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Home My WebLink About00070628THIS FORM REPLACES PREVIOUS FORM 3510 -6 (8 -98) Form Approved. OMB No. 2040.0188 See Reverse for Instructions United States Environmental Protection Agency NPDES E Pq Washington, to 20460 Awl N otice of Intent (NOI) for Storm Water Discharges Associated with FORM CONSTRUCTION ACTIVITY Under a NPDES General Permit Submission of this Notice of Intent constitutes notice that the party identified in Section I of this form intends to be authorized by a NPDES permit issued for storm water discharges associated with construction activity in the State /Indian Country Land identified in Section II of this form. Submission of this Notice of Intent also constitutes notice that the parry identified in Section 1 of this form meets the eligibility requirements in Part I.B. of the general permit (including those related to protection of endangered species determined through the procedures in Addendum A of the general permit), understands that continued authorization to discharge Is contingent on maintaining permit eligibility, and that implementation of the Storm Water Pollution Prevention Plan required under Part IV of the general permit will begin at the time the permittee commences work on the construction project identified in Secion II below. IN ORDER TO OBTAIN AUTHORIZATION, ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM. I. Owner /Ope (Applicant) Information I�1'►�1�%'I 1 Phone: -f / 191 ? 1�1bIQ1 3 1 7 1 913 10 1 Name: IvY I� I� Inl� l I f — Irl 4 1r I r lei Il- 1r1jVlYISI tlalr1 Status of j a I� 0 1 f� h (I l t► u I s I tl a l I /r� c-1 "I � I c- I l l e 1 I I I f I I Ir I I 1 1 1 1 Owner/Operalor: IF I Address: I 1 S S CI v l 1 � I State: LJJ � Zip Code: 17 1 I g 1 1 —1 1 1 1 1 City: IC I fl 1 I I I l Is the facility located on Indian 11. Project/Shte Information (, JI S b S N Country Lands? Yes ❑ No C 4 5 a f e o Gl l V o Project Name: S r I a l t f r I I I I dl 11• I� I I I►y Gd I I o S(� l!, Project Address/Location: IN I e I. l I l t l �Ir l e l I I 11 I le I'^f 1 1 I 1 I I I I State: Irlyl Zip Code: 171 1 4 l 51— 11 1 1 1 City O I I I Q l l 1 Latitude: 1 Of Z) Longitude: I 1 91 61 /1 6 111 0 ] County. 1,6 rl Q 1 ZI o S l I I I I I I I I I I I I Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes Ltd No ❑ Optional: Address of location of SWPPP for viewing [B in Section I above E] Address in Section 11 above ❑ Other address (if known) below: Phone: SWPPP Address:) I I I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I I I I I I I I V I I I I I I I I Cit I I I I► 1 I I I I I I I I I I I I I I I I I State: t J Zip Code: Name Receiving Water: I�I PI I t 1 1 1 1 ° I t IC l 1 I I I I I I I I I I I Q0 IZ161 Z OI QI 0I 1 01 31 1 f-1 0 1 0 1 I Based on instruction provided in Addendum A of the permit, are Morith D Ye Month Day Year there any listed endangered or threatened species, or designated Estimated Construction Start Date Estimated Completion Date critical habitat in the project area? Estimate of area to be disturbed (to nearest acre): I I 1 1 12151 Yes ❑ No Estimate of Likelihood of Discharge (choose only one): 1 have satisfied permit eligibility with regard to protection of endangered species through the indicated section of Part I.B.3.e.(2) 1. ❑ Unlikely 3. Once per week 5. ❑ Continual of the permit (check one or more boxes): 2_ r] Once per month 4. F] Once per day _ (a) U `b) ❑ (c) ❑ (d) ❑ III. Certification 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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage this 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: Signature: Date: 1,9191 z Iz 1 0 1 0 EPA Form 3510 -9 replaced 3510 -6 (8 -98) THIS FORM REPLACES PREVIOUS FORM 3510 -6 (8 -98) Form Approved. OMB No. 2040 -0t88 See Reverse for Instructions United States Environmental Protection Agency NPOES �� Washington, DC 20460 EPA Notice of Intent (No[) for Stone Water Discharges Associated with FORM �, \ CONSTRUCTIO ACTI VITY Under a NPOES General Permit Submission of this Notice of Intent constitutes notice that the party identified in Section I of this form intends to be authorized by a NPOES permit issued for storm water discharges associated with construction activity in the StateAndian Country Land identified in Section II of this form. Submission of this Notice of Intent also constitutes notice that the party identified in Section I of this form meets the eligibility, g requirements in Part I.B. of the permit (including those related to protection of endangered species determined through the procedures in Addendum A of the general permit), understands that continued authorization to discharge is contingent on maintaining permit eligibility, and that implementation of the Storm Water Pollution Prevention Plan required under Part IV of the general permit will begin at the time the permittee commences work on the construction project identified in Secion It below. IN ORDER TO OBTAIN AUTHORIZATION, ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM. Owner /Operator (Applicant) Information p .w1 p D G �7 Q Name: 1 161'Altloltdl IGIEINAiAAILl Iclop-IT1,4AILI -ICI I I I Phone: 111(I I�171 1(� I / pp,, QQ Status of Address - 1 X111 16*1 `I� It�1 1 1 1 1 1 1 1 1 1 1 1Y1 1 1 1 1 1 Owner/Operator. City- L' / j" 1 �1 V 1 -1 I SITI AIIA4 fro 1 I I 1 I I I I State: LrL Zip Code: 1 4151 -1 1 1 1 II. ProjecUShe Information Is the facility located on Indian Country Lands? Proiea // �� Name: Ik- A1 151u1Qlul�Vl�isI�IDIN1 I I I I I I I I Yes ❑ No / .r P lrlo"ii irlsl�l I�)OAM 111• 10 -C W. of s "p Project Address/Location: W 10 - A t I to I�I IV Ir K K I^ � I ' City: IG 4 �1E I �Ic I IS I I I �I TI� I� ICI I I I I I I I I State: � Zip Code: 17171 - Ji - I I I t r u o f a Latitude: 13 IO 1 1 ®I fll Longitude: 1 t 916 1 116 I ?I o f County: I —S AI" X121 IS► Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes &a--- No ❑ Optional: Address of location of SWPPP for viewing EP'Xddress in Section I above ❑Address in Section 11 above ❑Other address (if known) below Phone: SWPPP Address: l I I I I I I I I I I I I 11 1 1 I l l l 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 City: 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 State: LI Zip Code: Name of Receiving Water: II S I I I`t�l NI if l I 1 q C 121 01 O ( I 10 1113 to I Z L q 1 / I Based on instruction provided in Addendum A of the permit, are Month p YON Wren DaY Year there any listed endangered or threatened species. or designated Estimated Construction Start Date Estimated Completion Date critical habitat in the project area? Estimate of area to be disturbed (to nearest acre): L I 1 1 IZ I5 Yes Q No Estimate of Likelihood of Discharge (choose only one): 1. ❑ Unlikely 3. Once per week 2. ❑ Once per month 4. ❑ Once per day I have satisfied permit e6gNity with regard to protection of endangered species through the indicated season of Part 1.8.3.&.(2) 5_ ❑ Continual of the permit (check one or more boxes): (a) P--�-(b) ❑ (c) ❑ (d) ❑ III. Certification 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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage this 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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Print Name: Signature: T Oate: 1 01% 1 1 3 1 ° 1 o I EPA Form 3510 -9 replaced 3510 -6 (8 -98)