j15 ADEM Form 24- NOI.pdf

ADEM Form 24 08/16 m1 Page 1 of 2

NOTICE OF INTENT – GENERAL PERMIT NUMBER ALR100000

NPDES PERMIT NUMBER ALR100000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES THAT RESULT IN A TOTAL LAND DISTURBANCE OF ONE ACRE OR GREATER AND SITES LESS THAN ONE ACRE BUT ARE PART OF A LARGER COMMON PLAN OF DEVELOPMENT OR SALE

Mail to: Alabama Department of Environmental Management Water Division Stormwater Management Branch Post Office Box 301463 Montgomery, Alabama 36130-1463

PLEASE COMPLETE ALL QUESTIONS. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES WILL DELAY PROCESSING. 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. PERMITTEE INFORMATION Initial: Modification: Transfer: Renewal: Previous ALR10 _____________________

Permittee Name (Legal Name)

Responsible Official Phone Number

Responsible Owner/Operator or Official, and Title

Responsible Official E-Mail Address

Responsible Official (RO) Street/Physical Address

City, State, and Zip Code

Responsible Official (RO) Mailing Address

City, State, and Zip Code

Corporation Individual Sole Proprietorship Partnership LLC LLP Government Agency Other _______________

II. FACILITY INFORMATION

Facility/Site Name

Facility Contact and Title

Facility Street Address or Location Description

Facility Contact Company Name

City

Zip Code

County(s)

Facility Contact Phone Number

Facility Front Gate Latitude and Longitude (For linear projects, please include coordinates for both the beginning and ending points of the project.)

Facility Contact e-Mail Address:

Detailed Directions to the Site

III. ACTIVITY DESCRIPTION

Brief Description of Construction / Land disturbance activity(s):

(For Modifications Only) Brief description of the action/change that has resulted in the request for permit modification:

Primary SIC Code: Primary NAICS Code:

IV. PROPOSED SCHEDULE

Anticipated Activity schedule: Commencement date: Completion date:

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

V. PRIORITY CONSTRUCTION SITE

Is this a Priority Construction Site as defined by Part V of the construction stormwater general permit? Yes No If yes, attach/submit a copy of the CBMPP that meets or exceeds the requirements of Parts III A. and E. of the construction stormwater general permit.

ADEM Form 24 08/16 m1 Page 2 of 2

VI. TOPOGRAPHIC MAP SUBMITTAL

Please attach a recent 7.5 minute series USGS topographic map(s) no larger than 11 by 17 inches (several pages may be necessary), showing the location of the Facility including site boundaries, area of disturbance, a 1 mile radius, perennial, intermittent, and ephemeral streams, lakes/springs/wells/wetlands and contour lines. The map should also show the point(s) at which stormwater runoff will exit (outfall) the facility and the point(s) where stormwater runoff from the site will enter the receiving water.

VII. RECEIVING WATERS

Are there any surface waters within 25 feet of your project’s land disturbances? YES NO

List name of receiving water(s), latitude & longitude (decimal or deg, min, sec) of location(s) that run-off enters the receiving water, and the waterbody classification. Please refer to ADEM Admin. Code 335-6-11 for a detailed list of water use classifications. (Attach a separate list if necessary)

Receiving Water Latitude Longitude Waterbody Classification

VIII. GENERAL INFORMATION

Will flocculants or other chemical stabilization products be used on site? Yes No

IX. 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. The CBMPP meets the requirements of this permit and if properly implemented and maintained by the operator, 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 335-6-6-.23 and this Permit. The CBMPP describes the erosion and sediment control measures that must be fully implemented and regularly maintained as needed at the permitted site in accordance with sound sediment and erosion control 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

X. OPERATOR - RESPONSIBLE OFFICIAL SIGNATURE

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOI must be signed by a Responsible Official of the permittee 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 and Title (type or Print) Official Title

Signature Date Signed