amount due.

Responses from Item IV and Item VIII are used when determining potential registration duration and applicable fee amount.

3. Review ADEM Administrative Code Rule 335-6-12-.21 for preparation of the required Construction Best Management

Practices Plan (CBMPP). Regular inspections must be performed by a QCP or QCI, or by a qualified person under the direct supervision of a QCP, and all appropriate pollution abatement/prevention management and structural & nonstructural BMPs must be fully implemented prior to and concurrent with commencement of regulated activities and regularly maintained as needed for the site/activity, and associated regulated areas/activities, in accordance with good sediment, erosion, and other

4. While registration under ADEM Administrative Code Chapter 335-6-12 allows for noncoal, nonmetallic mining less than five acres in size, registration does not provide permit coverage for mining activities, associated areas, and material management sites described in ADEM Administrative Code Chapter 335-6-9 that at any time exceed 5 un-reclaimed acres.

Planned/proposed coal/mineral mining/recovery sites, mining sites greater than 5 acres in size, and material recovery/management sites with wet preparation or mineral beneficiation must apply for and obtain coverage under an NPDES

5. Hydraulic mining, mineral dredging, instream or between stream-bank mining, wet preparation, metallic ores mining/recovery, fuels mining, coal mining, or mining disturbances greater than five acres are not authorized under Chapter 335-6-12.

6. Pursuant to ADEM Administrative Code Rule 335-6-12-.30, a comprehensive Spill Prevention Control & Countermeasures

(SPCC) Plan must be prepared for onsite fuel/chemical use as part of the CBMPP, retained onsite, and be available for review by the Department upon request. You are not required to submit the SPCC plan unless specifically requested by the

7. NPDES construction stormwater registration coverage is not available for regulated disturbance and discharges of stormwater from landfill development, construction, operation, expansion, and closure. Landfill operators/owners are required to obtain permit coverage from ADEM’s Land Division for landfill development, construction, operation, expansion, and closure.

Please contact the Department’s Land Division at (334) 271-7700 or by email at Landmail@adem.state.al.us for additional

8. NPDES General Permit coverage is required for discharges of stormwater from a variety of other industrial facilities/activities associated with construction activities such as asphalt/cement plants, pipeline hydrostatic testing, recycling facilities, etc.

Please contact the Department’s Water Division at (334) 271-7700 or by email at H2omail@adem.state.al.us for additional

9. In recognition that projects are site specific in nature and conditions can change during project implementation, ADEM reserves the right to require the submission of additional information or require additional management measures to be implemented, as necessary on a case-by-case basis, in order to ensure the protection of water quality.

Item II – Legal Structure of Registrant

If the registrant is a company that is not incorporated, please identify registrant as an individual doing business as (dba) the company.

For example: John Smith dba Liberty Building Company.

Item III – Activity description & Information

If the response to (c) is "yes" - the project will result in a discharge to coastal waters or is within the Alabama Coastal Area - the operator may be required to apply for and obtain Coastal Zone Management Certification from the Department’s Mobile Branch.

Please contact the Mobile Branch office listed above.

Item IV – Proposed Schedule – Self-explanatory.

Item V – Violation History – Self-explanatory.

ITEM VI – Map Submittal

Attach to this Registration a 7.5 minute series USGS topographic map(s) or equivalent map(s) no larger than, or folded to a size of 8.5 by 11 inches (several pages may be necessary) of the area extending to at least one-mile beyond property boundaries. The topographic or equivalent map(s) must include a caption indicating the name of the topographic map, name of the registrant, site name, county, and township, range, & section(s) where the facility is located. Unless approved in advance by ADEM, the

(a) an outline of legal boundary of entire property (b) an outline of the facility (c) owners/lease or other boundaries

(d) all existing & proposed disturbed areas (e) location of discharge areas (f) buildings and structures

(g) perennial, intermittent, & ephemeral streams (h) hydro-geologic testing locations (i) all proposed structures

(j) all known facility dirt/improved access/haul roads (k) lakes/springs/wells/wetlands (l) drainage patterns/swales/washes

(m) contour lines, township-range-section lines (n) proposed and existing discharge points

(o) all surrounding unimproved/improved roads (p) high tension power lines & railroad tracks

Item VII – Proposed Activity To Be Conducted

List the federal Standard Industrial Code (SIC) for the project. Describe purpose or ultimate result of project, i.e. highway, subdivision, industrial park, shopping center, pipeline, golf course, etc.

Item VIII – Receiving Waters

List the exact name of the receiving stream(s) as found on the USGS or TVA topographic map. You may use "UT" to designate unnamed tributary of a named creek. List the Latitude & Longitude in degrees, minutes, & seconds of the point where pollutants enter the receiving waters.

Item IX – Modification & Re-Registration – Continuing Education & Inspection Information – Self-explanatory.

Item X – Qualified Credentialed Professional Certification – Self-explanatory.

Item XI – Responsible Official Signature

Please submit the completed NOR with original signatures of a responsible corporate official (RCO) according to ADEM

MBD0121A559.pdf

PLEASE READ THE INSTRUCTIONS BEGINNING ON PAGE 3 OF THIS FORM CAREFULLY BEFORE COMPLETING. COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES

WILL DELAY ACCEPTANCE OF REGISTRATION. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS

I. REGISTRANT INFORMATION Registration: Modification: Transfer: Re-Registration: AL_______________________

Responsible Owner/Operator or Official, and Title Site Contact and Title

City State Zip City State Zip

Corporation Individual Single Proprietorship Partnership LLC LLP Government Agency Other _______________

Yes No If not an Individual or Single Proprietorship, registrant is properly registered and in good standing with the Alabama Secretary

County(s) ________________________________ Township(s), Range(s), Section(s) __________________________________________

Directions To Site ____________________________________________________________________________________________________

Yes No Is/will this facility: Yes No

(a) an existing site which currently discharges to State waters? (b) discharge to waters of or be located in the Coastal

(c) a proposed site which will result in a discharge to State waters? (d) be located on Indian/ historically significant lands?

IV. PROPOSED SCHEDULE - Used to determine potential registration duration & applicable fee amount, considering responses to Item VIII.

Anticipated Activity schedule: Commencement date: __________________________ Completion date: ______________________________

Area of the Registered site: Total site area in acres: ____________________ Total disturbed area in acres: _____________________

Identify every Notice of Violation (NOV), Administrative Order, Directive, or Litigation filed by ADEM or EPA during the three year (36 months) period preceding the date on which this form is signed issued to the operator, owner, registrant, partner, parent corporation, subsidiary, LLP, or LLC Member. Indicate the date of issuance, briefly describe alleged violations, list actions (if any) to abate alleged violations, and indicate date of final

Yes No A 7.5 minute series USGS topographic map(s) or equivalent map(s) is attached according to the instructions beginning on Page

If Non-Coal, Non-Metallic Mining, Recovery, or Construction Material Management Site: Dirt-Chert Sand-Gravel Shale-Clay

Crushed-Dimension Stone Other ____________________ Other _____________________ Other _____________________

Primary SIC Code _________________ Brief Description Construction, Noncoal Mining, or Materials Management Activity:

List name of receiving water(s), latitude & longitude (decimal or deg,min,sec) of location(s) that run-off enters the receiving water, total number of disturbed acres, the total number of drainage acres which will drain through each treatment system or BMP, and the waterbody classification. If

Yes No Required inspections/monitoring by QCP/QCI have been performed and records retained. If “No”, explain:

List name(s) and designation/certification #s of QCPs/QCIs that performed required inspections/monitoring:

“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated areas/activities, utilizing effective BMPs from the Alabama Handbook For Erosion Control, Sediment Control, And Stormwater Management On Constructions Sites And Urban Areas, Alabama Soil and Water Conservation Committee, as amended (ASWCC). If the CBMPP is properly implemented and maintained by the registrant, discharges of pollutants in stormwater runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code Chapter 335-6-12. The CBMPP describes the pollution abatement/prevention management and effective structural & nonstructural BMPs that must be fully implemented and regularly maintained as needed at the registered site in accordance with sound sediment and erosion practices to ensure the protection of water quality.”

QCP Designation/Description: _________________________________________________________________________________

Address ____________________________________________________ Registration/Certification ____________________

Name and Title (type or print) __________________________________ Phone Number __________________________

Signature _________________________________________________ Date Signed _____________________________

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOR must be signed by a Responsible Official of the registrant who is the operator, owner, the sole proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government; or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity. “I certify under penalty of law that this form, the CBMPP, 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 qualified credentialed professional (QCP) and other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”

Name (type or print) _______________________________________ Official Title __________________________________

Signature ____________________________________________________ Date Signed _______________________________

Be advised that you are not authorized to commence regulated activity until a complete and correct NOR is received, Alabama Department of Environmental Management (ADEM) - Field Operation Division WebPage: www.adem.state.al.us

Send by Certified Mail, Overnight Mail, or Hand-Deliver NOR, including CBMPP and other attachments if

2. Attach correct registration fee (check or money-order). Registration may be requested for up to five (5) years. Multiply annual fee amount by the number of years for which coverage is being requested to determine the total fee amount due.

Responses from Item IV and Item VIII are used when determining potential registration duration and applicable fee amount.

3. Review ADEM Administrative Code Rule 335-6-12-.21 for preparation of the required Construction Best Management

Practices Plan (CBMPP). Regular inspections must be performed by a QCP or QCI, or by a qualified person under the direct supervision of a QCP, and all appropriate pollution abatement/prevention management and structural & nonstructural BMPs must be fully implemented prior to and concurrent with commencement of regulated activities and regularly maintained as needed for the site/activity, and associated regulated areas/activities, in accordance with good sediment, erosion, and other

4. While registration under ADEM Administrative Code Chapter 335-6-12 allows for noncoal, nonmetallic mining less than five acres in size, registration does not provide permit coverage for mining activities, associated areas, and material management sites described in ADEM Administrative Code Chapter 335-6-9 that at any time exceed 5 un-reclaimed acres.

Planned/proposed coal/mineral mining/recovery sites, mining sites greater than 5 acres in size, and material recovery/management sites with wet preparation or mineral beneficiation must apply for and obtain coverage under an NPDES

5. Hydraulic mining, mineral dredging, instream or between stream-bank mining, wet preparation, metallic ores mining/recovery,…