Notice Of Intent For General Npdes Permit For Storm Water Discharges printable pdf download

DEPARTMENT OF ENVIRONMENT AND CONSERVATION

DIVISION OF WATER POLLUTION CONTROL

1-888-891-8332 (TDEC)

Notice of Intent

for General NPDES Permit for Storm Water Discharges from

Construction Activities (TNR10-0000)

Site or Project

Existing Tracking

Name:

No.

Start date:

Street Address

or Location:

Estimated end date:

Latitude:

Site

Description:

Longitude:

Acres Disturbed:

County(ies):

MS4 Jurisdiction:

Total Acres:

Does a topographic map show dotted or solid blue lines

and/or wetlands

on or adjacent to the construction site?

If wetlands are located on-site and may be impacted, attach wetlands delineation report.

If an Aquatic Resource Alteration Permit has been obtained for this site, what is the permit number?

ARAP permit No.:

Receiving waters:



Attach the SWPPP with the NOI

Attach a site location map

SWPPP Attached

Map Attached

Name of Site Owner or Developer (Initial Primary Permittee): (person, company, or legal entity that has operational or design control over

construction plans and specifications):

Site Owner or Developer Contact Name: (individual responsible for

Title or Position: (president, vice-president or equivalent - the party

site):

who signs the certification below):

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

(

)

(

)

Optional Contact:

Title or Position:

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

(

)

(

)

Owner or Developer Certification (must be signed by president, vice-president or equivalent, or ranking elected official) (Primary Permittee)

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 gather and evaluate 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.

Signature:

Date:

Owner or Developer name (president, vice-president or equivalent );

print or type:

Contractor(s) Certification (must be signed by president, vice-president or equivalent, or ranking elected official) (Secondary Permittee)

I certify under penalty of law that I have reviewed this document, any attachments, and the SWPPP referenced above. Based on my inquiry of the construction site

owner/developer identified above and/or my inquiry of the person directly responsible for assembling this NOI and SWPPP, I believe the information submitted is

accurate. I am aware that this NOI, if approved, makes the above-described construction activity subject to NPDES permit number TNR100000, and that certain of

my activities on-site are thereby regulated. I am aware that there are significant penalties, including the possibility of fine and imprisonment for knowing violations,

and for failure to comply with these permit requirements.

Primary contractor name and address; print or type

Signature:

Date:

Other contractor name and address; print or type

Signature:

Date:

Other contractor name and address; print or type

Signature:

Date:

OFFICIAL STATE USE ONLY

Received Date: