Navigating the intricacies of environmental compliance, the DCR 199 148 form emerges as a critical document for entities managing small Municipal Separate Storm Sewer Systems (MS4s). This form serves as the General Permit Registration Statement for Stormwater Discharges, a necessary step for those needing to align with Virginia's stormwater management regulations. Required by any regulated small MS4 seeking coverage under the general permit, it encompasses various key components from identifying the regulated MS4 name and operator to detailing the hydrologic unit codes of affected watersheds. Moreover, the form requires a comprehensive account of BMPs (Best Management Practices) intended for implementation, underlining the commitment to mitigate the environmental impact of stormwater discharges. It doesn't simply stop at compliance; the form also lays the groundwork for proactive environmental stewardship, asking for detailed plans and objective metrics to ensure the effectiveness of stormwater management efforts. With sections dedicated to everything from TMDL (Total Maximum Daily Load) waste load allocations to MS4 Program Plans, this form is a testament to the rigorous planning and oversight essential for preserving water quality and managing stormwater runoff effectively. Entities are obliged to submit complete and true information, under penalty of law, illustrating the serious nature of these environmental commitments.
| Question | Answer |
|---|---|
| Form Name | Form Dcr 199 148 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | stmms4stmtfm va dcr var04 permit registration statement form |
VSMP GENERAL PERMIT REGISTRATION STATEMENT FOR STORMWATER DISCHARGES
FROM SMALL MUNICIPAL SEPARATE STORM SEWER SYSTEMS [VAR04]
(Please Type or Print All Information)
(The applicable fee specified in Form DCR
obtain coverage)
1.Regulated Small MS4
Name: _______________________________________________________________________________________
Type:
City |
County |
Incorporated Town |
Unincorporated Town |
College or University |
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Local School Board |
Military Installation |
Transport System |
Federal or State Facility |
Other |
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Location (County or City): ________________________________________________________________________
2. Regulated Small MS4 Operator
Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
City: ________________________________ State: ______ Zip: __________
3.Hydrologic Unit Code(s) as identified in the most recent version of Virginia’s 6th Order National Watershed Boundary Dataset currently receiving discharges or that have potential to receive discharges from the regulated small MS4:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4.Attach a description of the estimated drainage area, in acres, served by the regulated small MS4 discharging to any impaired receiving surface waters listed in the most recent Virginia 305(b)/303(d) Water Quality Assessment Integrated Report, and a description of the land use of each such drainage area.
5.Any TMDL waste loads allocated to the regulated small MS4 (this information may be found at http://www.deq.state.va.us/tmdl/develop.html):_____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
6.The name(s) of any regulated physically interconnected MS4s to which the regulated small MS4 discharges.
____________________________________________________________________________________________
____________________________________________________________________________________________
7.A copy of the MS4 Program Plan that includes:
a. A list of BMPs that the operator proposes to implement for each of the stormwater minimum control measures and their associated measurable goals pursuant to
i. A list of the existing policies, ordinances, schedules, inspection forms, written procedures, and other documents necessary for BMP implementation; and
ii.The individual, department, division, or unit responsible for implementing the BMP;
b.The objective and expected results of each BMP in meeting the measurable goals of the stormwater minimum control measures;
c.The implementation schedule including any interim milestones for the implementation of a proposed new BMP; and
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d. The method that will be utilized to determine the effectiveness of each BMP and the program as a whole.
8.List all existing signed agreements between the operator and any applicable third parties where the operator has entered into an agreement in order to implement minimum control measures or portions of minimum control measures.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
9.The name, address, telephone number and
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
10.The name, position title, address, telephone number and
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
11.Certification: "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."
Print Name: ____________________________________________ |
Title: ________________________________ |
Signature:_____________________________________________ |
Date:________________________________ |
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For Department of Conservation and Recreation Use Only |
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Accepted/Not Accepted by: __________________________________________ |
Date:___________________________________ |
Basin _____________________________ Stream Class ___________ Section _______ Special Standards _______________
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INSTRUCTIONS for FORM DCR
VSMP GENERAL PERMIT REGISTRATION STATEMENT FOR STORMWATER
DISCHARGES FROM SMALL MUNICIPAL SEPARATE STORM SEWER SYSTEMS [VAR04]
WHO MUST FILE THE REGISTRATION STATEMENT
This registration statement must be completed and submitted by any regulated small MS4 requesting coverage under the above general permit for stormwater discharges.
1.Operators are regulated if they operate a small MS4, including but not limited to systems operated by federal, state, and local governments, including the Virginia Department of Transportation; and:
a.The small MS4 is located in an urbanized area as determined by the latest Decennial Census by the Census Bureau. If the small MS4 is not located entirely within an urbanized area, only the portion that is within the urbanized area is regulated; or
b.The small MS4 is designated by the Board.
2.An MS4 may be the subject of a petition to the Board to require a VSMP permit for their discharge of stormwater. If the Board determines that an MS4 needs a permit, the owner may use this registration statement to apply for coverage under the above general permit.
WHERE TO FILE THE REGISTRATION STATEMENT
The completed registration statement (with all attachments), a copy of the fee form and a copy of your check should be sent to the DCR’s Stormwater Permitting Section in the Division of Soil and Water Conservation. The original fee form, application fee (as specified by Form DCR
COMPLETENESS
Complete all items except where indicated in order for your registration statement to be accepted. Attach separate sheets of paper for Item 4 (Impaired Waters Information) and Item 7 (MS4 Program Plan).
DEFINITIONS
"Best management practice (BMP)" means schedules of activities, prohibitions of practices, including both a structural or nonstructural practice, maintenance procedures, and other management practices to prevent or reduce the pollution of surface waters and groundwater systems from the impacts of
"Operator" means the owner or operator of any facility or activity subject to regulation under the VSMP program.
“Small MS4” means all separate storm sewers that are: (1) Owned or operated by the United States, a state, city, town, borough, county, parish, district, association, or other public body (created by or pursuant to state law) having jurisdiction over disposal of sewage, industrial wastes, stormwater, or other wastes, including special districts under state law such as a sewer district, flood control district or drainage district, or similar entity, or an Indian tribe or an authorized Indian tribal organization, or a designated and approved management agency under subsection 208 of the CWA that discharges to surface waters; and (2) Not defined as ''large'' or ''medium'' municipal separate storm sewer systems, or designated under 4
LINE BY LINE INSTRUCTIONS
Item 1. Regulated Small MS4
Provide the name of the regulated small MS4.
Check the appropriate type of regulated small MS4
Provide the location (county name or city name) where the small MS4 is located.
Item 2. Regulated Small MS4 Operator
Provide the name of the operator of the regulated small MS4. Provide the small MS4 operator’s address.
Provide the small MS4 operator’s city, state and zip code.
Item 3. Receiving Waters
Provide the Hydrologic Unit Codes as identified in the most recent version of Virginia’s 6th Order National Watershed Boundary Dataset currently receiving discharges or that have potential to receive discharges from the regulated small MS4. An interactive map is available
Item 4. Impaired Waters Information
Attach a description of the estimated drainage area, in acres, served by the regulated small MS4 discharging to any impaired receiving surface waters listed in the most recent Virginia 305(b)/303(d) Water Quality Assessment Integrated Report, and a description of the land use of each such drainage area.
Item 5. TMDL Waste Load Allocations
Provide any TMDL waste loads allocated to the regulated small MS4. This information may be found at: http://www.deq.state.va.us/tmdl/develop.html.
Item 6. Discharges to Physically Interconnected MS4s
List the name(s) of any regulated physically interconnected MS4s to which the regulated small MS4 discharges.
Item 7. MS4 Program Plan
Attach a copy of the MS4 Program Plan that includes:
a. A list of BMPs that the operator proposes to implement for each of the stormwater minimum control measures and their associated measurable goals pursuant to
i. A list of the existing policies, ordinances, schedules, inspection forms, written procedures, and other documents necessary for BMP implementation; and
ii.The individual, department, division, or unit responsible for implementing the BMP;
b. The objective and expected results of each BMP in meeting the measurable goals of the stormwater minimum control measures; c. The implementation schedule including any interim milestones for the implementation of a proposed new BMP; and
d. The method that will be utilized to determine the effectiveness of each BMP and the program as a whole.
Item 8. Signed Third Party Agreements
List all existing signed agreements between the operator and any applicable third parties where the operator has entered into an agreement in order to implement minimum control measures or portions of minimum control measures.
Item 9. Principal Executive Officer or Ranking Elected Official
Provide the name, address, telephone number and
10. Duly Authorized Representative
Provide the name, position title, address, telephone number and e- mail address of any duly authorized representative as defined in
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Item 11. Certification
State law provides for severe penalties for submitting false information on this Registration Statement. State regulations require this Registration Statement to be signed as follows:
(1)For a corporation: by a responsible corporate officer. For the purpose of this subsection, a responsible corporate officer means:
(a)A president, secretary, treasurer, or
(b)the manager of one or more manufacturing, production, or operating facilities , provided the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;
(2)For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or
(3)For a municipality, state, federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this subsection, a principal executive officer of a public agency includes:
(a)The chief executive officer of the agency, or
(b)A senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency.
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