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VPDES GENERAL PERMIT REGISTRATION STATEMENT

FOR DISCHARGES FROM PETROLEUM CONTAMINATED SITES,

GROUNDWATER REMEDIATION AND HYDROSTATIC TESTS (VAG83)

Please Type or Print All Information

1. Legal Name of Facility ________________________________________________________________

2. Facility Address or Location ____________________________________________________________

City _____________________________________ State ___________________ Zip _____________

Phone ___________________________ Email Address _____________________________________

3. Facility Owner Name _________________________________________________________________

Owner Address

______________________________________________________________________________________________

City _____________________________________ State ___________________ Zip _____________

Phone ___________________________ Email Address _____________________________________

4. Nature of the business conducted at the facility ______________________________________________

5. Type of petroleum or natural gas products, or chlorinated hydrocarbon solvents causing or that caused the

contamination ______________________________________________________________________

_____________________________________________________________________________________________________________

6. Which activities will result in a point source discharge from the site? (Check all that apply - See Instructions)

____ Aquifer Tests to Characterize Site Conditions

____ Pumping Contaminated Groundwater to Remove Free Product From The Ground

____ Other Petroleum Product or Chlorinated Hydrocarbon Solvent Cleanup Activity

(specify the activit ies) ________________________________________________________________

_________________________________________________________________________________

7. Has a site characterization report for this site been submitted to the Department of Environmental Quality?

Yes______ No______ N/A______

8. Characterize or describe the wastewater to be discharged including the types of contaminants present in the

wastewater (Please attach analytical data) _________________________________________________

_________________________________________________________________________________

9. Identify the discharge point and the waterbody into which the discharge will occur. For linear projects, identify

the location of all the proposed discharge points along the project length and the associated waterbody for each

discharge point (Attach additional sheets if necessary) ________________________________________

_________________________________________________________________________________

10. How often will the discharge occur (e.g., daily, monthly, continuously)? ____________________________

11. Estimate how long each discharge will last: ___________ hours or days

12. Estimate total volume of wastewater to be discharged: ________________ Gal.

VAG83 - RS

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10/11/2012

Form Vag83 - Rs - Vpdes General Permit Registration Statement For Discharges From Petroleum Contaminated Sites, Groundwater Remediation And Hydrostatic Tests