Cambridge Phase 2-CS 961202 THIS FORM REPLACES PREVIOUS FORM 3510-6 (8-92) Form Approved.
Se~Eleverse for Instructions ~
...,s iA,,United States Environmenta, r-rotectionAgenCYWashington, DC 20460
FORM "Notice of intefit (NOI) for Storm Water Discharges Associated with Industrial
· ".. -. Activity Under a NPDES General Permit
Submission of this Notice of Intent constitutes notice that the party identified in Section II of this form Intends to be authorized by a NPDES permit issued for
storm, water discharges as. soclated with Industrial activity in the State identified in Section III of this form. Beco_min_g a__l_~_._.rmittee obligates such discharger to
comply with the lerms aha conditions of the permit. ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM. :
I. Permit Selection: You must indicate the NPDES Storm Water general permit under which you are applying for coverage. Check one of these, following:
Baseline l~ Baseline ~:I Multi-Sector [-~
Industrial Construction (Group Permit)
II. Facility Operator Information
Status of
Iii. Facili¥Site Location Information
' ' ' - ' Indian ~nds? ~ or.N)
IV. Site Activity Information
MS4 Operator Name: ["'~,
Receiving Water Body: ~'
If you are filing as a co-permitlee,
enter storm water general permit number':
SIC or Designated
Activity Code: Primary:
Is the facility required to submit monitoring data? (1, 2, 3, or 4)
If You Have Another Existing NPDES
Permit, Enter Permit Number:
V. A(3clit]onal Information Required tor Construct]on Activities Only
Project Start Date: Completion Date:
L~l / ~)1/'~ z'"l~3 / I ~ Estimated Area to be
Disturbed (in Acres):
I I I'1 I I I I
I Range: l t, I
Multi-Sector Permit Aoolicants Only;
Based on the instructions provided in Addendum h of the
Multi-Sector permit, are species identified in Addendum H
in proximity to the storm water discharges to be covered
under this permit, or the areas of BMP construction to
control those storm water discharges? I I
(Y or N) '
Will construction (land disturbing activities) be conducted' r--']
for storm water controls? Cf or N)
Is applicant subject to and in c~mpliance with a written
historic preservation a~reement? (Y or N}
Is the Storm Water Pollution Prevention Plan
in compliance with State and/or Lecal r'~
J , ~ ~ ,. ~ol sediment and erosion plans? (YorN)
VI. Certification: The ce~ficafion statement in Box 1 applies to all applicants.
The certification statement in Box 2 applies ~3Jy. to facilities applying for the Multi-Sector storm water general permit.
BOX 1
ALL APPLICANTS:
I certify under penalty of law that this
document and all attachments were
prepared under my direction or supervision
~n accordance with a system designed to
assure that qualified personnel properly
gather and eva]uate the information
submitted. Based on my inquiry of 'the
person or per~3ns who manage the system,
or those persons directly resp<~nsible for
gathering the information, the information
submitted is, to the best of my knowledge
and belief, true, accurate, anc~ complete. I
am aware that there are significant penalties
for submitting false information, including the
possibility of fine and imprisonment for
knowing violations.
BOX 2
MULTI-SECTOR STORM WATER GENERAL PERMIT APPLICANTS ONLY:
I certify under penalty of law that I have read and understand the Part I.E. eligibility requirements for
coverage under the Multi-Sector storm water general permit, including those requirements relating to
the protection of species identified in Addendum H.
To the. best of my knowie.d_ge, the discharges covered under this permit, and construction of EMPs to
contra storm water run-on, are not likely to and will not likely adversely affect any species identified in
Addendum H of the Multi-Sector storm water general permit or are otherwise eligible for coverage due
to previous authorization under the Endangered Species Act. .
To the. best of my knowledge, I further certify that Such discharges, and construction of BMPs to
contro~ storm water mn-off, do not have an effect on properties listed or eligible for listing on the
NalJonal Register of Histodc Places under the National Historic Preservation Act, or are otherwise
eligible for coverage due to a previous agreement under the National Historic Preservation Act.
I understand that continued coverage under the Multi-Sector generaJ permit is contingent upon
maintaining eligibility as provided for in part I.E.
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