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TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 1 of 7 USVI Department of Planning and Natural Resources Notice of Intent (NOI) for Stormwater Discharges Associated with CONSTRUCTION ACTIVITY under the TPDES VI Construction General Permit (VI CGP) No. VIGSA0000 Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section II of this form requests authorization to discharge pursuant to the TPDES VI CGP identified in Section I of this form. Submission of this NOI also constitutes your notice to VIDPNR that the operator identified in Section II of this form meets the eligibility requirements of Parts 1.1 and 1.2 of the VI CGP for the project/site identified in Section III of this form. Permit coverage is required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in Part 8 of the VI CGP. 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 for assistance. I. Permit Tracking Number (VIDPNR Use Only) 1. TPDES Permit Tracking No. (this number will be assigned to you) II. Operator Information 1. Name _____________________________________________________________________________________ 2. IRS Employer Idenitification Number (EIN): _____________________________________ 3. Mailing Address _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Phone (_____)_______________ 5. Fax: (_____)_______________ 6. Email _____________________________________________________________________________________ 7. Point of Contact (Name): ______________________________________________________________________ III. Project/Site Information 1. Project/Site Name : _______________________________________________________________________ 2. Project/Site Physical Address __________________________________________________________________________ __________________________________________________________________________ 3. Latitude Longitude (Source of lat/long): ________________ 4. Estimated area of your project/site to be disturbed (to the nearest quarter acre): ________ acres TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 2 of 7 5. Estimated Project Start Date: / / Estimated Project Completion Date: / / 6. Are you requesting coverage under this NOI as a “federal operator as defined in Appendix A? 7. Have earth-disturbing activities commenced on your project/site? If yes, is your project an “emergency-related project”? 8. Have stormwater discharges from your project/site been covered previously under a TPDES permit? If yes, provide the permit number of the previous permit: __________________________ IV. Discharge Information 1. Does your project/site discharge stormwater into a Municipal Separate Storm Sewer System (MS4)? 2. Are there any surface waters within 50 feet of your project’s earth disturbances? 3. Receiving Waters and Wetlands Information (attach a separate list if necessary): Provide the names of any impaired waters to which you discharge and the pollutant(s) for which they are impaired Provide the names of any waters to which you discharge for which there is an VIDPNR approved or established TMDL, the name of the TMDL, and the pollutant(s) for which there is a TMDL Provide the name(s) of the first surface water that received stormwater directly from your site and/or from the MS4: Surface water name: Pollutant(s) causing the impairment: Surface water name: TMDL name: Pollutant(s) for which there is a TMDL: Impaired Waters Describe the methods you used to complete the above table: ___________________________________________________ ____________________________________________________________________________________________________ Are any of the surface waters to which you discharge designated by VIDPNR under its antidegradation policy as a Class A water? (See Appendix F). If yes, name(s) of the receiving water(s): ______________________________________________ TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 3 of 7 V. Chemical Treatment Information 1. Will you use polymers, flocculants, or other treatment chemicals at your construction site? If yes, will you use cationic treatment chemicals at your construction site*? If yes, have you been authorized to use cationic treatment chemicals by VIDPNR in advance of filing your NOI*? If you have been authorized to use cationic treatment chemicals by VIDPNR, attach a copy of your authorization letter and include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. Please indicate the treatment chemicals that you will use: ________________________________________________________ ______________________________________________________________________________________________________ *Note: You are ineligible for coverage under this permit unless you notify VIDPNR in advance and VIDPNR authorizes coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. VI. Storm Water Pollution Prevention Plan (SWPPP) Information Has the SWPPP been prepared in advance of filing this NOI? SWPPP Contact Information 1. Contact Name _____________________________________________________________________________________ 2. Organization Name _________________________________________________________________________________ 4. Phone (_____)_______________ 5. Fax: (_____)_______________ 6. Email _____________________________________________________________________________________ VII. Endangered Species Protection Using the instructions in Appendix C of the VI CGP, under which criterion listed in Appendix C are you eligible for coverage under this permit (check only one box)? A B C D E F Provide a brief summary of the basis for criterion selection listed in Appendix C (e.g., communication with VIDPNR-F&W, US Fish and Wildlife or National Marine Fisheries Services, specific study): __________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ If you select criterion B, provide the Tracking Number from the other operator’s notification of authorization under this permit: If you select criterion C, you must attach a copy of your site map (See Part 7.2.6 of the permit), and you must answer the following questions: What federally-listed species or federally-designated critical habitat(s) are located in your “action area”: _________ ___________________________________________________________________________________________ What locally-listed species or locally-designated critical habitat(s) are located in your “action area”: _____________ ___________________________________________________________________________________________ TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 4 of 7 What is the distance between your site and the listed species or critical habitat(s) in miles: ____________________ If you select criterion D, E, or F, attach copies of any letters or other communications between you and VIDPNR-F&W, the US Fish and Wildlife or the National Marine Fisheries Services VIII. Historic Preservation Are you installing any stormwater controls as described in Appendix D that require subsurface earth disturbance? (as found in Appendix D, Step 1) If yes, have prior surveys or evaluations conducted on the site already determined historic properties do not exist, or that prior disturbances have precluded the existence of historic properties? (Appendix D, Step 2) If no, have you determined that your installation of subsurface earth-disturbing stormwater controls will have no effect on historic properties? (Appendix D, Step 3) If no, did the SHPO respond to you within the 15 calendar days to indicate whether the subsurface earth disturbances caused by the installation of stormwater controls affect historic properties? (Appendix D, Step4) If yes, describe the nature of their response: Written indication that adverse effects to historic properties from the installation of stormwater controls can be mitigated by agreed upon actions No agreement has been reached regarding measures to mitigate effects to historic properties from the installation of stormwater controls Other: ____________________________________________________________ __________________________________________________________________ TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 5 of 7 IX. 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: __________________________________________________ NOI Preparer (Complete if NOI was prepared by someone other than the certifier) Preparer’s Name: _______________________________________________________________ Organization: _______________________________________________________________ Phone: _______________________________________________________________ Email: _______________________________________________________________ TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 6 of 7 Instructions for Completing the Notice of Intent (NOI) for Stormwater Discharges Associated with CONSTRUCTION ACTIVITY under the TPDES VI Construction General Permit (VI CGP) No. VIGSA0000 Who Must File A Notice of Intent (NOI) Form. The Clean Water Act, 33 USC § 1251 et. seq., (the “CWA”), 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 (2006 & Supp. 2011) et seq. (the “Act”) prohibits stormwater discharges from certain construction activities to waters of the United States Virgin Islands unless authorized under a Territorial Pollutant Discharge Elimination System (TPDES) permit. Operator of construction sites where one or more acres are disturbed, smaller sites that are part of a larger common plan of development or sale where there is a cumulative disturbance of at least one acre, or any other site specifically designated by the Commissioner, must submit an NOI to obtain coverage under a TPDES general permit. Each person, firm, public organization, or any other entity that meets either of the following criteria must file this form: (1) they have operational control over construction plans and specifications, including the ability to make modifications to those plans and specifications; or (2) they have day-to-day operational control of those activities at the project necessary to ensure compliance with the permit conditions. 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 for project located on St. Croix and (340) 774-3320 for projects located on St. Thomas or St. John. When To File NOI Form. Do not file your NOI until you have obtained and thoroughly read a copy of the VI CGP. A copy of the VI CGP can be obtained by contacting DPNR-DEP-WPC at (340) 773-1082 for project located on St. Croix and (340) 774-3320 for projects located on St. Thomas or St. John. The VI CGP 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 CGP once you have obtained coverage so that you can comply with the implementation requirements of the permit. Where To File NOI Form. NOIs must be sent to one of the following addresses, corresponding with the island on which the construction activity covered is located: STX: VIDPNR Water Pollution Control Program ATTN: TPDES Program 45 Mars Hill Frederiksted, VI 00840 STT & STJ: VIDPNR Water Pollution Control Program ATTN: TPDES Program 8100 Lindberg Bay, Suite #61 Cyril E King Airport, Terminal Building, Second 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 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. Fees Currently, there are no associated fees required to be paid to VIDPNR upon application for a new permit coverage or renewal. Notification will be made should regulation be amended to include fees. Section I: 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 CGP Coverage Number, and will be used as a tracking number for your coverage under the VI CGP in the future. Section II: Operator Information 1. Provide the legal name of the person, firm, public organization or any other public entity that operates the project described in this application. Refer to Appendix A for a definition of “operator”. 2. Provide the Operator’s EIN (also referred to as the taxpayer ID). If there is none, enter “NA” in the space provided. 3. Provide the operator’s mailing address here. Correspondence will be sent to this address. 4. Provide the telephone number of the line at the facility. 5. Provide a fax number (if one exists) 6. Provide an email address available to receive electronic correspondence. 7. Provide the name of the point of contact for the Operator. Section III: Project/Site Information 1. Provide the project/site’s name. 2. Provide the project/site’s physical address here. Do not use a P.O. Box. 3. Provide latitude/longitude. For consistency, VIDPNR requests you take measurements from the approximated center of your project/site, or the point of discharge of stormwater from your site. 4. Enter the estimated area land that will be disturbed, in acres. Estimate to the nearest quarter acre. 5. Provide the estimated project start and end dates. 6. Indicate whether you are seeking coverage under this permit as a “federal operator” as defined in Appendix A. 7. Indicate whether earth-disturbing activities have started, and if it is emergency related. 8. Indicate whether earth-disturbing activities have already commenced on your project/site. If earth-disturbing activities have commenced on your site because stormwater discharges from the site have been previously covered under a TPDES permit, you must provide the permit number Section IV: Discharge Information 1. Indicate whether you discharge to an MS4 or not. TPDES VI CGP – VIGSA0000 - Notice Of Intent (NOI) Form Page 7 of 7 2. Indicate whether there are surface waters within 50 feet of your project’s earth disturbances or not. 3. You must specify the names of any surface waters that receive stormwater directly from your site and/or from the MS4 to which you discharge. You must also specify the names of any surface waters that you discharge to that are listed as ”impaired” as defined in Appendix A, including any waters for which there is an approved or established TMDL, and the pollutants for which the water is impaired or for which there is a TMDL. This information will be used to determine if the site discharges to an impaired waterbody, which triggers additional requirements in Part 3.2.2 of the permit. Applicants must specify which method they used to determine whether or not their site discharges to impaired waters. Also, if a TMDL has been approved or established, identify the title or reference of the TMDL document. 4. Indicate whether any of the surface waters to which you discharge designated by VIDPNR under its antidegradation policy as a Class A water. Section V: Chemical Treatment Information Indicate whether the site will use polymers, flocculants, or other treatment chemicals. Indicate whether the site will employ cationic treatment chemicals. If the answer is “yes” to either question, indicate which chemical(s) you will use. Note that you are not eligible for coverage under this permit to use cationic treatment chemicals unless you notify VIDPNR in advance and VIDPNR authorizes coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. If you have been authorized to use cationic treatment chemicals by VIDPNR, attach a copy of your authorization letter and include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to a violation of water quality standards. Examples of cationic treatment chemicals include, but are not limited to: cationic polyacrylamide (C-PAM), PolyDADMAC (POLYDIALLYLDIMETHYLAMMONIUM CHLORIDE), and chitosan. Section VI: Storm Water Pollution Prevention Plan (SWPPP) Information All sites eligible for coverage under this permit are required to prepare a SWPPP in advance of filing the NOI, in accordance with Part 7. Indicate whether the SWPPP has been prepared in advance of filing the NOI. Indicate the contact information (name, organization, phone, fax, and email) for the person who is the SWPPP contact for this project. Section VII: Endangered Species Protection Using the instructions in Appendix C, indicate under which criterion (i.e., A, B, C, D, E, or F) of the permit the applicant is eligible with regard to protection of federally and locally listed endangered and threatened species and designated critical habitat. A description of the basis for the criterion selected must also be provided. If criterion B is selected, provide the Tracking Number for the other operator who had previously certified their eligibility under criterion A, C, D, E, or F. The Tracking Number was assigned when the operator received coverage under this permit, and is included in the notice of authorization. If criterion C is selected, you must attach copies of your site map. See Part 7.2.6 of the permit for information about what is required to be in your site map. You must also specify the federally- and locally-listed species or federally- and locally- designated critical habitat(s) that are located in the “action area” of the project, and provide the distance between the construction site and any listed endangered species or their critical habitat. If criterion D, E, or F is selected, attach copies of any communications between you and VIDPNR, and/or the U.S. Fish and Wildlife Service and National Marine Fisheries Service. Section VIII: Historic Preservation Use the instructions in Appendix D to complete the questions on the NOI form regarding historic preservation. Section IX: Certification Information Certification statement and signature (see Section 11 of Appendix H of the VI CGP 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. If the NOI was prepared by someone other than the certifier (for example, if the NOI was prepared by the facility SWPPP contact or a consultant for the certifier’s signature), include the name, organization, phone number and email address of the NOI preparer.