Eagle Point-CS 930127~1230 Federal Re~"~r / Vol. 57, N0. 175 / Wednesday, Septc,~r 9, 1992 / Notices
Appendix C - NOI Form Instructions
See Reverse for Instructions Foan.aVt, m~at
PA United Suites ~vlronmcntal Protection ^&ency, Washin[ton0 DC 20460
NPDE$~Xl~/~dnlh ~ Notice of Intent (NOI) for Storm Waste Discharge Associated with Industrial
FOR]~ ~m ActJviW Under the NPDES General Permit
Submission of this Noticcoflntent conslitutc~ not icc that thc [~arty identified in Section I of this form inlands robe authorizedbya NPDESpermit issued forstorm
water discharges as,,,ociated with indust rialaclivityin t he state identified in Se~t ion llof this form. I]ccominga permittcc obligates such discharger tocomplywith
thetcrmsandeondltionsoftbepermit. ALL NECESSARY INFORMATION MUST BE PROV1DEI) ON Tills FORM.
l. Facility Operator Information
Name: I I~S&IGIT, II~..I IP:Ol'flNl?l IDIEIVII~.ILIO~PIMIEINtI'I ILI'I'I[X I I I I I I I Phone: [PI1 !4J~tl'7 I~tl~tKIt~l~l
, .
Address: ~.AJ..A~MTJ~h'lJ'ri InlTITJTJ ~l'dnl I~,lr.l~/i~s~l k. lnl~tl I I I I I ] Statusof
Ow ncr/Operator:
City: I_rd M T]TJxI-~ I I I I I I I I I I I I I I I I I IJ State: Iq, I Y! ZIPCode: ['TJr, 191'Zll I-I I I I 1
II. Facility/Site Location Is the Facility Located on
Indian Lands? (Y or N)
Name: IEIAIGIT'!I~I I~..O~TINT'I'I IVITILIL/NGInl IAI~ IRI~IVII~IRIC!IfllH~II~I 1
Address: J nl TIvi~IR:C~IRI~I-qzi ID:Ri]IVIEI I I I I I I I I I I I I I I I I I I I l
City: I(~IOIpIIXMTJTJ I I I I I I I I I I I I I I I I I ! State: ]?lYI ZIPCode: 1'71,~lnlllql-I I I I I
Latitude:]~121~l'71,dl~ll Longitude:lql~,lg!~lK[~ Quartez:.l I l Section:J I I Township:l I I I IRan[e: I I I I !
IlL Site Activity Information
MS4 Operator Name: I RI&I~Ii'JI~ II=i~'iTIWI'~I In[~lulnlTJ~zdM~halq, I I~.l,plnl I I I III I
Receivin~ Water Body: IN I ol nI'PIRIIqlRIgI?I ID~,ILd&I~L I-' ll~lO.I M?I ¥ FLOOD CON~ROJ.,
Is the Facility Required ~]
if You arc FilinB as a Co-permittee, Enter Arc There Existin[ ~ to Submit Monitoring
Quantitative Data? (Y or N) Data? (1, 2, or ~)
Storm WatcrGeneralPermitNumber:. I I I I I I I I I !
SIC orDesignatedActivity Code: Primal: ~ 2nd:J I I I I 3rd: [ I I I [ 4lh:l J I I 1
If'This Facility is a Member of · Group
Applieation, EnlerOroupApplicationNumbec J I I I
if You Have Other Existing NPDF_.S
IV. Additional Information Required for Construction Activities Only
Project Completion is the Storm Water Pollution Prevention Plan
Start Date: Date: F.~timated Area to be In Compliance with State and/or Local
I OI2l~l'~lql~l IolS~lll SIcj~i Disturbed (in Acres): I I I I I~tl I Sediment and Erosion? (Y or N)
V. Ce~f'malion: ! ca,lifT un~r penalty ~ law that this document and all att~hn~mts were pa:Ixtr~d under my direclJc~ cc supervision in accoaJance with a system
designed to assure that qualifiedl)c rsonn¢lproperly~atherandcvnluatc the information submitted. Based on my inquiry of thc pc rson or personswho manage the
systcm,orthoscpersonsdircct lyre.sponsiblc for~nthcrlngt hein formation,t he informalionsubmitled is, to t he best of my knowledge and belief, true, accurate,and
complete, la maw'are that there arc si~nifi~nt penaltie~forsubmit t in~fals~ information,including the pc~sibilit),offine and imprisonment for know~ ri[viola t ions.
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