Adem Form 24 PDF Details

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QuestionAnswer
Form NameAdem Form 24
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCSW CGP NOI adem csw gp noi form 24

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NOTICE OF INTENT – GENERAL PERMIT NUMBER ALR100000

NPDES PERMIT NUMBER ALR100000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES THAT RESULT IN A TOTAL LAND DISTURBANCE OF ONE ACRE OR GREATER AND SITES LESS THAN ONE ACRE BUT ARE PART OF A LARGER COMMON PLAN OR DEVELOPMENT OR SALE

Mail to: Alabama Department of Environmental Management Water Division

Post Office Box 301463 Montgomery, Alabama 36130-1463

FOR OFFICE USE ONLY

NPDES PERMIT NUMBER

RECEIPT NUMBER

PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES WILL DELAY PROCESSING. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. ATTACH CBMPP AND OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN INK.

I. PERMITTEE INFORMATION Initial:

Modification:

Transfer:

Renewal:

Previous ALR_____________________

Permittee Name

 

 

 

Responsible Official Phone Number

 

 

 

 

 

 

 

 

 

 

Responsible Owner/Operator or Official, and Title

Responsible Official E-Mail Address

 

 

 

 

 

 

 

 

 

 

Responsible Official (RO) Street/Physical Address

City, State, and Zip Code

 

 

 

 

 

 

 

 

 

 

Responsible Official (RO) Mailing Address

City, State, and Zip Code

 

 

 

 

 

 

 

 

 

 

 

II. FACILITY INFORMATION

 

 

 

 

 

Facility/Site Name

 

 

 

Facility Contact and Title

 

 

 

 

 

 

 

 

 

 

 

Facility Street Address or

Location Description

Facility Contact Phone Number

 

 

 

 

 

 

 

 

 

 

 

Facility Front Gate Latitude and Longitude

City

Zip Code

County(s)

 

 

 

 

 

 

 

 

 

 

Directions to the Site

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. ACTIVITY DESCRIPTION

 

 

 

 

 

 

Brief Description of Construction / Land disturbance activity(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area of the Permitted site:

Total site area in acres:

Total disturbed area in acres:

 

 

 

 

 

 

 

 

 

 

 

 

IV. RECEIVING WATERS

List name of receiving water(s), latitude & longitude (decimal or deg,min,sec) of location(s) that run-off enters the receiving water, and the waterbody classification.

Receiving Water

Latitude

Longitude

Waterbody Classification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADEM Form 24 11-11.doc

Page 1 of 2

V. PRIORITY CONSTRUCTION SITE

Is this a Priority Construction Site? Yes

No

If yes, attach/submit a copy of the CBMPP

 

 

 

VI. FACILITY MAP

Please attach a USGS topographic map showing the location of the Facility including site boundaries.

VII. QUALIFIED CREDENTIALED PROFESSIONAL (QCP) CERTIFICATION

“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated areas/activities. The CBMPP meets the requirements of this permit and if properly implemented and maintained by the operator, discharges of pollutants in stormwater runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code Chapter 335-6-6-

.23 and this Permit. The CBMPP describes the erosion and sediment control measures that must be fully implemented and regularly maintained as needed at the permitted site in accordance with sound sediment and erosion control practices to ensure the protection of water quality.”

QCP Designation/Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

Registration / Certification:

 

 

 

 

 

 

 

 

 

 

Name and Title (type or Print)

 

 

Phone Number

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date Signed

 

 

VIII. OPERATOR - RESPONSIBLE OFFICIAL SIGNATURE

Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOI must be signed by a Responsible Official of the permittee who is the operator, owner, the sole proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government; or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity. “I certify under penalty of law that this form, the CBMPP, 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 qualified credentialed professional (QCP) and other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”

Name and Title (type or Print)

 

 

Official Title

Signature

 

 

 

Date Signed

ADEM Form 24 11-11.doc

Page 2 of 2

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1. It is very important fill out the Adem Form 24 accurately, thus pay close attention when filling in the segments containing these blank fields:

The best way to prepare Adem Form 24 part 1

2. Once your current task is complete, take the next step – fill out all of these fields - III ACTIVITY DESCRIPTION Brief, Total site area in acres, Total disturbed area in acres, IV RECEIVING WATERS List name of, Receiving Water, Latitude, Longitude, Waterbody Classification, ADEM Form doc, and Page of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Writing section 2 in Adem Form 24

3. The next segment is considered relatively simple, V PRIORITY CONSTRUCTION SITE, Is this a Priority Construction, If yes attachsubmit a copy of the, VI FACILITY MAP, Please attach a USGS topographic, VII QUALIFIED CREDENTIALED, QCP DesignationDescription, Address, Registration Certification, Name and Title type or Print, and Phone Number - each one of these empty fields is required to be filled in here.

VI FACILITY MAP, Is this a Priority Construction, and Address of Adem Form 24

4. This specific subsection comes next with the next few empty form fields to complete: Signature, Date Signed, VIII OPERATOR RESPONSIBLE, Name and Title type or Print, Signature, Official Title, and Date Signed.

Filling in section 4 in Adem Form 24

As for Date Signed and Name and Title type or Print, make sure you don't make any mistakes in this current part. Both of these could be the key ones in the file.

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