Revised 5/19/2020
Jenni Seven
For DEQ Use Only
Application #:_____________
Unpaid ACDF: ____________
DOC Confirm: ____________
A. Site and Contact Information (to be filled out by current owner/operator)
If you are no longer the owner/operator for the site, you need to fill out a Name Change/Permit Transfer Form and provide it to the new
owner/operator. If the permit is not properly transferred, you will be responsible for paying the annual permit fee.
1. Legal Name:
2. DEQ File #:
3. Name of Project: County:
Project Address: City:
Zip Code:
4. Legally Responsible Contact: Telephone #:
Mailing Address:
State: Zip Code: email:
5. Facility Contact: Telephone #:
Mailing Address: City:
State: Zip Code:
6. Invoice Contact:
Telephone #:
Mailing Address: City:
Zip Code:
B. Required Information (All questions must be answered for application to be considered complete.)
Has DEQ been provided the most recent version of the Erosion and Sediment Control Plan (ESCP)? YES NO Included
If an updated ESCP is included with this application, briefly describe the major modifications made to the project and the ESCP.
NOTE: DEQ may refuse to renew coverage if there are outstanding invoices (Annual Compliance Determination fees). For questions
regarding invoicing contact Rod Lemeni at 503-229-5437.
C. Signature of Legally Authorized Representative
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief. In
addition, I agree to pay all permit fees required by Oregon Administrative Rules 340-45, including a compliance determination fee
invoiced annually by DEQ to maintain the permit.
Legally Authorized Representative (type or print) Title
Signature of Legally Authorized Representative Date
Submit a Renewal Application for all construction projects extending beyond December 14, 2020 (expiration date for the current
1200-C permit). If you fail to submit the renewal application, you will have to reapply for coverage under the renewed
permit and pay the application fee.
There is no fee for this renewal action; however, incomplete applications will not be processed.
Renewal Application
National Pollutant Discharge Elimination System
General Stormwater Discharge Permit #1200-C
Oregon Department of Environmental Quality
For general information on DEQ’s #1200-C permit
go to
Revised 5/19/2020
Jenni Seven
NPDES General Permit 1200-C Renewal Application Instructions
A. Site and Contact Information
NOTE: If the applicant’s legal name has changed or you are no longer the owner/operator of the project, you must submit
Name Change/Permit Transfer Form to DEQ. Forms are available at:
1. Enter the legal name of the applicant. The name must be a legal, active name registered with the Secretary of State
Corporation Division, unless otherwise exempted by their rules:
2. The DEQ File Number can be found o
n your permit cover page or on your Renewal Application Letter.
3. Enter the Project/Common name of the site and the physical location of the project.
4. The Legally Responsible Contact is responsible for receiving official correspondence from DEQ and may be contacted if
there are questions concerning your renewal application.
5. The Facility Contact is the person located at the site that has specific knowledge of the project (e.g., the general
contractor) and may be contacted if there are specific questions.
6. Provide Invoice Contact information for billing of DEQ annual permit fee. This is the person or entity legally
responsible for payment of the annual fee invoice, not a third party independent of the applicant.
B. Required Information
Please include a brief description of any ESCP revisions and submit an ESCP
drawing with your application, if applicable.
C. Signature of Legally Authorized Representative
The signature of the legally authorized representative is required to process this application.
Definition of Legally Authorized Representative
See 40 CFR §122.22 for more detail. Also, please also provide the information requested in brackets [ ]
Corporation President, secretary, treasurer, vice-president, or any person who performs principal business functions;
a manager of one or more facilities that is authorized in accordance to corporate procedure to sign such documents.
Partnership General partner [list of general partners, their addresses and telephone numbers]
Sole Proprietorship Owner
City, County, State, Federal, or other Public Facility Principal executive officer or ranking elected official
Limited Liability Company Member [articles of organization]
Trusts Acting trustee [list of trustees, their addresses and telephone numbers]
Submit Your Application to:
City of Eugene
99 W. 10th Avenue
Eugene, OR 97401
City of Troutdale
342 SW 4th Street
Troutdale, OR 97060
Clean Water Services
2550 SW Hillsboro Highway
Hillsboro, OR 97123
Includes Banks, Beaverton, Cornelius,
Durham, Forest Grove, Gaston, Hillsboro,
King City, North Plains, Sherwood, Tigard,
Tualatin, and portions of Washington Co
DEQ Northwest Region DEQ Western Region DEQ Eastern Region
DEQ Northwest Region
700 NE Multnomah St, Suite 600
Portland, OR 97232-4100
503-229-5886 or 1-800-452-4011
DEQ Western Region
165 East 7th Avenue, Suite 100
Eugene, OR 97401
541-686-7930 or 1-800-844-8467
DEQ Eastern Region
800 SE Emigrant Avenue, Suite 330
Pendleton, OR 97801
541-278-4605 or 1-800-304-3513
Clackamas Benton Lane Baker Hood River Sherman
Clatsop Coos Lincoln Crook Jefferson Umatilla
Columbia Curry Linn Deschutes Klamath Union
Multnomah Douglas Marion Gilliam Lake Wallowa
Tillamook Jackson Polk Grant Malheur Wasco
Washington Josephine Yamhill Harney Marrow Wheeler
Rogue Valley Sewer
138 West Vilas Road,
PO Box 3130
Central Point, OR 97502
Includes Central Point, Phoenix, Talent, White
ity a
rtions of Jackson Co.