SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245 www.scdhec.gov
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 
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 
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              
                   
     
          

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              


                
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             
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
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CONTRACTOR CERTIFICATION FORM
NPDES Coverage No.: SCR ___________________ State Permit (Tracking) No.: ____________________
Project/Site Name: __________________________________________________________________________________
C. Contractor Certification Statements:
All contractors performing any land disturbing activity at a construction site must be certified and listed in
the On-Site SWPPP (OS-SWPPP) in order to work on the site. Read the Certification statements below
(in entirety) and provide date and signature of agreement below.
I certify by my signature below that I or I (on behalf of my company and its contractors and
agents), as the case may be,
(a) Understand, accept, and will adhere to the provisions of the Stormwater Pollution
Prevention Plan (SWPPP) as it pertains to the portion of the project I am or my
company is responsible for, and as required by the coverage under the National
Pollutant Discharge Elimination System (NPDES) General Permit for Stormwater
Discharges From Construction Activities SCR100000 issued to the Owner/Operator of
the construction activity with whom I am or my company is under contract to perform
construction related professional services;
(b) Am legally accountable to the SC Department of Health and Environmental Control
(DHEC), under the authorities of the Clean Water Act and the SC Pollution Control Act,
to ensure compliance with the terms and conditions of the SWPPP applicable to my or
my companys portion of the project;
(c) Must comply with the terms and conditions of the Construction General Permit (CGP),
will adhere to applicable standards and stormwater erosion control practices established
in the SWPPP and in the Best Management Practices (BMP) manual at all times while
performing work at the project site, and agree to implement corrective actions identified
by the qualified inspector during a site inspection; and
(d) Understand that DHEC enforcement actions may be taken against any specific or
combination of permittees and contractors if the terms and conditions of the SWPPP are
not met.
Therefore, having understood the above information, I am signing this certification as
contractor to the aforementioned NPDES general permit.”
DHEC 0437 (10/2012)
C. CONTRACTOR CERTIFICATION AGREEMENTS
(Sheet 1)
NPDES Coverage No.: SCR ________________ State Permit (Tracking) No.: ______________________
Project/Site Name: __________________________________________________________________________________
Please print legibly and complete all spaces on the form. If you are an approved Blanket Utility Provider, you do not need to sign this form, but you
must submit a copy of your Annual Blanket NOI registration information to the Owner/Operator. Abbreviate if necessary and submit the completed
form to the Owner/Operator. (When your land-disturbing activities at this site are complete, sign and date the termination agreement below. After this
date, you may not perform any land-disturbing activities at this site unless you sign a new contractor certification agreement). Additional certification
agreement pages may be attached as necessary. DO NOT SIGN IN BLACK INK!
Contractor Information
:
Name: _____________________________________________ Title/Position: ______________________________________
Company Name (As Applicable) _____________________________________________________________________________
Mailing Address: ______________________________________ City: __________________ State: ____ Zip: _______________
Phone: _________________________ Email Address: ___________________________________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_____________________________________ ______________________________________
Signature of Contractor Date Signed
Contractor Information:
Name: _____________________________________________ Title/Position: ____________________________________
Company Name (As Applicable) _____________________________________________________________________________
Mailing Address: ______________________________________ City: __________________ State: ____ Zip: _______________
Phone: _________________________ Email Address: ___________________________________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_____________________________________ ______________________________________
Signature of Contractor Date Signed
Contractor Information:
Name: _____________________________________________ Title/Position: ____________________________________
Company Name (As Applicable) _____________________________________________________________________________
Mailing Address: ______________________________________ City: __________________ State: ____ Zip: _______________
Phone: _________________________ Email Address: ___________________________________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_____________________________________ ______________________________________
Signature of Contractor Date Signed
DHEC 0437 (10/2012)
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C. CONTRACTOR CERTIFICATION AGREEMENTS
(Company Certifications)
(Sheet 2)
Use this sheet for certification agreements of contractors, subcontractors, etc. employed by the Contracting Company identified below
ONLY. If you do not work for the company listed below, do not sign this sheet. If you are an approved Blanket Utility Provider, you do
not need to sign this form, but you must submit a copy of your Annual Blanket NOI registration information to the Owner/Operator.
Abbreviate if necessary and submit the completed form to the Owner/Operator. (When your land-disturbing activities at this site are complete,
sign and date the termination agreement below. After this date, you may not perform any land-disturbing activities at this site unless you sign
a new contractor certification agreement). Additional certification agreement pages may be attached as necessary. Please print legibly and
complete all spaces on the form.
DO NOT SIGN IN BLACK INK!
NPDES Coverage No.: SCR ________________ State Permit (Tracking) No.: ______________________
Project/Site Name: __________________________________________________________________________________
Contracting Company Information:
Company Name _______________________________________________________________________________________________
Mailing Address: __________________________________________ City: __________________ State: ______ Zip: _______________
Phone: ___________________________ Email Address: _______________________________________________________________
Contractor Information:
Contractor Name: _______________________________________ Title/Position: ____________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_
______________________________________ ______________________________________
Signature of Contractor Date Signed
Contractor Name: _______________________________________ Title/Position: ____________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Contractor Name: _______________________________________ Title/Position: ____________________________________
Contractor Certification (Signature of Agreement): Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
Termination of Contractor Certification Agreement: Provide date and signature. DO NOT SIGN IN BLACK INK!
_______________________________________ ______________________________________
Signature of Contractor Date Signed
DHEC 0437 (10/2012)
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Instructions for Completing the Contractor Certification Form
If you are uncertain whether you need to obtain coverage under the NPDES General Permit for Stormwater Discharges From Construction
Activities SCR100000 (CGP), if you cannot access the websites listed in these instructions, or if you have any questions, contact the Bureau
of Water Stormwater Permitting Section at (803) 898-4300 or the Coastal Stormwater Permitting Section at (843) 953-0200. Please see the
Bureau of Water, Stormwater Permitting website (http://www.scdhec.gov/stormwater) for guidance and additional information.
DHEC 0437 (10/2012)
Who Must Complete a Contractor Certification Form
Contractors (who are not Permittees or Annual Blanket Utility providers), employed by a Primary or Secondary
Permittee of a construction project or site, must complete a Contractor Certification Form before performing any
land-disturbing activities at the construction site. Contractor Certification Forms do not require Department
approval, however, this form must be signed, dated, and submitted by each contractor to the Owner/Operator
prior to commencement of land-disturbing activities by the contractor.
General Guidance for this Form
Are there Other Requirements for Contractors
Completing this form?
Contractors completing this form must also attend a
pre-construction conference, and sign and date a Pre-
Construction Conference Certification Agreement for
each project or construction site where they will be
performing construction activities. Contractors cannot
work at a construction site until they sign this
certification form and document attendance at the Pre-
Construction Conference held for the project or
construction site.
See Section 4.1 of the 2012 CGP for
additional information.
What Does This Certification Mean?
Upon signing this certification, the contractor is
accountable to DHEC to ensure the terms and
conditions of the approved Stormwater Pollution
Prevention Plan (developed for the respective
construction project or site) and the Construction
General Permit (CGP) are implemented and adhered to
in the respective area(s) of the plan where each
contractor and/or company signing this form will be
performing work. Each contractor becomes subject to
DHEC enforcement actions if permit conditions are not
met.
See Sections 2.2.3 and 2.3.2 of the 2012 CGP for
additional information.
Should the Owner/Operator Retain This Form?
The Owner/Operator of the construction site must
retain completed Contractor Certification Forms with
the approved On-Site SWPPP. This form must be
retained for at least three years from the date permit
coverage expires or is terminated.
Instructions for Completing this Form
Please print legibly and complete all spaces on the
form. Abbreviate if necessary to stay within the space
allowed for each item and submit the completed form
to the Owner/Operator for the specific project or
construction site listed in Section A.
Section A - Project Information
Provide all requested information. Enter the date,
NPDES coverage number, and Tracking No. provided
by the Department for the approved SWPPP. Enter
the official or legal name of the project or site, as
approved by the Department. If this project is for an
individual lot or group of lots, provide the lot
number(s). Provide the name of the Owner/Operator.
Section B –Contractor Information
Provide your legal name and title/position. As
applicable, provide the legal (formal) name of the
company, firm, public organization, or any other entity
(you are employed by or represent) on whose behalf
you will be performing contractor construction
activities. Provide your mailing address, telephone
and e-mail address. Briefly describe construction-
related duties and responsibilities you or your
company will perform for this project at the
construction site.
Section C Contractor Certification Statements &
Agreement
Read the certification statements (in entirety). Provide
your printed name and title or position. Date and sign
the certification agreement. Return the signed and
dated form to the Owner/Operator. DO NOT SIGN IN
BLACK INK. Sheets 1 and 2 are formatted for
multiple contractor signatures. Sheet 2 is ONLY for
signatures within a specific company. Each may be
copied as necessary. Sign and date the Termination
of Contractor Certification Agreement when the
services you provide for this project are complete.
Return the signed and dated form to the
Owner/Operator for record retention as a part of the
On-Site SWPPP (OS-SWPPP).