Fill - Free fillable VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY GENERAL VPDES PERMIT (Town of Ashland, VA) PDF form

VIRGINIA DEPARTMENT OF ENVIRONMENTAL QUALITY

GENERAL VPDES PERMIT FOR DISCHARGES OF STORMWATER FROM

CONSTRUCTION ACTIVITIES (VAR10)

REGISTRATION STATEMENT 2019

Rev 11/2020 PAGE 1 | 6

PERMIT #:

PLAN/ID #:

TECHNICAL CRITERIA: IIB ☐ IIC ☐

Application type.

☐ NEW PERMIT ISSUANCE

(CHOOSE ONE)

☐ MODIFICATION WITH ACREAGE INCREASE

☐ MODIFICATION WITHOUT ACREAGE INCREASE

☐ EXISTING PERMIT RE-ISSUANCE

Section I. Operator/Permittee Information.

A. Construction Activity Operator (Permittee). The person or entity that is applying for permit coverage and will have

operational control over construction activities to ensure compliance with the general permit. A person with

signatory authority for this operator must sign the certification in Section V. (per Part III. K. of the VAR10 Permit).

Operator Name:

Contact person:

Address:

City, State and Zip Code:

Phone Number:

Primary and CC Email:

B. Electronic correspondence. To receive an emailed coverage letter or to pay by credit card, you must choose YES

and include a valid email. May we transmit correspondence electronically? YES ☐ NO ☐

Section II. Construction Activity Information.

A. Include a site map showing the location of the existing or proposed land-disturbing activities, the limits of land

disturbance, construction entrances and all waterbodies receiving stormwater discharges from the site.

B. Project site location information.

Construction Activity Name:

Address:

City and/or County and Zip Code:

Construction Activity Entrance Location

(description, street address and/or

latitude/longitude in decimal degrees):

Latitude and Longitude

(6-digit, decimal degrees format):

C. Acreage totals for all land-disturbing activities to be included under this permit coverage. Report to the nearest

one-hundredth of an acre.

Total land area of development (include entire area to be

disturbed as approved in the Stormwater Management Plan):

Primary estimated area to be disturbed (include portions with

Erosion and Sediment Control Plan approval only):

Off-site estimated area to be disturbed (if applicable):

D. Property Owner Status:

FEDERAL ☐ STATE ☐ PUBLIC ☐ PRIVATE ☐

E. Nature of the Construction Activity Description (i.e. commercial,

industrial, residential, agricultural, environmental, utility):

F. Municipal Separate Storm Sewer System (MS4) name(s) (if the

site is discharging to a MS4):

G. Estimated Project Dates (MM/DD/YYYY).

Start Date:

Completion Date:

H. Is this construction activity part of a larger common plan of

development or sale?

YES ☐ NO ☐

CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019

Rev 11/2020 PAGE 2 | 6

I. 6

Order Hydrologic Unit Code (HUC) and Receiving Water Name(s). Include additional areas on a separate page.

HUC

NAME(S) OF RECEIVING WATERBODY

Section III. Off-site Support Activity Location Information.

List all off-site support activities and excavated material disposal areas being utilized for this project. Include additional

areas on a separate page.

Off-site Activity Name:

Address:

City or County:

Off-site Activity Entrance Location (description, street

address and/or latitude/longitude in decimal degrees):

Latitude and Longitude (6-digit, decimal degrees format):

Is this off-site activity an excavated material disposal

area?

YES ☐ NO ☐

If this off-site activity is an excavated material disposal

area, list the contents of the excavated fill material:

Will a separate VPDES permit cover this off-site activity?

YES ☐ NO ☐

Section IV. Other Information.

A. A stormwater pollution prevention plan (SWPPP) must be prepared in accordance with the requirements of the

General VPDES Permit for Discharges of Stormwater from Construction Activities prior to submitting the

Registration Statement. By signing the Registration Statement, the operator is certifying that the SWPPP has been

prepared.

B. Has an Erosion and Sediment Control Plan been

submitted to the VESC Authority for review?

YES ☐ NO ☐

Erosion and Sediment Control Plan Approval Date (for

the estimated area to be disturbed MM/DD/YYYY):

C. Has land-disturbance commenced?

YES ☐ NO ☐

D. Annual Standards and Specifications. If this project is utilizing approved Annual Standards and Specifications

(AS&S), attached the completed AS&S Entity Form.

AS&S Entity Name (if different from the Operator

identified in Section I):

E. Billing information (leave blank if same as the Operator identified in Section I. above). This entity will receive

Annual Permit Maintenance and Permit Modification Fee invoices (if applicable).

Billing Name:

Contact Name:

Address:

City, State and Zip Code:

Phone Number:

Primary and CC Email:

CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019

Rev 11/2020 PAGE 3 | 6

Section V. Certification. A person representing the operator as identified in Section I. A. and meeting the requirements

of 9VAC25-880-70. Part III. K must physically sign this certification. A typed signature is not acceptable. Please note that

operator is defined in 9VAC25-870-10 as follows:

"Operator" means the owner or operator of any facility or activity subject to the Act and this chapter. In the context of stormwater

associated with a large or small construction activity, operator means any person associated with a construction project that meets

either of the following two criteria: (i) the person has direct operational control over construction plans and specifications, including

the ability to make modifications to those plans and specifications or (ii) the person has day-to-day operational control of those

activities at a project that are necessary to ensure compliance with a stormwater pollution prevention plan for the site or other state

permit or VSMP authority permit conditions (i.e., they are authorized to direct workers at a site to carry out activities required by the

stormwater pollution prevention plan or comply with other permit conditions). In the context of stormwater discharges from

Municipal Separate Storm Sewer Systems (MS4s), operator means the operator of the regulated MS4 system.

9VAC25-880-70. Part III. K. Signatory Requirements. Registration Statement. All Registration Statements shall be signed as follows:

a. For a corporation: by a responsible corporate officer. For the purpose of this chapter, a responsible corporate officer

means: (i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or

any other person who performs similar policy-making or decision-making functions for the corporation; or (ii) the manager

of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management

decisions that govern the operation of the regulated facility including having the explicit or implicit duty of making major

capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term

compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or

actions taken to gather complete and accurate information for state permit application requirements; and where authority

to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

b. For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or

c. For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected official.

For purposes of this chapter, a principal executive officer of a public agency includes: (i) the chief executive officer of the

agency or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the

agency.

Certification: "I certify under penalty of law that I have read and understand this Registration Statement and that this

document and all attachments were prepared in accordance with a system designed to assure that qualified personnel

properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage

the 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."

Printed Name:

Signature (signed in ink):

Date Signed:

Section VI. Submittal Instructions. Submit this form to the VSMP Authority. If the locality is the VSMP Authority, please

send your Registration Statement submittal directly to the locality; do NOT send this form to DEQ. A list of local VSMP

Authorities is available here: VSMP Authorities.

If DEQ is the VSMP Authority, please send to: If the locality is the VSMP Authority, please send to:

Department of Environmental Quality The Local VSMP Authority (insert address below)

Office of Stormwater Management Suite 1400

PO Box 1105

Richmond VA 23218

constructiongp@deq.virginia.gov

Town of Ashland

PO Box 1600

Ashland, VA 23005

CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS

PLEASE DO NOT PRINT OR SUBMIT

Rev 11/2020 PAGE 4 | 6

This Registration Statement is for coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities. This form

covers the following permit actions: new permit issuance, existing permit modification with an increase in acreage, existing permit modifications

that result in a plan modification but do not result in an increase in disturbed acreage, and reissuance of an active permit coverage.

Application type. Select NEW PERMIT ISSUANCE to obtain a new permit coverage. Modifications are for modifying an existing, active permit

coverage. Select MODIFICATION WITH ACREAGE INCREASE when the previously approved acreage(s) increases (permit modifications are not

performed for decreases in acreage unless they result in plan changes – see Modification WITHOUT Acreage Increase). Select MODIFICATION

WITHOUT ACREAGE INCREASE when there is a change to the site design resulting in a change to the approved plans with no increase in acreage(s).

Select EXISTING PERMIT REISSUANCE to extend an expiring permit coverage for the next permit cycle and include the existing permit number.

Section I. Operator/Permittee Information.

A. Construction Activity Operator (Permittee). The person or entity that is applying for permit coverage and will have operational control over

construction activities to ensure compliance with the general permit. For companies, use the complete, active, legal entity name as registered with

a state corporation commission. Entities that are considered operators commonly consist of the property owner, developer of a project (the party

with control of project plans and specifications), or general contractor (the party with day-to-day operational control of the activities at the project

site that are necessary to ensure compliance with the general permit). If an individual person is listed as the operator, that person (or a legal

representative of) must sign the certification in Section V. An operator may be one of the following:

9VAC25-870-10. Definitions.

"Operator" means the owner or operator of any facility or activity subject to the Act and this chapter. In the context of stormwater associated with a

large or small construction activity, operator means any person associated with a construction project that meets either of the following two

criteria: (i) the person has direct operational control over construction plans and specifications, including the ability to make modifications to those

plans and specifications or (ii) the person has day-to-day operational control of those activities at a project that are necessary to ensure compliance

with a stormwater pollution prevention plan for the site or other state permit or VSMP authority permit conditions (i.e., they are authorized to direct

workers at a site to carry out activities required by the stormwater pollution prevention plan or comply with other permit conditions). In the context

of stormwater discharges from Municipal Separate Storm Sewer Systems (MS4s), operator means the operator of the regulated MS4 system.

"Owner" means the Commonwealth or any of its political subdivisions including, but not limited to, sanitation district commissions and authorities,

and any public or private institution, corporation, association, firm or company organized or existing under the laws of this or any other state or

country, or any officer or agency of the United States, or any person or group of persons acting individually or as a group that owns, operates,

charters, rents, or otherwise exercises control over or is responsible for any actual or potential discharge of sewage, industrial wastes, or other

wastes or pollutants to state waters, or any facility or operation that has the capability to alter the physical, chemical, or biological properties of

state waters in contravention of § 62.1-44.5 of the Code of Virginia, the Act and this chapter.

"Person" means any individual, corporation, partnership, association, state, municipality, commission, or political subdivision of a state,

governmental body, including a federal, state, or local entity as applicable, any interstate body or any other legal entity.

B. May we transmit correspondence electronically? If you choose YES to this question and provide an email address in Section I. A., all

correspondence, forms, invoices and notifications will be transmitted by email to the operator. This will also give the operator the ability to pay by

credit card and to receive permit coverage approval letters immediately upon permit approval.

Section II. Construction Activity Information.

A. A site map indicating the location of the existing or proposed land-disturbing activities, the limits of land disturbance, construction entrances

and all water bodies receiving stormwater discharges from the site must be included with the submittal of this form. Aerial imagery maps or

topographic maps showing the required items are acceptable. Plan sheet sized site maps are not required. Please consult your VSMP authority if

you have additional questions regarding site map requirements.

B. Construction Activity Name and location. Provide a descriptive project name (it is helpful to use the same naming convention as listed on the

Stormwater Management plans), 911 street address (if available), city/county of the construction activity, and the 6-digit latitude and longitude in

decimal degrees format for the centroid, main construction entrance or start and end points for linear projects (i.e. 37.1234N/-77.1234W).

C. Acreage totals for all land-disturbing activities, on- and off-site, to be included under this permit. Acreages are to be reported to the nearest

one-hundredth acre (two decimal places; i.e. 1.15 acres). Provide the total acreage of the primary development site as approved on the

Stormwater Management Plans and the primary on-site estimated acreage to be disturbed by the construction activity as approved under the

Erosion and Sediment Control Plans. The off-site estimated area to be disturbed is the sum of the disturbed acreages for all off-site support

activities to be covered under this general permit. Do not include the off-site acreage totals in the primary, on-site total and estimated disturbed

acreage totals. Permit fees are calculated based on your disturbed acreage total for all on- and off-site areas being disturbed under this permit

coverage (the sum of all on-site and off-site disturbed acreages).

D. Property owner status. The status of the construction activity property owner. Any property not owned by a government entity or agency (i.e.

federal, state or local governments) is PRIVATE.

CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS

PLEASE DO NOT PRINT OR SUBMIT

Rev 11/2020 PAGE 5 | 6

E. Nature of the construction activity description. Choose the designation that best describes the post-construction use of this project (you may

choose more than one). (i.e. Residential, Commercial, Industrial, Agricultural, Environmental, Educational, Oil and Gas, Utility, Transportation,

Institutional, etc.). Describe the post-construction use of the project (i.e. Commercial – one new office building and associated parking and

utilities; Transportation – Linear roads, sidewalks and utilities; Agricultural – 3 Poultry Houses, etc.).

F. Municipal Separate Storm Sewer System (MS4) name(s) if discharging to a MS4. If stormwater is discharged through a MS4 (either partially or

completely), provide the name of the MS4(s) that will be receiving water from this construction activity. The MS4 name is typically the town, city,

county, institute or federal facility where the construction activity is located.

G. Estimated project dates. Provide the estimated project start date and completion date in Month/Day/Year or MM/DD/YYYY format (i.e.

07/30/2019).

H. Is this construction activity is part of a larger common plan of development or sale? "Common plan of development or sale" means a contiguous

area where separate and distinct construction activities may be taking place at different times on different schedules per 9VAC25-870-10.

Definitions. I.e. a subdivision, commercial development, business park, etc.

I. 6th Order Hydrologic Unit Code (HUC) and associated Receiving Water Name(s). Provide all 6th order HUCs and receiving waterbody names, for

the primary site and any Off-site areas included under this permit coverage, that could potentially receive stormwater runoff discharging from this

activity. The HUC can be either a 12-digit number (i.e. 0208010101) or 2-letter, 2-number code (i.e. JL52). Include additional HUCs or receiving

waters on a separate page. You may utilize DEQ’s web-based GIS application, VEGIS, to obtain this information.

 VEGIS application link: DEQ's VEGIS Mapping Application

 Instructions for utilizing DEQ’s VEGIS application link: CGP-GIS_HUC Instructions

Section III. Off-site Support Activity Location Information.

This general permit also authorizes stormwater discharges from support activities (e.g., concrete or asphalt batch plants, equipment staging yards,

material storage areas, excavated material disposal areas, borrow areas) located on-site or off-site provided that (i) the support activity is directly

related to a construction activity that is required to have general permit coverage; (ii) the support activity is not a commercial operation, nor does

it serve multiple unrelated construction activities by different operators; (iii) the support activity does not operate beyond the completion of the

construction activity it supports; (iv) the support activity is identified in the Registration Statement at the time of general permit coverage; (v)

appropriate control measures are identified in a SWPPP and implemented to address the discharges from the support activity areas; and (vi) all

applicable state, federal, and local approvals are obtained for the support activity.

Off-site activity name and location information. Provide a descriptive off-site project name, 911 street address (if available), construction entrance

location (address or decimal degrees coordinates and description), city/county and the 6-digit latitude and longitude in decimal degrees (i.e.

37.1234N,-77.1234W) of all off-site support activities. Indicate whether the off-site support activity will be covered under this general permit or a

separate VPDES permit.

If excavated material (i.e., fill) will be transported off-site for disposal, the name and physical location address, when available, of all off-site

excavated material disposal areas including city or county; 6-digit latitude and longitude in decimal degrees (i.e. 37.1234N,-77.1234W) and the

contents of the excavated material.

List additional off-site areas to be included under this permit coverage on a separate page. Off-site areas not included on this registration will need

to obtain coverage under a separate VPDES permit.

Section IV. Other Information.

A. A stormwater pollution prevention plan (SWPPP) must be prepared prior to submitting the Registration Statement per 9VAC25-880. See

9VAC25-880-70. Part II. of the General Permit for the SWPPP requirements.

B. If the Erosion and Sediment Control Plan for the estimated area to be disturbed listed in Section II. C. has been submitted to the VESC Authority

for review and plan approval, choose YES. If you are submitting this application to reissue an existing permit coverage, please provide the date that

the VESC Authority approved the Erosion and Sediment Control Plan for the estimated area to be disturbed.

C. If land disturbance has commenced, choose YES. "Land disturbance" or "land-disturbing activity" means a man-made change to the land surface

that may result in soil erosion or has the potential to change its runoff characteristics, including construction activity such as the clearing, grading,

excavating, or filling of land per §62.1-44.15:24. Definitions.

D. If this project is using approved Annual Standards and Specifications (AS&S), attach the completed AS&S Entity Form.

If the AS&S Entity is different from the operator identified in Section I. A., list the AS&S Entity Name. The AS&S entity is the entity or agency that

holds the approved annual standards & specification. Please indicate if this project is also requesting a plan waiver.

 AS&S Entity Form link: Annual Standards and Specifications Entity Information Form

CONSTRUCTION GENERAL PERMIT (VAR10) REGISTRATION STATEMENT 2019 INSTRUCTIONS

PLEASE DO NOT PRINT OR SUBMIT

Rev 11/2020 PAGE 6 | 6

E. Billing information. If the person or entity responsible for billing/invoicing is different from the operator, please complete this section. If they

are the same, leave this section blank.

Section V. Certification.

A properly authorized individual associated with the operator identified in Section I. A. of the Registration Statement is responsible for certifying

and signing the Registration Statement. A person must physically sign the certification, a typed signature is unacceptable. State statutes provide

for severe penalties for submitting false information on the Registration Statement. State regulations require that the Registration Statement be

signed as follows per 9VAC25-880-70 Part III. K. 1.:

a. For a corporation: by a responsible corporate officer. For the purpose of this part, a responsible corporate officer means:

(i) A president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who

performs similar policy-making or decision-making functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make

management decisions that govern the operation of the regulated facility including having the explicit or implicit duty of making major

capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term compliance with

environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather

complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or

delegated to the manager in accordance with corporate procedures.

b. For a partnership or sole proprietorship: by a general partner or the proprietor, respectively.

c. For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected official. For purposes of this part,

a principal executive officer of a public agency includes:

(i) The chief executive officer of the agency, or

(ii) A senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency.

Section VI. Submittal Instructions.

Submit this form to the VSMP Authority that has jurisdiction for your construction activity. The VSMP Authority may be either DEQ or your locality

depending on the location and type of project. If your project is under the jurisdiction of a Local VSMP Authority, please contact the locality for

additional submittal instructions. A blank area is provided for the Local VSMP Authority’s mailing address.

Who is the VSMP Authority for my project? DEQ or the locality?

 DEQ: DEQ is the VSMP Authority and administers permit coverage for land-disturbing activities that are:

 within a locality that is not a VSMP Authority;

 owned by the State or Federal government; or

 utilizing approved Annual Standards and Specifications.

 The Locality: The local government (locality) is the VSMP Authority and administers permit coverage for all other projects not covered by DEQ

as listed above. For these projects, please submit permit forms directly to the Local VSMP Authority. A list of Local VSMP Authorities is

available on DEQ’s website here: Local VSMP Authority List.

DEQ'S CONSTRUCTION GENERAL PERMIT WEBSITE

www.deq.virginia.gov/Programs/Water/StormwaterManagement/VSMPPermits/ConstructionGeneralPermit.aspx

Email the completed and signed form to:

constructiongp@deq.virginia.gov

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