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ECY 020-85 (Rev. 06/09) 1 NOTICE OF INTENT (NOI) APPLICATION FORM Construction Stormwater General Permit Check if applicable: Change or Update Permit Information Modification of Permit Coverage Permit Please print or type all sections of this application. All fields are required unless otherwise marked. I. Operator/Permittee (Party with operational control over plans and specifications; or day-to-day operational control of activities which ensure compliance with and permit conditions. Ecology will send correspondence and permit fee invoices to the permit holder on record.) Name: Company: Business Phone: Ext. Cell Phone (Optional): Fax (Optional): E-mail: Unified Business Identifier (UBI): (UBI is a nine-digit number used to identify a business entity. Write “none” if you do not have a UBI number.) Mailing Address: City: State: Zip + 4: II. On-site Contact Person (Typically the Certified Erosion & Sediment Control Lead or Operator/Permittee) Name: Company: Business Phone: Ext. Cell Phone (Optional): Fax (Optional): E-mail: Mailing Address: City: State: Zip + 4: III. Site Information Site or Project Name Site Acreage Total size of your site/project (that you own/control): acres. Total area of soil disturbance (grading and/or excavating) for your site/project over the life of the project: acres. (Note: 1 acre = 43,560 ft2.) Concrete / Engineered Soils How many yards of concrete will be poured? yd3 (estimate) How many yards of recycled concrete will be used? yd3 (estimate) Will any engineered soils be used? (For example: cement treated base, cement kiln dust, etc.) Yes No Street Address or Location Description (If the site lacks a street address, list its specific location. For example, Intersection of Highway 61 and 34.) Parcel ID#: (Optional) Type of Construction Activity (check all that apply): Residential Commercial Industrial Highway or Road (city ,county, state) Utilities (specify): Other (specify): City (or nearest city): County: Zip Code: Estimated project start-up date (mm/dd/yy): Estimated project completion date (mm/dd/yy): Record the latitude and longitude of the main entrance to the site or the approximate center of site. Degrees Minutes Seconds Degrees Minutes Seconds Latitude: ° ’ ”N Longitude: ° ’ ”W For assistance with latitude and longitude, refer to any of the following websites: www.getlatlon.com or http://www.epa.gov/tri/report/siting_tool/index.htm. Please convert all latitude and longitude coordinates into degrees, minutes, seconds format. For help with this process, go to: decimal.html. ---PAGE BREAK--- ECY 020-85 (Rev. 06/09) 2 IV. Stormwater Pollution Prevention Plan Do not submit your with your application. You must develop a prior to starting construction. V. Discharge/Receiving Water Information Indicate whether your site’s stormwater and/or dewatering water could enter surface waters, directly and/or indirectly: Water will discharge directly or indirectly (through a storm drain system or roadside ditch) into one or more surface waterbodies (wetlands, creeks, lakes, and all other surface waters and water courses). If the discharge is to a storm sewer system, the name of the operator of the storm sewer system City of Tacoma): (NOTE: If your stormwater discharges to a storm sewer system operated by the City of Seattle, King County, Snohomish County, City of Tacoma, Pierce County, or Clark County, you must also submit a copy of this NOI to the appropriate jurisdiction.) To ground with 100% infiltration, with no potential to reach surface waters under any conditions. If your project includes dewatering, you must include dewatering plans and discharge locations in your site Stormwater Pollution Prevention Plan. Location of Discharge into Surface Waterbody Enter the waterbody name and latitude/longitude* of the point(s) where the site has the potential to discharge into a waterbody (enter all locations). Include the names and locations of both direct and indirect discharges to surface waterbodies, even if the risk of discharge is low or limited to periods of extreme weather. Some large construction projects (for example, subdivisions, roads, or pipelines) may discharge into several waterbodies. If the creek or tributary is unnamed, use a format such as “unnamed tributary to Deschutes River.” Attach a separate list if necessary. Surface Waterbody Name Latitude degrees, minutes, seconds Longitude degrees, minutes, seconds ’ N ’ W ’ N ’ W ’ N ’ W ’ N ’ W ’ N ’ W If your site discharges to a waterbody that is on the impaired waterbodies list 303(d) list) for turbidity, fine sediment, high pH, or phosphorus, you must sample for more parameters. Ecology will notify you if any additional sampling requirements apply. Information on impaired waterbodies is available online at: http://www.ecy.wa.gov/programs/wq/stormwater/construction/impaired.html. ---PAGE BREAK--- ECY 020-85 (Rev. 06/09) 3 VI. State Environmental Policy Act (SEPA) This Notice of Intent (NOI) is incomplete and cannot be approved until the applicable SEPA requirements under Chapter 197-11 WAC are met. Has the SEPA lead agency issued a final decision on your checklist? No Yes Exempt* If No: The NOI is incomplete. Ecology will hold the application until a final SEPA decision is made or the Construction Stormwater NOI public comment period ends, whichever is later. You must notify Ecology once the lead agency has issued a determination. If Yes: Type of SEPA decision issued: Determination of Non-Significance (DNS) Mitigated DNS (MDNS) Determination of Significance (DS) Final Environmental Impact Statement (EIS) Other: Date of final SEPA decision: If a supplemental EIS, SEPA addendum, or some other type of additional SEPA review was required, please attach and submit with this form. Date when all SEPA-related comment & appeal periods are exhausted: . *If Exempt: Attach written documentation, check type of exemption below, and proceed to Section VII. Watershed Restoration & Fish Habitat Enhancement Exemption (RCW 43.21C.0382). Infill Development Exemption (RCW 43.21C.229). Planned Action Exemption (RCW 43.21C.031). Categorical Exemption. Under what section of the SEPA Rule (WAC 197-11-800) is it exempt? (for example, WAC 197-11-800(1) Minor New Construction) More SEPA information is available at: http://www.ecy.wa.gov/programs/sea/sepa/e-review.html. VII. Public Notice You must publish a public notice at least once a week for two consecutive weeks with seven days in between publications, in at least a single newspaper of general circulation in the county in which the construction is to take place. Ecology cannot grant permit coverage sooner than the end of the 30-day public comment period, which begins on the date of the second public notice. Mail or fax ([PHONE REDACTED]) the NOI to Ecology on or before the first public notice date. If you fax the public notice to Ecology, you must also mail a hard copy. Failure to do so may delay the issuance of your permit. Provide the exact dates (mm/dd/yy) that the first and second public notices will appear in the newspaper(s): First notice: / / Second notice: / / (Begins 30-day public comment period.) For example: First notice: 01/01/10 Second notice: 01/08/10 Name of the newspaper(s) publishing the notices: ---PAGE BREAK--- ECY 020-85 (Rev. 06/09) 4 PUBLIC NOTICE TEMPLATE Complete this template using project-specific information and submit to a local newspaper with general circulation within the county where the project is located. The bold language is required by WAC 173-226- 130 and must be included in its entirety. (Either use the fill-in template below or attach on a separate sheet of paper, if necessary.) (Note: This section is unprotected so you can delete text in parentheses) (Name of operator/permittee) (address of operator/permittee) is seeking coverage under the Washington State Department of Ecology’s Construction Stormwater General Permit. The proposed project, ,(project name) is located at (street address, intersection, crossroads, or other descriptive site location) in (name of nearest city), in (County). This project involves acres of soil disturbance for construction activities. (List all construction activities, for example, residential, commercial, industrial, highway, utility). Stormwater will be discharged to (List all named and un-named receiving waters identified in section Any persons desiring to present their views to the Department of Ecology regarding this application, or interested in the Department’s action on this application, may notify Ecology in writing within 30 days of the last date of publication of this notice. Comments may be submitted to: Department of Ecology Water Quality Program P.O. Box 47696 Olympia, WA 98504-7696 VIII. Certification of Permittees “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 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.” / Printed Name / Company Title Signature * Date * Federal regulations require this application is signed by one of the following: A. For a corporation: By a principal executive officer of at least the level of vice president. B. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively. C. For a municipality, state, federal, or other public facility: By either a principal executive officer or ranking elected official. Please sign and return this document to the following address: Washington Department of Ecology - Stormwater P.O. Box 47696 Olympia, WA 98504-7696 ---PAGE BREAK--- ECY 020-85 (Rev. 06/09) 5 DO NOT SUBMIT THIS PAGE WITH APPLICATION More information is available at: http://www.ecy.wa.gov/programs/wq/stormwater/construction/. To ask about the availability of this document in a version for the visually impaired, call the Water Quality Program at 360- 407-6401. Persons with hearing loss, call 711 for Washington Relay Service. Persons with a speech disability, call 877- 833-6341. If you have questions about this form, contact the following Ecology staff: Location Contact Name Phone E-mail City of Seattle, Kitsap, Pierce, and Thurston counties Josh Klimek [PHONE REDACTED] [EMAIL REDACTED] Island, King, and San Juan counties Elaine Tomita [PHONE REDACTED] [EMAIL REDACTED] Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant, Lincoln, Pend Oreille, Skagit, Snohomish, Spokane, Stevens, Walla, Whatcom, and Whitman counties. Charles Gilman [PHONE REDACTED] [EMAIL REDACTED] Benton, Chelan, Clallam, Clark, Cowlitz, Douglas, Grays Harbor, Jefferson, Kittitas, Klickitat, Lewis, Mason, Okanogan, Pacific, Skamania, Wahkiakum, and Yakima counties. Joyce Smith [PHONE REDACTED] [EMAIL REDACTED]