Dep Form 62 621 300 4 B – Fill Out and Use This PDF

NOTICE OF INTENT

TO USE

GENERIC PERMIT FOR STORMWATER DISCHARGE FROM LARGE AND SMALL CONSTRUCTION ACTIVITIES

(RULE 62-621.300(4), F.A.C.)

This Notice of Intent (NOI) form is to be completed and submitted to the Department before use of the Generic Permit for Stormwater Discharge From Large and Small Construction Activities provided in subsection 62-621.300(4), F.A.C. The type of project or activity that qualifies for use of the generic permit, the conditions of the permit and additional requirements to request coverage are specified in the generic permit document [DEP Document 62-621.300(4)(a)]. The appropriate generic permit fee, as specified in paragraph 62-4.050(4)(d), F.A.C., shall be submitted with this NOI in order to obtain permit coverage. Permit coverage will not be granted without submittal of the appropriate generic permit fee. You should familiarize yourself with the generic permit document and the attached instructions before completing this NOI form. Please print or type information in the appropriate areas below.

II.APPLICANT INFORMATION:

C. Address:

G. Responsible Authority:

H. Responsible Authority’s Phone No.:

I. Responsible Authority’s Fax No.:

J. Responsible Authority’s E-mail Address:

III.PROJECT/SITE LOCATION INFORMATION:

A.Project Name:

B.Project Address/Location:

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DEP Form 62-621.300(4)(b)

Effective February 17, 2009

J. Project Contact:

K. Project Contact’s Phone No.:

L. Project Contact’s Fax No.:

M. Project Contact’s E-mail Address:

IV. PROJECT/SITE ACTIVITY INFORMATION:

B. Approximate total area of land disturbance from commencement through completion of construction: _________ acres

V.DISCHARGE INFORMATION:

A.MS4 Operator Name (if applicable):

B.Receiving Water Name:

VI. CERTIFICATION1:

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.

Responsible Authority Name and Official Title (Type or Print):

1Signatory requirements are contained in Rule 62-620.305, F.A.C. Page 2 of 5

DEP Form 62-621.300(4)(b) Effective February 17, 2009

Items G. – J.: Provide the name, telephone and fax number (including area code) and E-mail address of the person authorized to submit this NOI on behalf of the operator (e.g., Jane Smith, President of Smith Construction Company on behalf of the operator, Smith Construction Company; John Doe, Public Works Director on behalf of the operator, City of Townsville; etc.). This should be the same person as indicated in the certification in Part VI.

Part III – Project/Site Location Information:

Items A. – E.: Enter the official or legal name and complete street address, including city, state and zip code of the project. Do not provide a P.O. Box number as the street address. If it lacks a street address, describe the project site location (e. g., intersection of State Road 1 and Smith Street).

Item F.: Enter the county in which the project is located.

Item G.: Enter the latitude and longitude, in degrees-minutes-seconds format, of the approximate center of the project.

Item H.: Indicate whether the project is located on Indian Country Lands.

Item I.: Enter the appropriate five or six letter code from the list below to indicate the Water Management District the project is located within:

NWFWMD = Northwest Florida Water Management District

Items J. – M.: Give the name, telephone and fax number (including area code) and E-mail address of the project contact person. The project contact is the person who is thoroughly familiar with the project, the facts reported in this NOI and who can be contacted by the Department if necessary.

Part IV – Project/Site Activity Information:

Item A.: Check the appropriate box to indicate whether the project involves large construction activity or small construction activity. Check one box only.

“Large Construction Activity” means construction activity that results in the disturbance of five (5) or more acres of total land area. Large construction activity also includes the disturbance of less than five acres of total land area that is part of a larger common plan of development or that will ultimately disturb five acres or more.

“Small Construction Activity” means construction activity that results in the disturbance of equal to or greater than one (1) acre and less than five (5) acres of total land area. Small construction activity also includes the disturbance of less than one acre of total land area that is part of a larger common plan of development or sale that will ultimately disturb equal to or greater than one acre and less than five acres.

Item B.: Provide the approximate total area of land disturbance, in acres, that the project will involve from commencement of construction through completion.

Items C. - G.: Indicate the location where the Stormwater Pollution Prevention Plan (SWPPP) can be viewed. Provide the address where the SWPPP can be viewed if other than as provided in Parts II or III of the NOI. Note that to be eligible for coverage under the generic permit, the SWPPP must have been prepared prior to filing this NOI.

Item H.: Enter the estimated construction start and completion dates in the MM/DD/YY format.

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DEP Form 62-621.300(4)(b) Effective February 17, 2009

Part V – Discharge Information:

To be covered under a CGP, the facility must have the potential to discharge stormwater associated with construction activity to a MS4, a surface water body or both. NOIs submitted without discharge information cannot be processed.

Item A.: If stormwater from the project discharges to a municipal separate storm sewer system (MS4), enter the name of the

operator of the MS4 (e.g., City of Tallahassee MS4, Orange County MS4, FDOT District 5 MS4, etc.). If stormwater from the project does not discharge to an MS4 but to surface waters of the State, leave this item blank or indicate “N/A” and skip

to Item B. of this part. Please note that if the project discharges stormwater to an MS4, you must provide the MS4 operator with a copy of the completed NOI.

Item B.: If the project discharges stormwater to surface waters of the State, and not to an MS4, enter the name of the

receiving water body to which the stormwater is discharged. Please provide the first named water body to which the stormwater from the project is discharged (e.g., Cypress Creek, Tampa Bay, unnamed ditch to St. Johns River, Tate’s Hell

Swamp, etc.).

In certain cases, stormwater from the project will discharge to both an MS4 and surface waters of the State. In this case, complete both Item A. and Item B.

Part VI – Certification:

Type or print the name and official title of the Responsible Authority signing the certification. Please note that this must be the same person indicated in Item II.G. as the Responsible Authority. Sign and date the certification.

Section 403.161, F.S., provides severe penalties for submitting false information on this application (NOI) or any reports or records required by a permit. There are both civil and criminal penalties, in addition to the revocation of permit coverage for submitting false information.

Rule 62-620.305, F.A.C., requires that the NOI and any reports required by the permit be signed as follows:

A.For a corporation, by a responsible corporate officer as described in Rule 62-620.305, F.A.C.;

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 facility, by a principal executive officer or elected official.

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DEP Form 62-621.300(4)(b) Effective February 17, 2009