Ohio Epa 4496 Form PDF Details

Understanding the Ohio EPA Form 4496 is essential for entities engaging in construction activities that could impact stormwater quality. This form serves as a Notice of Intent (NOI) for entities seeking coverage under Ohio’s National Pollutant Discharge Elimination System (NPDES) general permit, specifically tailored for stormwater discharges associated with construction. By submitting this form, applicants are signaling their intention to comply with the stringent terms and conditions laid out by the NPDES permit, which governs stormwater management and pollution prevention measures during construction projects. Detailed within the form are sections necessitating comprehensive information about the applicant, including company name, contact information, and details about the construction site. It also requires a certification by the applicant, confirming the accuracy and truthfulness of the submitted information under penalty of law. Notably, the form emphasizes the importance of submitting complete and unaltered information, highlighting that any corrections or modifications should avoid using correction fluid. Furthermore, it specifies that fax submissions are not permissible, and applicants can find some relief in knowing there are no fees associated with the form’s submission. Understanding and correctly completing this form is crucial for maintaining compliance and avoiding the severe legal consequences that can arise from non-compliance or the submission of false information.

QuestionAnswer
Form NameOhio Epa 4496 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesco permittee noi, epa, coverage, under

Form Preview Example

Co-Permittee Notice of Intent for Coverage Under

Ohio EPA Storm Water Construction General Permit

Submission of this NOI constitutes notice that the party identified in Section I of this form intends to be authorized by Ohio’s NPDES general permit for storm water associated with construction activity. Becoming a permittee obligates a discharger to comply with the terms and conditions of the permit. NOTE: All necessary information must be provided on this form. Read the accompanying instructions carefully before completing the form. Do not use correction fluid on this form. Forms transmitted by fax will not accepted. There is no fee associated with submitting this form.

I.Applicant Information/Mailing Address

Company (Applicant) Name:

Mailing (Applicant) Address:

__________________________________________________________________________________

City:

 

 

 

State:

 

 

Zip Code:

 

Contact Person:

 

 

Phone:

 

 

 

Fax:

 

Contact E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

II. Facility/Site Location Information

Existing Ohio EPA Facility Permit Number: ______________________________

 

 

 

 

 

 

Initial Permittee Name:

 

 

 

 

 

 

 

 

 

Phone:

 

 

Facility/Site Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

Township(s):

 

 

 

 

 

 

 

 

County(ies):

 

 

 

State:

 

Ohio

 

 

Zip Code:

 

 

Facility Contact Person:

 

 

 

Phone:

 

 

 

 

Fax:

 

 

Facility Contact E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. 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.

Applicant Name:

 

Title:

 

 

Applicant Signature:

 

 

 

Date:

 

 

EPA 4496 (Rev. 2/10)

CLICK TO CLEAR ALL ENTERED INFORMATION

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