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C3ai(2) C 3 Data Form-SCVURPPP_rev 7-2-10_due 120109 Page 1 of 4 7/2/10 Santa Clara Valley Urban Runoff Pollution Prevention Program PROVISION C.3 DATA FORM * Note: For restaurants, uncovered parking lots, auto service facilities and retail gasoline outlets that receive final discretionary approval on or after December 1, 2011, the threshold will be reduced to 5,000 sq. ft. 1. Project Information Project Name: # Project Address: Cross Streets: Applicant/Developer Name: Project Phase(s): Engineer: Project Type (Check all that apply): Residential Commercial Industrial Mixed Use Public Institutional Restaurant Uncovered Parking Auto Service Retail Gas Outlet Other Project Description: Project Watershed/Receiving Water: Which Projects Must Comply with Stormwater Requirements? All projects creating, adding, or replacing 10,000 sq. ft.* or more of impervious surface on the project site must fill out this worksheet and submit it to [enter name of department]____ with the development project application. Interior remodeling projects, routine maintenance or repair projects such as re-roofing and re-paving, and single family homes that are not part of a larger plan of development are NOT required to complete this worksheet. What is an Impervious Surface? An impervious surface is a surface covering or pavement that prevents the land’s natural ability to absorb and infiltrate rainfall/stormwater. Impervious surfaces include, but are not limited to rooftops, walkways, paved patios, driveways, parking lots, storage areas, impervious concrete and asphalt, and any other continuous watertight pavement or covering. Pervious pavement, underlain with pervious soil or pervious storage material drain rock), that infiltrates rainfall at a rate equal to or greater than surrounding unpaved areas OR that stores and infiltrates the water quality design volume specified in Provision C.3.d of the Municipal Regional Stormwater Permit (MRP), is not considered an impervious surface. For More Information For more information regarding selection of Best Management Practices for stormwater pollution i ---PAGE BREAK--- C3ai(2) C 3 Data Form-SCVURPPP_rev 7-2-10_due 120109 Page 2 of 4 7/2/10 2. Project Size: 3. MRP Provision C.3. and State Construction General Permit Applicability: a. Is #2.f. equal to 10,000 sq. ft. or more? Yes, C.3. source control, site design and treatment requirements apply No, C.3. source control and site design requirements may apply – check with local agency b. Is #2.h. equal to 50% or more? Yes, C.3. requirements (site design and source control, as appropriate, and stormwater treatment) apply to entire site No, C.3. requirements only apply to impervious area created or replaced c. Is #2.b. equal to 1 acre or more? Yes, applicant must obtain coverage under the State Construction General Permit file a Notice of Intent and prepare a Stormwater Pollution Prevention Plan) (see for details). No, applicant does not need coverage under the State Construction General Permit. 4. Types of Stormwater Controls Used (check all that apply, using lists on next page): Source Controls Site Design Measures Treatment Systems 5. Hydromodification Management (HM) Applicability: a. Does project create and/or replace one acre or more of impervious surface AND create an increase in total impervious surface from the pre-project condition is 2.g. > Yes (continue) No – exempt from HM, go to page 3 b. Is the project located in an area of HM applicability (green or pink area) on the HM Applicability Map? ( www.scvurppp-w2k.com/hmp_maps.htm ) Yes, project must implement HM requirements No, project is exempt from HM requirements a. Total site area acres b. Estimated area of land disturbance during construction (including clearing, grading, or excavating). c. Existing (pre-project) impervious surface area sq. ft. d. Existing impervious surface area replaced as part of project sq. ft. e. New impervious surface area created/added as part of project sq. ft. f. Total new and replaced impervious surface area (d + e) sq. ft. g. Total post-project impervious surface area (c + e) sq. ft. h. Percent increase/replacement of impervious surface area (f ÷ c × 100) % (For redevelopment projects only) ---PAGE BREAK--- C3ai(2) C 3 Data Form-SCVURPPP_rev 7-2-10_due 120109 Page 3 of 4 7/2/10 Specific Stormwater Control Measures: Source Controls Alternative building materials Wash area/racks, drain to sanitary sewer2 Covered dumpster area, drain to sanitary sewer2 Sanitary sewer connection or accessible cleanout for swimming pool/spa/fountain1 Beneficial landscaping (minimizes irrigation, runoff, pesticides and fertilizers; promotes treatment) Outdoor material storage protection Covers, drains for loading docks, maintenance bays, fueling areas Maintenance (pavement sweeping, catch basin cleaning, good housekeeping) Storm drain labeling Other Site Design Measures Minimum land disturbance Minimized impervious surfaces Minimum-impact street design Minimum-impact parking lot design Cluster structures/ pavement Permeable pavement Alternative driveway design Roof downspouts drain to landscaping Microdetention in landscape Rainwater harvesting and reuse rain barrel, cistern connected to roof drains) Preserved open space: ac. or sq. ft .(circle one) Protected riparian and wetland areas, riparian buffers (Setback from top of bank: Other Treatment Systems2 LID Treatment Infiltrating vegetated swale Vegetated filter strip Bioretention area Flow-through planter Green roof Infiltration trench/basin Underground detention and infiltration system (e.g. pervious pavement drain rock, large diameter conduit) Retention/irrigation Other Other Treatment Methods Flow-through vegetated swale (no infiltration) Dry detention basin Wet pond Media filter (sand, compost, or manufactured media) Hydrodynamic separator3 Water quality inlet filter3 Other Flow Duration Controls for Hydromodification Management (HM) Detention basin Underground tank or vault Bioretention with outlet control Other 1 Subject to sanitary sewer authority requirements. 2 Stormwater treatment is currently required for all projects that create and/or replace 10,000 square feet or more of impervious surface > 10,000 sf). Low Impact Development (LID) treatment methods are strongly encouraged, and will be required for projects that receive final discretionary approval on or after 12/1/11, except in special cases. 3 Only allowed as part of a multi-step treatment process. ---PAGE BREAK--- C3ai(2) C 3 Data Form-SCVURPPP_rev 7-2-10_due 120109 Page 4 of 4 7/2/10 6. Treatment System Sizing for Projects with Treatment Requirements Indicate the hydraulic sizing criteria used and provide the calculated design flow or volume: Treatment System Component Hydraulic Sizing Criteria Used3 Design Flow or Volume (cfs or cu.ft.) 3Key: 1a: Volume – WEF Method 1b: Volume – CASQA BMP Handbook Method 2a: Flow – Factored Flood Flow Method 2b: Flow – CASQA BMP Handbook Method 2c: Flow – Uniform Intensity Method 3: Combination Flow and Volume Design Basis 7. Alternative Certification: Was the treatment system sizing and design reviewed by a qualified professional that is not a member of the agency staff? Yes No Name of Reviewer 8. Operation & Maintenance Information A. Property Owner’s Name B. Responsible Party for Stormwater Treatment/Hydromodification Control O&M: a. Name: b. Address: c. Phone/E-mail: This section to be completed by Municipal staff. O&M Responsibility Mechanism Indicate how responsibility for O&M is assured. Check all that apply: O&M Agreement Other mechanism that assigns responsibility (describe below): Reviewed: Community Development Department Public Works Department Planning Division: Engineering: Building Division: Other (Specify): Return form to: Data entry performed by: