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VI PGP FEE PAYMENT 1 DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION WATER CONTROL PROGRAM USVI Territorial Pollution Discharge Elimination System (TPDES) Pesticide General Permit (VI PGP) Application Fees and Annual Discharge Fees for Discharges from the Application of Pesticides This form is used when paying application and annual discharge fees related to a Notice of Intent for coverage under the pesticide general TPDES permit. 12 VIRR § 184-35(b) requires permit applicants and permittees to pay: ▪ an application fee when applying for a new or renewed TPDES permit; • an annual discharge fee each year (or partial year) in which the permit is in effect; and • a special fee when applying for certain modifications to an existing permit. I. FEE PAYMENT: After you have completed section IV below (Determining Your Fee Payment) complete this section to indicate the type of fee you are paying and the amount. I am paying (check one): ☐ an application fee because I am applying for new or renewed coverage under the PGP ☐ an annual discharge fee ☐ a special application fee to modify coverage under the PGP The amount of my fee is [enter number determined below in section IV, Determining Your Fee Payment]. $_______________ Submit your fee payment and this completed form by either hand delivering them to DPNR-DEP before going to the DPNR Cashier's office OR by mailing them to one of the following addresses: DPNR-DEP DPNR-DEP ATTN: WPC Program ATTN: WPC Program CW Turnbull Public Library #45 Mars Hill 4607 Tutu Park Mall Frederiksted, VI 00840 St. Thomas, VI 00802 Make checks payable to: Department of Planning and Natural Resources DPNR will send receipts for payments submitted by mail. II. PERMIT TRACKING TPDES Permit Tracking Number (if known) III. OPERATOR/PERMITTEE INFORMATION Operator Name IRS Employer Identification Number (EIN) Phone VI PGP FEE PAYMENT 2 Email Contact Name IV. DETERMINING YOUR FEE PAYMENT: Check the box for the type of fee you are paying (new permit or permit renewal, special application fee for permit modification, or annual discharge fee) and then follow the directions in that section to determine your fee. Check the appropriate fee and enter the information requested. ☐ APPLICATION FEE FOR NEW PERMIT OR PERMIT RENEWAL Due when you submit your Notice of Intent. ☐ I am filing a Notice of Intent for coverage under the Pesticide General Permit. This is your Application Fee. Enter this amount in Section I above. $250.00 ☐ I am a private school, municipality, or church or other religious organization, and I am filing a Notice of Intent for coverage under the Pesticide General Permit. This is your Application Fee. Enter this amount in Section I above. $37.50 ☐ I am a public school. Enter $0 in Section I above. $0 ☐ ANNUAL DISCHARGE FEE: Effective and due on October 1, 2020, an annual discharge fee is required for each pesticide permittee who filed a Notice of Intent for coverage under the Pesticide General Permit. Each year after, the annual discharge fee is due on March 31. For the first year you are covered by a permit, if the coverage starts after February 1, the annual fee is due 60 days after the date coverage starts. ☐ Full year fee – I filed a Notice of Intent for coverage under the Pesticide General Permit that covers the entire current calendar year. This is your Annual Discharge Fee. Enter this amount in Section I above. $500.00 ☐ Partial year fee – I filed a Notice of Intent for coverage under the Pesticide General Permit that covers months of the current calendar year. If the number to the right does not fill in automatically, enter the amount that is $500 times the number of months you are covered under the PGP and then divide by 12. This is your Annual Discharge Fee. Enter this amount in Section I above. ☐ I am a private school, municipality or church or other religious organization, and I filed a Notice of Intent for coverage under the Pesticide General Permit that covers the entire current calendar year. This is your Annual Discharge Fee. Enter this amount in Section I above. $75.00 ☐ I am a private school, municipality or church or other religious organization, and filed a Notice of Intent for coverage under the Pesticide General Permit that covers months of the current calendar year. If the number to the right does not fill in automatically, enter the amount that is $75 times the number of months you are covered under the PGP and then divide by 12. This is your Annual Discharge Fee. Enter this amount in Section I above. ☐ I am a public school. Enter $0 in Section I above. $0 0 0 Select Select VI PGP FEE PAYMENT 3 ☐ SPECIAL APPLICATION FEE FOR PERMIT MODIFICATIONS: Due when you apply to modify your permit at any time other during permit renewal. ☐ I am making a minor modification (as set forth in 12 VIRR 184-75 (see the bottom of this form). Enter $0 in Section I above. $0 ☐ I am making a modification to my coverage under the PGP that is not a minor modification and that will increase my permitted capacity. This is your Special Application Fee. Enter this amount in Section I above. $250.00 ☐ I am making a modification to my coverage under the PGP that is not a minor modification and that will not increase my permitted capacity. This is your Special Application Fee. Enter this amount in Section I above. $125.50 ☐ I am a private school, municipality, or church or other religious organization. I am making a modification to my coverage under the PGP that is not a minor modification and that will increase my permitted capacity. This is your Special Application Fee. Enter this amount in Section I above. $37.50 ☐ I am a private school, municipality, or church or other religious organization. I am making a modification to my coverage under the PGP that is not a minor modification and that will not increase my permitted capacity. This is your Special Application Fee. Enter this amount in Section I above. $18.75 V. CERTIFICATION I certify under penalty of law that this document and all attachments (if any) 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 FOR INTERNAL DPNR USE ONLY: Payment received by: ☐ mail ☐ in person ☐ Payment of $__________ sent to Cashier’s Office by ______________________ on ____________ ☐ Receipt sent to permittee by _______________________________ on ______________ ☐ Fee determination verified by ______________________________ on ______________ ☐ Fee payment recorded in data base by _______________________ on ______________ ☐ Form filed by ____________________________________________ on __________________ VI PGP FEE PAYMENT 4 Minor modifications are defined in 12 VIRR §184-75 in relevant part as modifications that only: (a) Correct typographical errors; * * * (d) Allow for a change in ownership or operational control of a facility where the Director determines that no other change in the permit is necessary, provided that a written agreement containing a specific date for transfer of permit responsibility, coverage, and liability between the current and new permittees has been submitted to the Director.