Npdes Form 1200 C – Fill Out and Use This PDF

NPDES #1200-C Permit Application Form

Oregon Department of Environmental Quality

APPLICATION FOR NEW NPDES GENERAL PERMIT #1200-C

For stormwater discharges to surface waters from construction activities disturbing 1 acre or more.

Please answer all questions. No line may be left blank. An incomplete application will not be processed and will be

returned. If the information requested is not applicable or not yet available, please indicate as such.

A. PROJECT INFORMATION

1.

_________________________________________________________

2. If fee invoicing is different than Applicant, provide contact info:

Applicant (Owner, Developer, or General Contractor)

_________________________________________________________

__________________________________________________________

Invoice Name

Contact Name

_________________________________________________________

_________________________________________________________

Address

Address

_______________

_________________

____________

City

State

Zip

_______________

__________________

____________

___________________

______________________________

City

State

Zip

Telephone

E-Mail Address

____________________

______________________________

Telephone

E-Mail Address

3.

_________________________________________________________

4.

__________________________________________________________

Architect/Engineering Firm (Erosion & Sediment Control Plan)

Applicant's Designated Erosion and Sediment Control Inspector

_________________________________________________________

_________________________________________________________

Project Manager

Contact Name

___________________

______________________________

____________________

______________________________

Telephone

E-Mail Address

Telephone

E-Mail Address

5.

_________________________________________________________

6. Nature of the Construction Activity

Name of Project

Single Family (SIC Code 1521)

_________________________________________________________

Multi-Family Residential (SIC Code 1522)

Address or Cross Street

Commercial (SIC Code 1542)

_______________

_________________

____________

Industrial (SIC Code 1541)

Highway (SIC Code 1611)

City

State

Zip

Utilities (SIC Code 1623):

__________________________________

_______________

Other:

________________________________________________

County

7.

Site Location by Latitude and Longitude:

8. Project Size:

Latitude:

______

/

________

/

_______

Total Site Acreage (acres):

___________________________________

Degrees

Minutes

Seconds

Total Construction Area (acres):

______________________________

Longitude:

______

/

________

/

_______

Degrees

Minutes

Seconds

Disturbed Area for this phase, if multiple phases:

_________________

Total Number of Lots:

______________________________________

DEQ USE ONLY

App. #: ________________________ File #: __________________ LLID #: ______________________ River Mile: ________

Date Received: ______________ Amount: ________________ Check Name: _______________________________________

Check #: __________ Deposit #: _____________ Receipt #: ___________ Legal Name Confirmed:

NPDES General Permit 1200-C Application Instructions For Construction Activities

A. PROJECT INFORMATION

A1 Enter the legal name of the applicant. Permit coverage will be issued to this entity. This is the person, business, public organization, or other entity responsible for assuring that erosion and sediment controls are in place and in working order through the life of the project. This must be the legal Oregon name (i.e., Acme Products, Inc.) or the legal representative of the company if it operates under an assumed business name (i.e., John Smith, dba Acme Products). The name must be a legal, active name registered with the Oregon Department of Commerce, Corporation Division in Salem at 503-378-4752 or http://egov.sos.state.or.us/br/pkg_web_name_srch_inq.login, unless otherwise exempted by their rules. If the name of the applicant is not registered with the Corporation Division and the applicant is a partnership or doing business as a corporate entity, attach legal documents that verify the entity’s existence with the application. The applicant may not use an assumed business name.

To streamline administration and provide continuous permit coverage, the permit may be transferred from one party to another. For example, if a contractor feels that they will not be able to get a permit before the projected start date, the developer may apply for a permit and then transfer the permit over to the contractor. The transfer fee is $60. Transfer forms are available from DEQ or at http://www.deq.state.or.us/wq/stormwater/constappl.htm

A2 Enter invoicing information for annual fee billing if different from the Applicant in A1 (e.g., "Invoice To: Business Office – Accounts Payable"). Provide permanent address or P.O. Box, if applicable.

A3 Provide the contact information for the Architect or Consulting Engineer who designed the Erosion and Sediment Control Plan (ESCP) so that they may be contacted should questions concerning the ESCP Drawings or Narrative arise.

A4 Provide information on the Erosion and Sediment Control Inspector. This is a person that works for the applicant and not a government employee. If the inspector has not been selected yet, please provide the name of consultant who prepared the Erosion and Sediment Control Plan (ESCP). Upon designating an inspector(s), submit to the DEQ or the Agent an Action Plan, which is an addendum to the ESCP, that identifies their name(s), contact information and training and experience as required in Schedule A, condition 6(b) of the permit.

A5 Provide the common name of the site. What is it to be called? Provide the location of the site with respect to cross roads in the area or a street address if appropriate.

A6 Place a check mark in the box that best describes the use for which the site is being constructed. If other is selected, describe the use.

A7 Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds to the nearest 15 seconds. Latitude and longitude can be obtained from United States Geological Survey (USGS) quadrangle topographic maps by calling toll- free at 1-888-ASK-USGS (1-888-275-8747) or by using DEQ’s location finder web site http://www.deq.state.or.us/wq/wqpermit/permits.htm. In using DEQ’s location finder web site, if you do not know your address, go to “locate place” on the left side of the page and click on “latitude and longitude” and then click on “map it.” To get the longitude and latitude to appear you may have to zoom in and re-center until you find the area. You may want to turn off DEQ interests to eliminate the yellow dots and you may want to turn on the Aerial Photos to help you locate the site. The latitude and longitude will be indicated on the left side of the page. Instructions for obtaining latitude and longitude from topographic maps may be obtained at http://www.deq.state.or.us/wq/pubs/guides/latlonginstr.pdf

A8 Provide property size information. What is the total acreage of the site? Provide an estimate, in the case of a multi-phased project, or if all of the property has not yet been purchased.

A9 Indicate where the runoff goes after leaving the site during construction. If it goes in to the City storm drain system, provide best estimate of the receiving stream in addition to checking the Municipal Storm Sewer box.

A10 Indicate whether stormwater runoff will be discharging directly to, or into a storm sewer or drainage system that discharges to “impaired” waters listed on the 303(d) list for sediment or turbidity or are covered by a Total Maximum Daily Load (TMDL) for sediment or turbidity. A map and table identifying “impaired” water bodies and affected river miles for sediment or turbidity is available on DEQ’s web site at http://www.deq.state.or.us/wq/stormwater/construction.htm:

B. LAND USE COMPATIBILITY STATEMENT

Land Use Compatibility Statement (LUCS) must be signed by local planning department. If there are any conditions placed on the land use approval, the findings must be included. The LUCS form may be obtained from DEQ at http://www.deq.state.or.us/pubs/permithandbook/lucs.htm.

C. SIGNATURE

The legally authorized representative for the applicant must sign the application. The following are authorized to sign the document

♦Corporation — president, secretary, treasurer, vice-president, or any person who performs principal business functions; or a manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million that is assigned or delegated in accordance to corporate procedure to sign such documents.

♦Partnership — General partner.

♦Sole Proprietorship — Owner. If more than one person is the sole proprietor, each person must sign the form.

♦City, County, State, Federal, or other Public Facility — Principal executive officer or ranking elected official.

♦Limited Liability Company — Member

♦Trusts— Acting trustee

APPLICATION SUBMITTAL AND FEES

If you have a DEQ Agent in the area where your project is located, send the application to the DEQ Agent (See the DEQ Agent list in Attachment A). Otherwise, send the application to the DEQ office in your area (See DEQ office locations in Attachment B).

The permit application fee is $795, which includes a $392 new permit application fee, and $403 first year annual fee. The permittee will also be billed an annual fee for every year the permit is in effect. If you have a DEQ Agent in the area, where your project is located contact them and verify fees. (See Attachment A for list of Agents)

In order to authorize permit registration, the following must be completed and submitted to DEQ office or a DEQ Agent (see Attachment A for list of Agents):

Application form with original signature

Land Use Compatibility Statement with original signature of the local land use authority

Stormwater Erosion and Sediment Control Plan Narrative

Stormwater Erosion and Sediment Control Plan Drawings

$795 fee (includes $392 for new permit application and $403 for first year annual fee) to the appropriate DEQ regional office and make the check payable to the Department of Environmental Quality. If you are sending your application to a DEQ Agent, check with the Agent for the appropriate fees.