HomeMy WebLinkAbout00071616THIS FORM REPLACES PREVIOUS FORM 3510-6 (8-98) Form Approved. OMB No. 2040-0188
See Reverse for Instructions
NPDES
United States Environmental Protection Agency
Washington, DC 20460
FORM
Awl ~P Notice of Intent (NO[) for Storm Water Discharges Associated with
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 party 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 11 below. IN ORDER TO
OBTAIN AUTHORIZATION, ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM.
1. Owner/Operator (Applicant) Information
C~ ,
Name: IAA It- IE I (~I El 1~i - I lA i l ( I 0A NI A S191 1 ( - 1 SIN I I I 1=1 ~i I I I Phone: I `1719 1-11 0 1 1 1 10 1 C1
F1 Status of
O
Address: I! 11 210 19 1 F1 I Q C I,/1 ICI ~ 8 1 1 IV-11 ICI RIPI I I I I I I I I I I I I
wnner/Operator:
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City: I~ I Ut-I~I`r'!I it 1/1~6I~1 119 N~ I I I I I I I State: 7r n I Zip Code: 1717 IC 1 X171-I I I I
Is the facility located on Indian
II. Project/Site Information Country Lands?
16 15Z1 1 n1 1 Pd 121 I C I GIN II I EIV-1 P) D Fl 124 1 1 1 1 1 1 1 1 1 I Yes E] No ffr
Project Name:
Project Address/Location: I! t21 (~19 1 1 CI ~i 1? 11Z~I I e4-1 I El I +~I I I I I I I I I I I I
City: 1 Ir1 L. 1 =1 al EF I I. Il 8 IZ 11 I G 1)41 I11 1 1 1 1 1 1 State: W Zip Code: 117 ISM I - I I I I
Latitude: ly' I I I ' 1`' I Longitude: 1 %F 1 I SIG I County: 1 1 I I I I I I I I I I I I I I I I I 1
Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes 0 No ❑
Optional: Address of location of
SWPPP for viewing ❑ Address in Section I above ❑ Address in Section II above Other address (if known) below:
SWPPP / Phone,
'i'r=1~{1Ai~1 t~IjI1 I%I~I~#~I I I I I I I I I I~I~I~rI~~I~3aI~
Address:
City: I IC- I L IL I y IL'Vf l 1~I-1 VaI'l I I I CIt I I I I I I I I State: 1X1 Zip Code: R 1! lel~ ~c I -I I I I
141 ^50 1 I I 1 I LI; FC- 4F- IJa-I~~I I
I-1
I~T,I GI ICIV
-
-
Name of Receiving Water:
r) K-- ) ZI , I 1 I IC IC~ I C I- r (tI C- ~ 121 CIG I2,1 Based on instruction provided in Addendum A of the permit, are
Month Day Year 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 I I I I ID Yes ❑ No
Estimate of Likelihood of Discharge (choose only one): I have satisfied permit eligibility with regard to protection of
endangered species through the indicated section of Part 1.B.3.e.(2)
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nlikely 3. ❑ Once per week 5. ❑ Continual of the permit (check one or more boxes):
1. 1~
2. ❑ Once per month 4. ❑ Once per day (a) ❑ (b) ❑ (c) ❑ (d) ❑
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
mprisonment for knowing violations.
Tint Name: I I'Y
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