HomeMy WebLinkAbout01-00500272- 00075685THIS FORM REPLACES PREVIOUS FORM 3510 -6 (8 -98) Form Approved. OMB No. 2040-0188
See Reverse for Instructions
NPDES
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United States Environmental Protection Agency
Washington, � 20460
FORM
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Notice of Intent (NOQ for Stain Water Discharges Associated with
PA
CONSTRUCTION ACTIVITY Under a NPDES General Permit
Submission of this Notice of Intent consiftutes 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 Statelindian Country Land identified in Section 11 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 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 Polkion Prevention Plan required under
Part IV of the general permit will begin at the time the permittee commences work on the constriction 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.
L Owner/Operator (Applicant) Information q0
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Name: I l l d I� I I v I I I I I i i I 11 I 1 1 1 1 1 1 1 1 1 1 I Phone: I 1 l
/1 � Status Of
DI h V I 1 141 1
Address: I t I 1� I I 131 1 i UI 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Owner/Operator:
A 0I UI � �l �' N I I I I I I I I I I I I 1 I ( l� ITi3i�l `
City. State: tU Tip Code:
U Project/Site Information
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Is the facility mated on Indian
Country Lands?
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Project Name: I ti G M " A, � I y1 t 1 (Il� I C; I 1 I I I I I i I I I I I I
Yes No d
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ProjectAddresal ocation: U c i l `Id I VI1 1(11 161 Q Irfu Ir,:5 , 11
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Zip
I ` I ` I e 4 Q I e 4 161 State: �/L�^JZ
City: Code:
^ ,5
Latitude: O Longitude: ` ; County: ( � 4 �I 11 I 1 1 I 1 I 1 1 1 11
Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes B/ No ❑
Optional: Address of location of
SWPPP for viewing ❑ Address in Section I above ❑ Address in Section 11 above Other address (if known) below:
SWPPP F I I I ( ,r / `/ yr c / � /�
Address: 161 1 1` 1 1 U � I hr 1 ti ' 1 �1' I� W b V't f Vlal Jlk I� I� � Al C1 �i 6 141 1 1 1 1 1 I4 li 1
I 0 1 1 1 1 E 1 IF, A tl i ` I�I�t vl l M — I I I I
City: State: Zip Code:
IV�f (I� N IJ I ►rt-le-1 K I I I 1 I 1 I I I I I I I
Name of Receiving Water:
I � 1 �r 4 Q OI al (� In a 11A avl�
Based on instruction provided in Addendum A of the permit, are
Month Day W"r Month Day *ar
there any listed endangered or threatened species, or designated
Estimated Construction Start Date Estimated Completion Date critical habitat in the project area?
� Estimate
�
I Yes ❑ No
of area to be disturbed (to nearest acre): I 1 5 , • 1 `I
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. WOnce per week 5. ❑ Continual of the permit (check one or more boxes):
2. ❑ Once per month 4. ❑ Once per day (a) ❑ (b) ❑ (c) ❑ (d) d
Ni. 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: L 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 11 1 1 1 1 I I Date: 1 1 I 1 I 1 I
Signature:
EPA Form 3510 -9 replaced 35106 (8-98)