NOI to use NPDES Generic permit for Stormwater Discharge from Large and Small Construction Activities

me (if different

than

“Operator”),

applicable:

: ss

: :

NOTICE OF INTENT

TO USE

NPDES GENERIC PERMIT FOR STORMWATER

DISCHARGE FROM LARGE AND SMALL

CONSTRUCTION ACTIVITIES

(RULE 62-621.300(4), F.A.C.)

You must submit this completed Notice of Intent (NOI) form to the Department to get coverage under the Generic Permit for

Stormwater Discharge from Large and Small Construction Activities provided in subsection 62-621.300(4), F.A.C. The

Generic Permit document [DEP Document 62-621.300(4)(a)] tells you what construction activity qualifies for coverage, how

you obtain and terminate coverage, what you must do to minimize pollution from your construction site, and what conditions

apply to your project to use the generic permit. You must submit the appropriate generic permit fee, as specified in

paragraph 62-4.050(4)(d), F.A.C., with this NOI Form to obtain permit coverage. You must read and understand the

requirements of the generic permit document and the attached instructions before completing this NOI form. Please print

or type information in the appropriate areas below.

For construction activities also requiring an Individual Environmental Resource Permit (ERP), under Chapter 62-

330, F.A.C.:

If your construction activities are already authorized by a valid Individual ERP issued by the Department, Water

Management District or a Delegated Local Government, you may also elect to use this NOI form to provide the

required notice of commencement of construction, in lieu of Form 62-330.350(1) (“Construction Commencement

Notice”).

Do you wish to also provide notice of commencement of construction activities authorized under an Individual ERP

permit through the use of this form? Yes No

I. IDENTIFICATION NUMBER:

A. Facility ID (if renewing coverage): _____________________________________________

B. ERP Permit Number* (if applicable): ___________________________________________

C. ERP Permitting Agency (if applicable): _________________________________________

*If the ERP permit authorizes phased construction, please also indicate which phase.

II. STORMWATER POLLUTION PREVENTION PLAN (SWPPP) DEVELOPED AND READY TO BE

IMPLEMENTED: Yes No

*If No, you may not submit your NOI at this time.

III. APPLICANT INFORMATION:

A. Operator Nam

* ERP Permittee Na

B. Operator Statu

C. Addre

D. City E. State eF. Zip Cod

G. Responsible Authority

Page 1 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015

. :

′ ″

y: te : e:

J. Project Contact:

K. Project Contact’s Phone No .:

L. Project Contact’s Fax No. :

M. Project Contact’s E-mail Address :

N. Additional E-mail correspondence, optiona l:

e: ° ′ ″

t y:

te: C

te : G :

H. Responsible Authority’s Phone No

Responsible Authority’s Fax No

Responsible Authority’s E-mail Address

. P

ROJECT/SITE LOCATION INFORMATION

Project Name:

Project Address/Location

Cit D

Sta E

Zip Cod

Count

Latitud

e: ° L

ongitud

H. I

s the site located on Indian Country Land

s? Yes o

N I.

Water Management Distric

V. P

ROJECT/SITE ACTIVITY INFORMATION

Indicate whether t

roject is Large or Smal

onstruction (check onl

ne)

arge Construction (Project will disturb 5 or more acres of land, Fee $400)

Small Construction (Project will disturb between 1 and 4.99 acres of land, Fee $250)

Approximate total area of land disturbance from commencement through completion of construction

: _________ acres

C. SWPPP Location:

ddress in Part III above

Address in Part IV above ther address (specify below)

SWPPP Addres

Sta . Zip Code

Construction Period

: S

tart Da ompletion Date

VI. DEWATERING INFORMATION:

Will dewatering operations be performed as part of the construction activities?

below. If no, skip this part and go to Part VII.

yes, complete

B. Is the project site currently identified as contaminated, or is there a site within 500 feet of the

dewatering project identified as contaminated by a DEP or EPA cleanup/restoration program? You

ay use the Quick Link to DEP’s Contamination Locator Map (CLM) and DEP’s Institutiona

ntrols Registry (ICR) Web Viewer to determine cleanup restoration status. You may access th

CLM at: http://webapps.dep.state.fl.us/DepClnup/welcome.do or

Page 2 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015

C. H

__________________________________________________________ ____

______________________________

http://ca.dep.state.fl.us/mapdirect/?focus=contamlocator. The ICR may be accessed at:

http://www.dep.state.fl.us/waste/categories/brownfields/pages/ICR.htm, or

http://ca.dep.state.fl.us/mapdirect/?focus=icr

YES Continue to VI.C, below.

NO Continue to Part VII.

as the site been remediated?

YES Continue to Part VII.

NO Continue to VI.D, below.

con

cov

Rul

Are the pollutants of concern (i.e. contamination) present in ground water at the dewatering project site at

centrations equal to or exceeding the surface water criteria in Rule 62-302.530?

YES Dewatering activities do not qualify for coverage under this generic permit. However, the site may qualify for

erage under Rule 62-621.300(1), F.A.C., or under an individual wastewater permit on the appropriate form listed in

e 62-620.910, F.A.C.

NO Continue to Part VII.

VII. DISCHARGE INFORMATION:

MS4 Operator Name (if applicable

Receiving Water Nam

VIII.CERTIFICATION

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.

If providing notice of commencement of construction as required by an Individual Environmental Resource Permit, I also

certify that I am authorized by the Permittee (identified in Part III.A., above), to commence construction activities

authorized by the ERP Permit (identified in Part I.B., above).

Responsible Authority Name and Official Title (Type or Print):

Responsible Authority Signature: Date Signed:

Signatory requirements are contained in Rule 62-620.305, F.A.C.

Page 3 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015

INSTRUCTIONS – DEP FORM 62-621.300(4)(b)

NOTICE OF INTENT (NOI) TO USE GENERIC PERMIT FOR STORMWATER DISCHARGE FROM LARGE

AND SMALL CONSTRUCTION ACTIVITIES

Who Must File an NOI:

You must file the NOI and obtain coverage under the Construction Generic Permit if you discharge stormwater associated

with large or small construction activities to surface waters of the State, including through a Municipal Separate Storm

Sewer System (MS4), http://www.dep.state.fl.us/water/stormwater/npdes/docs/all_ms4_by_county.pdf.

Where to File NOI:

The Department encourages the electronic submission of NOIs using the Department’s Interactive Notice of Intent (iNOI)

available at http://www.fldepportal.com/go/. NOIs also may be submitted by paper copy to the following address:

NPDES Stormwater Notices Center, MS #3585

Florida Department of Environmental Protection

2600 Blair Stone Road

Tallahassee, Florida 32399-2400

Permit Fee:

Permit fees for large and small construction activities to be covered under the generic permit are specified in paragraph 62-

4.050(4)(d), F.A.C. and available on our http://www.dep.state.fl.us/water/stormwater/npdes/fees.htm. You must submit the

appropriate generic permit fee (either for large 5+ acres $400 or small 1- 4.99 acres $250 construction activities) with the

completed NOI to obtain coverage under the generic permit. Generic permit coverage will not be granted without

payment of the appropriate permit fee.

If the NOI is submitted electronically, the permit fee must be paid on-line by credit card or check. If the NOI is submitted

using a paper copy, the permit fee must be paid by either check or money order made payable to: “Florida Department of

Environmental Protection”.

Part I – Identification Number:

If you are renewing coverage, please enter the project’s DEP identification number (generic permit coverage number) if

known. If this is a new project without an ID number then leave this item blank. If you know your ERP Permit Number or

ERP Permitting Agency (if applicable) please identify it here, if not then leave these items blank.

Part II – Stormwater Pollution Prevention Plan (SWPPP) Completed:

Check the box to indicate whether you have completed your Stormwater Pollution Prevention Plan. You must complete your

SWPPP and be ready to implement it before submitting your NOI.

Part III – Applicant Information:

Item A.: Provide the legal name of the person, firm, contractor, public organization or other legal entity that owns or

operates the construction activity described in this NOI. The operator is the legal entity that has authority to control those

activities at the project necessary to ensure compliance with the terms and conditions of the generic permit.

Item B.: Enter the appropriate one letter code from the list below to indicate the legal status of the operator:

F = Federal; S = State; P = Private; M = Public (other than federal or state); O = Other

Items C. – F.: Provide the complete mailing address of the operator, including city, state and zip code.

Page 4 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015

Items G. – J.: Provide the name, telephone and fax number (including area code) and E-mail address of the person

authorized to submit this NOI on behalf of the operator (e.g., Jane Smith, President of Smith Construction Company on

behalf of the operator, Smith Construction Company; John Doe, Public Works Director on behalf of the operator, City of

Townsville; etc.). This should be the same person as indicated in the certification in Part VI.

Part IV – Project/Site Location Information:

Items A. – E.: Enter the official or legal name and complete street address, including city, state and zip code of the project.

Do not provide a P.O. Box number as the street address. If it lacks a street address, describe the project site location (e.g.,

intersection of State Road 1 and Smith Street).

Item F.: Enter the county in which the project is located.

Item G.: Enter the latitude and longitude, in degrees-minutes-seconds format, of the approximate center of the project.

Item H.: Indicate whether the project is located on Indian Country Lands. If the project is located on Indian Lands you

may not use this generic permit. Instead, you must apply to the http://cfpub.epa.gov/npdes/stormwater/const.cfm (EPA) for

coverage.

Item I.: Enter the appropriate five or six letter code from the list below to indicate the

http://www.dep.state.fl.us/secretary/watman/default.htm in which your project is located:

NWFWMD = Northwest Florida Water Management District

SRWMD = Suwannee River Water Management District

SFWMD = South Florida Water Management District

SWFWMD = Southwest Florida Water Management District

SJRWMD = St. John’s River Water Management District

Items J. – M.: Enter the name, telephone and fax number (including area code) and E-mail address of the project contact

person. The project contact is the person who is thoroughly familiar with the project, the facts reported in this NOI and

who can be contacted by the Department if necessary.

Item N.: Enter additional E-mail correspondence as needed to receive permit related documentation. (Optional)

Part V – Project/Site Activity Information:

Item A.: Check the appropriate box to indicate whether the project involves large construction activity or small construction

activity. Check one box only.

“Large Construction Activity” means construction activity resulting in the disturbance of five (5) or more acres of total land

area. Large construction activity also includes the disturbance of less than five acres of total land area that is part of a

larger common plan of development or sale such as a subdivision that will ultimately disturb five acres or more.

“Small Construction Activity” means construction activity resulting in the disturbance of equal to or greater than one (1)

acre and less than five (5) acres of total land area. Small construction activity also includes the disturbance of less than one

acre of total land area that is part of a larger common plan of development or sale that will ultimately disturb equal to or

greater than one acre and less than five acres.

Item B.: Provide the approximate total area of land disturbance, in acres, that the project will involve from commencement

of construction through completion.

Items C. - G.: Indicate the location where the Stormwater Pollution Prevention Plan (SWPPP) can be viewed. Provide the

address where the SWPPP can be viewed if other than as provided in Parts II or III of the NOI. Note that to be eligible for

coverage under the generic permit, the SWPPP must have been prepared prior to filing this NOI.

Item H.: Enter the estimated construction start and completion dates in the MM/DD/YY format.

Page 5 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015

Part VI – Dewatering Information:

If your site has “noncontaminated ground water”, the CGP also authorizes discharges from ground water dewatering activities.

A site will be presumed to have uncontaminated if it is not contaminated and there are no known contamination sites within

500 feet of the site. You may use the Department’s http://webapps.dep.state.fl.us/DepClnup/welcome.do or the Institutional

Controls Registry (ICR) Web Viewer http://www.dep.state.fl.us/waste/categories/brownfields/pages/ICR.htm, to determine

the location of contaminate sites. The CGP does not authorize the discharge of contaminated ground water.

Part VII – Discharge Information:

To be covered under a CGP, you must provide the following information about where the discharge from your project will

go. NOIs submitted without discharge information cannot be processed.

Item A.: If stormwater from your project discharges to a MS4 enter the name of the MS4 (e.g., City of Tallahassee MS4,

Orange County MS4, FDOT District 5 MS4, etc.). If stormwater from your project does not discharge to an MS4 but to

surface waters of the State, leave this item blank or indicate “N/A” and skip to Item B. of this part. Please note that if

your project discharges stormwater to an MS4, you must provide the MS4 operator with a copy of the completed

NOI. http://www.dep.state.fl.us/water/stormwater/npdes/docs/all_ms4_by_county.pdf

Item B.: If your project discharges stormwater to surface waters of the State, and not to an MS4, enter the name of the

receiving water body to which the stormwater is discharged. Please provide the first named water body to which the

stormwater from the project is discharged (e.g., Cypress Creek, Tampa Bay, unnamed ditch to St. Johns River, Tate’s Hell

Swamp, etc.).

In certain cases, stormwater from the project will discharge to both an MS4 and surface waters of the State. In this case,

complete both Item A. and Item B.

Part VIII – Certification:

Type or print the name and official title of the Responsible Authority signing the certification. Please note that this must be

the same person indicated in Item II.G. as the Responsible Authority. Sign and date the certification.

Section 403.161, F.S., provides severe penalties for submitting false information on this application (NOI) or any reports or

records required by a permit. There are both civil and criminal penalties, in addition to the revocation of permit coverage for

submitting false information.

Rule 62-620.305, F.A.C., requires that the NOI and any reports required by the permit be signed as follows:

A. For a corporation, by a responsible corporate officer as described in Rule 62-620.305, F.A.C.;

or a partnership or sole proprietorship, by a general partner or the proprietor, respectively; o

or a municipality, state, federal or other public facility, by a principal executive officer or elected official

age 6 of 6

DEP Form 62-621.300(4)(b)

Effective Date: 02/2015