3150 Pm Bwew0228 Form PDF Details

The 3150-PM-BWEW0228 form is a crucial document for entities in Pennsylvania involved in construction activities that may affect stormwater discharges, requiring compliance with the National Pollutant Discharge Elimination System (NPDES) permits. Introduced by the Commonwealth of Pennsylvania's Department of Environmental Protection, Bureau of Waterways Engineering and Wetlands, this application serves multiple purposes. It facilitates the transfer of permit responsibility, coverage, and liability from a current permittee to a new one, or the addition of co-permittees to an existing permit. The form demands detailed information about the permit, the current permittee, the site of the construction activity, the transferee or co-permittee, and a thorough compliance review. Additionally, it incorporates a certification and signature section, ensuring that applicants acknowledge the accuracy of the information provided and agree to comply with relevant regulations. Notably, the document emphasizes the importance of a written agreement among parties involved in the transfer or sharing of permit responsibilities, demonstrating the state's commitment to maintaining environmental protections amid changes in project ownership or operational control. The inclusion of templates for Co-Permittee and Transferee Agreement letters offers guidance, aiming to streamline the process. This form underscores the proactive measures required to ensure ongoing compliance with environmental laws, particularly regarding stormwater management in construction areas.

QuestionAnswer
Form Name3150 Pm Bwew0228 Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other nameslic form 3150, pa co permittee npdes form, co permittee npdes, co permittee

Form Preview Example

3150-PM-BWEW0228 Rev. 9/2016

Application

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF WATERWAYS ENGINEERING AND WETLANDS

OFFICIAL USE ONLY

PA

TRANSFEREE/CO-PERMITTEE APPLICATION FOR A GENERAL OR INDIVIDUAL NPDES PERMIT FOR STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES

TYPE OR PRINT IN BLOCK LETTERS

A. PERMIT INFORMATION

Check here if applying for permit transfer.

Check here if applying to be added as a co-permittee.

GENERAL OR INDIVIDUAL NPDES PERMIT FOR DISCHARGES OF STORMWATER ASSOCIATED WITH CONSTRUCTION ACTIVITIES FOR WHICH APPLYING AS TRANSFEREE/CO-PERMITTEE.

PERMIT NO.:DATE ISSUED:

B. CURRENT PERMITTEE INFORMATION

DEP Client ID# (if known)

 

Organization Name or Registered Fictitious Name

 

Employer ID# (EIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Last Name

First Name

 

MI

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Individual Last Name

First Name

 

MI

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

ZIP+4

County

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. SITE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

DEP Site ID# (if known)

Site Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEVELOPMENT NAME (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SITE ADDRESS/LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY:

 

 

MUNICIPALITY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF TRANSFER OF PERMIT RESPONSIBILITY, COVERAGE AND LIABILITY:

 

 

, 20

 

 

 

CO-PERMITTEE/TRANSFEREE AGREEMENT: Attach a written agreement signed by all parties involved with the change of operational control. The letter should provide a specific date (not less than 30 days after the date this application is submitted) for the transfer or sharing of permit responsibility, coverage, and liability between the current and new permittee/co-permittee. A SAMPLE Co-Permittee Agreement letter and a SAMPLE Transferee Agreement letter are attached for reference.

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3150-PM-BWEW0228 Rev. 9/2016

Application

D. TRANSFEREE/CO-PERMITTEE INFORMATION

Corporations for profit, corporations not-for-profit, limited liability companies, partnerships or sole proprietorships, limited partnerships, professional associations and business or statutory trusts that were not created or formed under the laws of Pennsylvania desiring to do business in this Commonwealth must register with the Pennsylvania Department of State.

DEP Client ID# (if known)

 

 

 

Applicant Type (e.g. Owner, Operator, etc.)

 

 

 

 

Organization Name or Registered Fictitious Name

 

 

Employer ID# (EIN)

 

 

 

 

 

 

Individual Last Name

First Name

 

 

MI

Suffix

 

 

 

 

 

 

Additional Individual Last Name

First Name

 

 

MI

Suffix

 

 

 

 

 

 

Mailing Address Street

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP+4

County

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

Phone

 

 

 

 

 

 

 

E. COMPLIANCE REVIEW

 

 

 

 

 

Yes

No

Does the applicant

(owner and/or

operator) have

or require other

environmental permits issued by the

Department for this project? If yes, list each permit and the compliance history of the permitted facility or operation.

Permit Program:

Permit Number:

Brief Description:

Compliance History:

If the applicant is not in compliance with any environmental law or regulation, or Department permit, order or schedule of compliance, or has failed and continues to fail to comply, or has shown a lack of ability or intent to comply with environmental laws or regulations or any Department permit, order, or schedule of compliance, as indicated by past or continuing violations, provide a narrative description of how the applicant will achieve compliance including the appropriate milestones.

- 2 -

Phone
FAX

3150-PM-BWEW0228 Rev. 9/2016

Application

F. CERTIFICATION AND SIGNATURE OF APPLICANT

Applicant Certification

I certify under penalty of law that this application and all related attachments were prepared by me or 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 own knowledge and on inquiry of the person or persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. The responsible official’s signature also verifies that the activity is eligible to participate in the NPDES permit, and that BMP’s, E&S Plan, PPC Plan, PCSM Plan, and other controls are

being or will be, implemented to ensure that water quality standards and effluent limits are attained. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment or both for knowing violations pursuant to Section 309(c)(4) of the Clean Water Act and, 18 Pa. C.S. §§4903-4904.

I grant permission to the agencies responsible for the permitting of this work, or their duly authorized representative to enter the project site for inspection purposes. I will abide by the conditions of the permit if issued and will not begin work prior to permit issuance.

(For individuals no indication of title is necessary, choose the box below. All others proceed to the next paragraph)

Individual; proceed to signature portion.

I hereby certify that I am the signatory pursuant to 25 Pa, Code § 92a.22 and 40 CFR §122.22 and that I am the person who is responsible for decision-making regarding environmental compliance functions for Enter Entity name, the manager of one or more manufacturing, production, or operating facilities of the applicant and am authorized to make management decisions which govern the

operation of regulated facility including having explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure the applicant’s long term environmental compliance with

environmental laws and regulations; and I am responsible for ensuring that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements.

(choose one of the following; not applicable for individuals):

The responsible corporate officer

president

vice president

secretary

treasure of

 

Corporation/Company

Entity name

The member or

The general partner of

manager of

 

LLC

Entity name partnership/LP/LLP

Entity name

 

The principal executive officer or ranking elected official of

Municipality/State/Federal/other public agency

Entity name

Power of Attorney/delegation of contractual authority (documentation supporting delegation of contracting authority must be provided) for

Entity name

 

 

 

 

SIGNATURES

Applicant

 

 

Co-Applicant (if applicable)

 

 

 

 

Print Name and Title of Person Signing

 

 

Print Name and Title of Person Signing

 

 

 

 

Signature of Applicant

 

 

Signature of Co-Applicant

 

 

 

 

Date Signed

 

 

Date Signed

Please note below the name, address and telephone number of the individual that should be contacted in the event additional information is required.

Name

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3150-PM-BWEW0228 Rev. 9/2016

Application

Notarization:

 

 

Commonwealth of Pennsylvania

 

 

 

 

 

County of

Sworn to and Subscribed to Before Me This

 

 

 

 

 

 

 

 

 

 

NOTARY

 

Day of

, 20

 

 

 

 

 

 

 

 

SEAL

My Commission Expires:

Notary Public

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3150-PM-BWEW0228 Rev. 9/2016

Application

CO-PERMITTEE AGREEMENT

ASSUMPTION OF RESPONSIBILITY UNDER A GENERAL OR INDIVIDUAL NPDES PERMIT FOR STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES

(Permit Number)

(Name of Facility/Project) (Municipality)

(County)

The following parties agree to a change in ownership and/or operational control under the above referenced permit

effective

(date)

.

 

 

(New Co-Permittee name and address)

hereby assumes joint and

severable responsibility, coverage, and liability under the permit for any obligations, duties, responsibilities and

violations under said permit. (Current Permittee) shall remain liable under the permit for

violations of the permit conditions up to and including the above referenced date AND until a Notice of Termination is filed and acknowledged by the (Conservation District OR DEP Regional Office).

[The following paragraph should be used for multiple co-permittees.]

Attached is a description of site responsibilities and a map or plan drawing depicting the limits of permit responsibility, coverage, and liability for each co-permittee.

(Current Permittee(s)) (Company Name, if applicable)

(New Co-permittee(s))

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3150-PM-BWEW0228 Rev. 9/2016

Application

TRANSFEREE AGREEMENT

ASSUMPTION OF RESPONSIBILITY UNDER A GENERAL OR INDIVIDUAL NPDES PERMIT FOR STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES

(Permit Number)

(Name of Facility/Project) (Municipality)

(County)

The following parties agree to transfer ownership and/or operational control under the above referenced permit.

(Transferee name & address) hereby assumes, effective (date)all responsibility,

coverage and liability under the permit for any obligations, duties, responsibilities, and violations under said permit. (Transferor, Name and Address) shall remain liable under the permit for violations of the permit up to and

including

(date) AND until the

(Conservation

District/DEP Regional

Office) acknowledges

the

 

 

 

 

 

 

 

 

 

 

 

Co-Permittee/Transferee Form. The Department may hold

(transferor) and

(transferee) jointly

and

 

 

 

 

 

 

severably liable under said permit for any breach of permit obligations, responsibilities, or violations.

 

[The following paragraph should be used for multiple transferees.]

Attached is a description of site responsibilities and a map or plan drawing depicting the limits of permit responsibility, coverage, and liability for each transferee.

(Current Permittee(s)

 

(Transferee(s))

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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3150-PM-BWEW0228 Rev. 9/2016

COMMONWEALTH OF PENNSYLVANIA

Instructions

DEPARTMENT OF ENVIRONMENTAL PROTECTION

 

BUREAU OF WATERWAYS ENGINEERING AND WETLANDS

INSTRUCTIONS FOR THE

TRANSFEREE/CO-PERMITTEE APPLICATION FORM FOR A GENERAL OR

INDIVIDUAL NPDES PERMIT FOR STORMWATER DISCHARGES

ASSOCIATED WITH CONSTRUCTION ACTIVITIES

Who may file the Transferee/Co-Permittee Application Form: This form may be used by an applicant seeking to apply for either complete or partial operational control of earth disturbance activities at a site which are already authorized by either an Individual or General NPDES Permit. Federal NPDES Regulations at 40 C.F.R. §122.21(b) require that Operator(s) must become a permittee. An operator is a person who meets either of the following criteria: 1.) You have operational control of construction project plans and specifications, including the ability to make modifications to those plans and specifications; OR 2.) You have day-to-day operational control (supervision) of those activities at the project that are necessary to ensure compliance with the Erosion and Sediment Control Plan for the site or ensure compliance with other permit conditions, i.e., General Contractors. Subcontractors generally do not have supervisory control over earth disturbance activities and therefore usually should not become a permittee or co-permittee. If prior to construction activities, there is no operator, the owner must apply for the permit. Once the operator has been selected, the operator must use this application either to be made a co-permittee or to have the permit transferred to the contractor. Failure of the operator to be added to the permit is a violation of federal and state law and regulation.

Where to file the Transferee/Co-Permittee Application Form: Send this form to the reviewing entity, either to the local county conservation district that is participating as the reviewing entity or, if the Department is the reviewing entity, to the appropriate DEP Regional Office, Permitting and Technical Services Section.

When to file the Application: This application must be filed at least 30 days prior to the proposed change of ownership and/or operational control which will result in the transfer of permit responsibility, coverage and liability.

Completing the Application: TYPE OR PRINT IN BLOCK LETTERS IN THE APPROPRIATE SPACES

Section A. Permit Information - Check the appropriate box and enter the Permit Number and date of issuance of the existing Individual or General NPDES Permit assigned to the construction activity at the site identified in Section C below.

Section B. Current Permittee Information - Enter the full name, address and telephone number of the individual or organization that is the current permittee. The Regional Office can supply the Client ID #, if known.

Section C. Site Information - Enter the DEP Site ID#, site name, site address/location, county and municipality of the site where the construction activity authorized by the NPDES Permit is located. Include the date on which the transfer of Permit responsibility, coverage and liability will occur. The Regional Office can supply the Site ID #.

Section D. Transferee/Co-Permittee Information - Enter the full name, address, email address, and telephone number of the individual or organization that is applying to assume operational control of construction activities at the site. The Regional Office can supply the Client ID #, if known.

Section E. Compliance Review - The individual or organization referenced in Section D must indicate if any other environmental permits have been received or are pending from DEP as well as their past compliance history and if they are currently in compliance with environmental laws, rules and regulations, permits, orders and schedules of compliance.

Section F. Certification and Signature of Applicant - The new Transferee/Co-Permittee Applicant (named in Section D) must complete the required certification to include the printed applicant name and title. The application shall be signed as follows:

a.For a corporation -- By a responsible corporate officer, which means: (1) A 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 (2) The manager of one or more manufacturing, production or operating facilities if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

b.For a partnership or sole proprietorship -- By a general partner or the proprietor, respectively; or

c.For a municipality, State, Federal or other public agency -- by either a principal executive officer or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: (1) the chief executive officer of the agency, or (2) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrators of EPA).

d.For individuals, no indication of title is necessary.

If anyone else signs on behalf of a corporation, partnership, or public agency, documentation supporting delegation of contracting authority must be provided

The application shall be notarized in the space provided.

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