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VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 1 of 9 USVI Department of Planning and Natural Resources NOTICE OF INTENT (NOI) FORM for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the 2017 TPDES Multi-Sector General Permit (VI MSGP) No. VIR050000 Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to the 2017 TPDES Stormwater Multi-Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that the operator identified in Section C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI. A. Permit Tracking Number (VIDPNR Use Only) 1. TPDES Permit Tracking No. B. Permit Information 1. Are you a new discharger or a new source as defined in Appendix A of the VI MSGP? YES NO (If yes, skip to Part C). 2. If you are not a new discharger or a new source, have stormwater discharges from your facility been covered previously under an NPDES permit? YES NO 3. If yes, provide the TPDES permit tracking number if you had coverage under EPA’s 2012 VI MSGP or the TPDES permit number if you had coverage under a VI DPNR individual permit: TPDES Permit Tracking No. C. Facility Operator Information 1. OPERATOR Information: Operator Name _______________________________________________________________________________ Mailing Address _______________________________________________________________________ _______________________________________________________________________ Phone (_____)_______________ Fax: (_____)_______________ Email ____________________________________________________________________________________ 2. OPERATOR Point of Contact Information: First, Middle Initial, Last Name: ___________________________________________________________________ Title: _______________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 2 of 9 3. NOI Preparer Information (Complete if NOI was prepared by someone other than the certifier): First, Middle Initial, Last Name: ___________________________________________________________________ Organization: _______________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ D. Facility Information 1. Facility Name _____________________________________________________________________________ 2. Facility Physical Address _____________________________________________________________________________ _____________________________________________________________________________ 3. 4. Estimated area of industrial activity at your site exposed to stormwater: ________ acres (to the nearest quarter acre) 5. Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A? YES NO 6. What is the ownership type of the facility? Federal Facility (US Gov’t) Municipality State Government School District Privately Owned Facility Corporation District Mixed Ownership 7. Sector Specific Information Identify the 4-digit Standard Industrial Classification (SIC) code or 2-letter Activity Code that best represents the products produced or services rendered for which your facility is primarily engaged, as defined in the MSGP: Primary SIC Code: OR Primary Activity Code: Sector Subsector Identify the applicable Part(s) and subsector(s) of industrial activity, including co-located industrial activity, for which you are requesting permit coverage: a.Sector Subsector b. Sector Subsector c. Sector Subsector d.Sector Subsector e. Sector Subsector f. Sector Subsector Is your site presently inactive and unstaffed? YES NO If yes, is your site expected to be inactive and unstaffed for the entire permit term? YES NO If your site is expected to become active at some time during this permit cycle, then indicate the length of time that you expect your facility to be inactive and unstaffed:_________________________________________________ VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 3 of 9 E. Discharge Information 1. By indicating “Yes” below, I confirm that I understand that the VI MSGP only authorizes the allowable stormwater discharges in Part 1.1.2 and the allowable non-stormwater discharges listed in Part 1.1.3. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA section 402(k) by disclosure to EPA or VIDPNR after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the allowable stormwater and non-stormwater discharges listed in Parts 1.1.2 and 1.1.3 will be discharged, they must be covered under another NPDES permit. YES 2. Federal Effluent Limitation Guidelines Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines? YES NO If yes, which effluent limitation guidelines apply to your stormwater discharges? 40 CFR Part/Subpart Eligible Discharges Affected MSGP Sector New Source Date Check if Applicable Part 411, Subpart C Runoff from material storage piles at cement manufacturing facilities E 2/20/1974 Part 418 Subpart A Runoff from phosphate fertilizer manufacturing facilities that comes into contact with any raw materials, finished product, by- products or waste products (SIC 2874) C 4/8/1974 Part 423 Coal pile runoff at steam electric generating facilities O 11/19/1982 10/8/19741 Part 429, Subpart I Discharges resulting from spray down or intentional wetting of logs at wet deck storage areas A 1/26/1981 Part 436, Subpart B, C, or D Mine dewatering discharges at crushed stone mines, construction sand and gravel mines, or industrial sand mines J N/A Part 443, Subpart A Runoff from asphalt emulsion facilities D 7/28/1975 Part 445, Subparts A & B Runoff from hazardous waste and non-hazardous waste landfills K, L 2/2/2000 1NSPS promulgated in 1974 were not removed via the 1982 regulation; therefore wastewaters generated by Part 423-applicable sources that were New Sources under the 1974 regulations are subject to the 1974 NSPS. 3. Receiving Waters Information: (Attach a separate list if necessary) List all of the stormwater outfalls from your facility. Each outfall must be identified by a unique 3-digit ID (e.g., 001, 002). Also provide the latitude and longitude in degrees decimal for each outfall. For each outfall, provide the following receiving water information: Provide the name of the first water of the U.S. that receives stormwater directly from the outfall and/or from the MS4 that the outfall discharges to: If the receiving water is impaired (on the CWA 303(d) list), list the pollutants that are causing the impairment: If a TMDL been completed for this receiving waterbody, providing the following information: Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 4 of 9 Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude Outfall ID TMDL Name and ID: Pollutant(s) for which there is a TMDL: Latitude Longitude VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 5 of 9 F. Stormwater Pollution Prevention Plan (SWPPP) Information 1. Has the SWPPP been prepared in advance of filing this NOI, as required? YES NO 2. SWPPP Contact Information: Name _____________________________________________________________________________________ Mailing Address _____________________________________________________________________________________ _____________________________________________________________________________________ Phone (_____)_______________ 4. Fax: (_____)_______________ Email _____________________________________________________________________________________ 3. SWPPP Availability: Your current SWPPP must be made available through one of the following two options. Select one or both of the options and provide the required information*: * Note: You are not required to post any confidential business information (CBI) or restricted information (as defined in Appendix A) (such information may be redacted), but you must clearly identify those portions of the SWPPP that are being withheld from public access. Option 1: Maintain a current copy of your SWPPP on an Internet page (Universal Resource Locator or URL). Provide the web address URL:_____________________________________________________________________________ Option 2: Provide the full SWPPP with this NOI Form. G. Endangered Species Protection 1. Using the instructions in Appendix D of the VI MSGP, under which endangered species criterion listed in Part 1.1.4.5 are you eligible for coverage under this permit (only check 1 box)?* A B C D E *Note: After you submit your NOI and before your NOI is authorized, VIDPNR may notify you if any additional controls are necessary to ensure your discharges have no likely adverse affects on listed species and critical habitat. 2. Provide a brief summary of the basis for the criterion selected in Appendix D (e.g., communication with VIDPNR-F&W, U.S. Fish and Wildlife Service or National Marine Fisheries Service to determine no species in action area; implementation of controls approved by VIDPNR and the Services): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 3. If you select criterion B, provide the TPDES ID from the other operator’s NOI authorized under this permit: _______________ 4. If you select criterion C, you must answer the following questions: a. What federally or locally-listed species or designated critical habitat are located in your “action area”: _________________________________________________________________________________________________ _________________________________________________________________________________________________ VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 6 of 9 b. Using the Appendix D worksheet, check which of the following is applicable to your facility and answer any corresponding questions: I submitted my completed Criterion C Eligibility Form to VIDPNR at least 30 days prior to submitting this NOI and agree to implement any additional measures that were determined by VIDPNR to be necessary to ensure that my discharges and/or discharge-related activities will not have likely adverse affects on listed species and critical habitat. Date your Criterion C Eligibilty Form was sent to EPA: Describe any VIDPNR-approved measures you will implement to ensure no likely adverse affects on listed species and critical habitat: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and have not been notified of any additional measures necessary to ensure no likely adverse affects on listed species and critical habitat. Date your Criterion C Eligibility Form was sent to EPA: 5. If you select criterion D or E, you must attach copies of any letters or other communications with the VIDPNR-F&W, U.S. Fish and Wildlife Service or National Marine Fisheries Service. H. Historic Preservation 1. Has your site be subject to a historical study (I.e. Phase 1, 2, 3 historical study)? YES NO If yes, provide the name of the study, the date performed, and who performed it:____________________________________ ____________________________________________________________________________________________________ Additionally, provide a copy of that report with this NOI Form. 2. Using the instructions in Appendix E of the VI MSGP, under which historic properties preservation criterion listed in Part 1.1.4.6 are you eligible for coverage under this permit (only check 1 box)? A B C D VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 7 of 9 I. 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 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: ______________ Email: __________________________________________________ VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 8 of 9 Instructions for Completing the Notice Of Intent (NOI) For Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the VIDPNR TPDES Multi-Sector General Permit (VI MSGP) Who Must File A Notice of Intent (NOI) Form. The Clean Water Act, 33 USC §1251 et. seq., (hereafter referred to as the “CWA” or the “Act”), as amended by the Water Quality Act of 1987, P.L. 100-4, and the Virgin Islands Water Pollution Control Act, 12 V.I. CODE ANN. §184 (1998 & Supp. 2004) et. seq. prohibit operators of industrial activities from discharging stormwater to waters of the United States Virgin Islands unless authorized under a Territorial Pollutant Discharge Elimination System (TPDES) permit. The operator of such a facility can obtain coverage under the TPDES Virgin Islands Multi-Sector General Permit (VI MSGP) by submitting a completed NOI if you operate a facility:  that discharges stormwater associated with industrial activities, identified in Appendix C of the VI MSGP,  that meets the eligibility requirements in Part 1.1 of the permit,  that develops a stormwater pollution prevention plan (SWPPP) in accordance with Part 5 of the VI MSGP; and  that installs and implements control measures in accordance with Part 2 and Part 8 to meet numeric and non-numeric effluent limits. If you have questions about whether you need a permit under the TPDES Program, or if you need information about said program, contact DPNR-DEP-WPC at (340) 773-1082 in St. Croix or (340) 774-3320 in St. Thomas. One NOI must be submitted for each facility or site for which you are seeking permit coverage. You do not need to submit separate NOIs for each type of industrial activity present at your facility, provided your SWPPP covers all activities. Where To File NOI Form. NOIs must be submitted to VI DPNR at the office in the district where the facility operates, as follows: St. Croix Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 45 Mars Hill Frederiksted, VI 00841 St. Thomas Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 8100 Lindberg Bay, Ste. #61 Cyril E. King Airport Terminal Bldg., 2nd Floor St. Thomas, VI 00802 Please submit the original with a signature in ink – Do Not Send Copies. Also, faxed copies will not be accepted. Completing the Form Do not file your NOI until you have obtained and thoroughly read a copy of the VI MSGP. Obtain and read a copy of this form and a copy of the 2017 VI MSGP, viewable at http://dpnr.vi.gov/environmental-protection/water-pollution- control-program/. A copy of the VI MSPG can also be obtained by contacting DPNR-DEP-WPC at (340) 773-1082 in St. Croix or (340) 774-3320 in St. Thomas. The MSGP describes procedures to ensure your eligibility, prepare your SWPPP, install and implement appropriate stormwater control measures, and complete the NOI form questions – all of which must be done before you sign the NOI certification statement attesting to the accuracy and completeness of your NOI. You will also need a copy of the VI MSGP once you have obtained coverage so that you can comply with the implementation requirements of the permit. Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. Please submit original document with signature in ink - do not send a photocopied signature. Fees Fees are due on submittal of an application form, or modification of permit coverage. Annual fees are also due as applicable. See 12 VIRR §184-35 for exact fees due for your application/project. Section A: Permit Number. For VIDPNR use only. VIDPNR will assign a number to your application for use as a tracking ID. It will also function as your VI MSGP Coverage Number, and will be used as a reference number for your coverage under the VI MSGP in the future. Section B: Permit Information Note if you are a new discharger. If existing, provide previous/existing coverage number as reference. Section C: Facility Operator Information 1. Provide the operator’s official or legal name. Provide the operator’s mailing address here. Do not use a physical address, it must be able to receive mail. Provide the operator’s phone, fax and email contact information. 2. Provide the operator’s point of contact official or legal name and Title. Provide the operator’s point of contact mailing address here. Do not use a physical address, it must be able to receive mail. Provide the operator’s point of contact phone, fax and email contact information. 3. If the NOI was prepared by a third party, provide the preparer’s point of contact official or legal name and Organization. Provide the preparer’s point of contact phone, fax and email contact information. Section D: Facility Information 1. Provide the facility’s official or legal name. 2. Provide the facility physical location address here. 3. Provide latitude/longitude of the facility itself (central location approximately). 4. Enter the estimated area of industrial activity at your site exposed to stormwater, in acres. 5. Note if you are a federal operator 6. Ownership type must be noted here. 7. Note which SIC code applies to your facility. 8. Note if your site inactive, unstaffed, and if so, estimated length of time. VIDPNR Permit No: VIR050000 - Notice of Intent (NOI) Form Page 9 of 9 Section E: Discharge Information 1. Verify you understand the allowable discharges noted in the VI MSGP. 2. Federal Effluent Limitation Guidelines and Sector- Specific Requirements. a. Please review the VI MSGP to determine if you are subject to effluent limitation guidelines. b. The table reflects the VI MSGP, and those Sectors to which it applies. Please check those Sectors under which you fall. 3. List all your outfalls, their GPS points, and the receiving waters they eventually discharge into, including whether the waters are impaired or have established TMDLs. Section F: Stormwater Pollution Prevention Plan (SWPPP) Information 1. Note whether the SWPPP has been submitted with the NOI. 2. Provide the name of the person that will serve as a contact for VIDPNR on issues related to stormwater management at your facility. This person should be able to answer questions related to stormwater discharges, the SWPPP, and other issues related to stormwater permit coverage, or have immediate access to individuals with that knowledge. This person does not have to be the facility operator, but should have intimate knowledge of stormwater management activities at the facility. Provide the SWPPP contact’s mailing address here. Correspondence will be sent to this address. Provide the telephone number of the SWPPP contact. Provide a fax number (if one exists). Provide an email address of the SWPPP contact available to receive electronic correspondence. 3. Note if you provide a website to access your SWPPP, or if you will just submit a SWPPP with the NOI, and keep a physical copy of the SWPPP at the facility. Section G: Endangered Species Protection Based on the instruction provided in Appendix D of the VI MSGP, indicate which permit criterion (A,B,C,D, or E) listed in Part 1.1.4.5 you are using to satisfy your eligibility obligations for protection of endangered and threatened species, and designated critical habitat. Section H: Historic Preservation Based on the instruction provided in Appendix E of the VI MSGP, indicate which permit criterion (A, B, C, or D) listed in Part 1.1.4.6 of the MSGP you used to satisfy your eligibility obligations for protection of historic properties. Section I: Certification Certification statement and signature (see Section 11 of Appendix B of the MSGP for more information). Enter certifier’s printed name, title and email address. Sign and date the form. (CAUTION: An unsigned or undated NOI form will prevent the granting of permit coverage.) Territorial statutes provide for severe penalties for submitting false information on this application form. Territorial regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy 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 which 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 environmental 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; For a partnership or sole proprietorship: by a general partner or the proprietor; or For a municipal, State, Federal, or other public facility: by either a principal executive or ranking elected official. .