Summit P1-CS 960905 THIS FORM.~pLAcEs PREVIOUS FORM 3510-6 (8-92) ~ Form Approved. OMBNo. 2040-~)M
Sr '{eveme for Instructions ~.,~,~
· Washington. DC 20460 [ ~,,~IL~ '~ .
FORM ~m ' Notice of Inter~t (NOI) for Storm Water Discharges Assoclatl[d-:l~t~'l~dustrlal
m . · . Activity Under a NPDES General Permit ~
Submission of this Notice of Intent constitutes notice that the party idanlified in Section !1 of this form Intends to be. authorized by a NPDES permit issued for
storm water discharges associated with industrial activity in the State identified in Section III of this form. Becoming a permittee obligates such discharger to
comply with the terms and conditions of the permit. ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM. :
I. Permit Selection: You must indicate the NPDES Storm Water ganeraJ permit under which you are applying for coverage. Check one of these.'foilowing:
Industrial Construction (Group Permit)
II. Facility Operator Information
Name: I/~,~',~r,/V,~',.~,, ,,~',,,~,o,~,,~,,~,/~,/,e-,~, ,/,,v;,¢ ...... , , I phona:lZ~/,41?,7,~l~,3,3,31
Status of
Address: I/,~,O,1, ,~/..,,~, ,.5,~, ,5','r',~ ~/,7, o,0,,,,, ~ ~,,,,, I Owner/Operator:
city: IOv~'~C,Z-~-f., t,,,,,,,,,,,,,, I state:lTTX-I Z~PCode: 17,5';,Z.,d,l,',?,Z,d-,ll
III. Facility/Site Location Information
· Is the facility located on
Name: I:~,L/,~1/,7';, ,,q-iT, ,7';//,£, ,5',/',,~,/,/v,d,5,,,,,,,,, I Indian Lands? (Y or.N)
Address: I ~ ~ , , ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i s ~ ~ ~ ~ ~ i i i i i
city: I~'~d~?~,~,:,C.,,,,,,,,,,,,,, ,, I state: I;7',;(I ZIPCc~:Ie:I, ~,, I'1 ~ I ~J
~atit~da: ~ .ong.ude:i ,~,/~lS',?l~,?lOua.er:l ~ ISect~on:l ~ I Tow~ship:l,,, I Ranae:l,,, I
IV. Site Activity Information
MS4 Operator Name: I i i i I I I I t i I I I I t I I I , , , , ~ , ~ ~ ~ ~ ~ ~ ~
ReceivingWaterBody:l~'~(s~EtV~/I/V~/'--~ ,~,~,~',~,K,,,,,,,,,
Multi-Sector Permit Aoolicants Only:
If you are tiling as a co-permit'tee,
enter storm water general permit numbe~ I I Based on the instructions provided in Addendum H of the
........ Multi-Sector permit, are species identified in Addendum H
SIC or Designated in proximity to the storm water discharges to be covered
Activity Code: Primary: I~' ,O, , I 2nd: I , , , I under this permit, or the areas of BMP construction to
control those storm water discharges? .
(Y or N)
Is the facility required to submit monitoring data? (1,2, 3, or 4) L~ Will construction (land disturbing activities) be conducted' [---]
If You Have Another Existing NPDES for storm water controls? ("Y or N)
Permit, Enter Permit Number: I ~ , , ~ ~ ~ ~ ~
Is applicant subject to and in compliance with a written
historic preservation a~reement?. (Y or N)
V. Adclitional Information Required for Construction Activities Only
Project Start Date: Completion Date: Is the Storm Water Pollution Prevention Plan
Estimated Area to be in compliance with State and/or Local L~
IC),~/l~,l I?,(-I ICe, glc~, i1'/,~1 O~sturbed(~nAcras): ~ aediment and erosion plans? (Y or N)
VI. Certification: The cer~ficafion statement in Box I applies to all applicants.
The certification statement in Box 2 applies ~ to facilities applying for the Multi-Sector storm water general permit.
BOX 1 BOX 2
ALL APPLICANTS: MULTI-SECTOR STORM WATER GENERAL PERMIT APPLICANTS ONLY:
I certify under penalty of law that this I certify under penalty of law that I have read and understand the Part I:.B. eligibility requi.rem.an.!s fo.r
document and all attachments were coverage under the Multi-Sector storm water general permit, including mose requirements re~ating
the protection of species identified in Addendum H.
prepared under my direction or supervision
~n accordance with a system designed to
assure that qualitied personnel properly To the best of my knowledge, the discharges covered under this permit, .an.d conatruction of. BMP_s .to
gather and evaluate the information control storm water run-off, are not likely to and will not likely adversely enact any species ioantifiecl in
submitted. Based on my inquiry of 'the Addendum H of the Multi-Sector storm water general pen"nit or are otherwise eligible for coverage due
parson or persons who manage the system, to previous authorization under the Endangered Species Act.
or those persons directly responsible for
gathering the information, the information To the best of my knowledge, I further certify that such discharges, and ..c..o~.....truc. tio.n..of BMPs.[to
submitted is, to the best of my knowledge control storm water run-off, do not have an effect on properties listed or e~igible TOr lisang .o.n me
and belief, true, accurate, and complete. I National Register of Historic Places under the National Historic Preservation Act, or are otherwise
am aware that there are significant penalties eligible for coverage due to a previous agreement under the National Historic Preservation Act.
for submitting false information, including the
possibility of fine and imprisonment for I understand that continued coverage under the Multi-Sector general permit is contingent upon
knowing violations, maintaining eligibility as provided for in Part I.B.
PdntName: ~IM,I ,C,J~,~,~';~/... , ,~,..-,, ,~.~.4-,~-~,A/,~:'~P-~ ,,,,,,,,,,, I Date: ~
' Sicnature: f~~/
EPA Form 3510-6 (8-98) j
In,Inactions - EPA Form
Notice Of Intent.,~LoI) For S~ W~r ~cha~ee ~d ~ I~ ~
r 'To ~ ~Ve~ Under · NP~S ~ml Pa~
Who Must File A l~tica Of In~?t (NO,) Form
Lssoc~ted w~A indu~La~ actable' to I wiser body(mo) of the U.S. wW~out I Nlttonll
Petulant Di~.herge Elin~n System (NPDES) perm~ '1~ operetor of an k~lustrlel
acttv'~y that has ~uch a storm water discharge must aubmit · NOI to ob*f. in ~ge
under a NPt3E$ Storm Water Genarel Permit. If you have quesUona abeut whether you
need a permit under the NPDES Storm Water pro~rem, or If you need information aa
tD whether a par'dculer p~rem is administered by EPA or = state agent% tMephona
or w~e to the NoUce of Intent Processing Center at (70:3) 931-3230.
Where To File NOI Form
NOIs must be sent to the following address:
Completing The Form
Storm Water Notice of Intent (4203)
401 U Street. S.W.
Washington, DC 20460
You must type or print, using upper-case letters, in the appropriate areas only. Please
place each character between the marks. Abbreviate if necessary to stay within the
number of charectem allowed for each item. Use one space for breal~ between words,
but not for punctuation marks unless they ere needed to clarify your response, If you
have Iffy questJons on this form, cell the Notice of Intent Pm(:essing Center at (703)
931-3230.
Section I Permit Selection
You must indicate the NPDES storm water general permit under which you are
ipplying for c~verage. Check one box only. The Baseline Ifldustdal and Baseline
Constructwfl perm~ wee issued in September 1992. The Multi-Sector Permit became
effective October 1. lg95.
Section II Facility Operator Information
Iht, in descending o~for of significance, up to two 4-digit 8fandarcl industMI
ciaseifica~on (SIC) codas ~at best describe the principal products or sea,cos pmvMed
at the faciity or site ldenUfied in Section !11 of this eppltca'don, If you am applying for
Coverage under the construction genareJ pem~t. Inter "CO' (v~ represent~ SlC
codes 1500 - 1790).
For indu~rlal ~Mbes dM'mad in 40 CFR 122~6(bX14)0)-(~ lima do not have SIC
codes that ocourately describe Ihs principal products pfnduMd or services provided,
use the following 2-character
HZ - Hazamous waste ~ree~nent, storage, or disposal fac~Jes, including those mat
are operating under Imodm sta~s or · permit under suMJ0e C of RCRA [40
CFR 122.20 (bX14Xiv)]:
LF · Landf*dls. land applioaUon sites, end open dumps ~at racoJve or have reoeived
any indualrlel wastes, including those that ere mJbjoct to reguJatiofl under
m~Mme D of Reft, [40 CFR 122.20 (bX14Xv)]:
SE - Steam o~ jx~ver genareUng fadings, including coal handling s~es [40 CFR
122.2e
TW· Treatment wo~.s Vee~ng demesne sewage or any o~er sewage sludge or
vrestawater raiment device or system, used in the storage, ~reatmeflt,
recycflng, and f~:famelJon of' municipal or domos~ sewoge [40 CFR 122.26
~DX~ 4)0x)]: or,
CO - CenstflJc~on ack. es [40 CFR 122.2S CoXI4Xx)].
If there is another NPDES permit presenlJy issued for the fadJty or site Glted. in S~cttofl
IlL enter the permit number. If an application for the fac~/has been subn~ted t~fl no
permit number has been assigned, enter tho applice~n number.
Faciiitms applying for coverage under the Mum-Sector storm water genaral per~ must
answer the last three questions in Sec~on IV. R~er to Addendum H of t~e Multi-Sector
0eflerel perm~ for 8 list of species that are ei~er proposed or I~ed as threatened or
endangered. 'aMP'. means 'bsa Management Practices* that are used to
storm water discharges.
Provide t~e legal name of tAe per3on, firm, public organization, or any other entity that
operates the facil~ or site described in this application. The name of the operator may
or may not be the same as the name of aha facility. The responsible patly is the legal
entW that c~ntrois the faci]W's operation, rather than the plant or site manager. Do not
use a colloquial name. Enter the complete address and telephone number of the
operator.
Enter tAe appropriate letter to indicate the legal status of the operator of the facility:
F = Federal; S = State; M · Public (other than federal or state); P = Pdvete.
Section II1 Facili~lSita Location Information
Enter the facil~'s or site's off'c, ial or legal name and compJete street address, including
c~ty. state. Incl ZIP code. If ~e fac~l~ or site lacks a street addrese. Indicate the stets
and either the le~tucle and longitude of the fa~l~ to the nearest 15 seconds or the
quarter, secSon, township, and renge (to the nearest quarter sect~n) of the approximate
center of the site. Do not provide a P.O. Box number aa the ab~aet address.
Indicate whether any construc',ion will be conducted to inataJl or develop storm water
runoff controls.
Section V Add~onel Information Required for ConllTUC~On Ac~ltJei Only
Constmctmn a(:tA, itMs must complete Se(:~on V in IddWon ~o SecUons I through IV.
Only construction ac~vibes need to complem SecUon V.
Enter me project mart date and the estimated omnpletion date for the entire
development plan.
Provide an estimate of the total number of acres of the Nee on which ioii wil be
disturbed (round lc) the nearest acm).
Indicate whether the storm wirer pollution prevention pen for the site is in compliance
wi~ approved state and/or iocel MKliment and ero~on p~na. permits, or storm water
management Paisa.
Indicate whether the ~ac~ity is located on Indian lends.
Section V! C4rUflcaUofl
Section IV Sits Activity Infofln~Uofl
ff the stem~ water discharges fo a ~n~pal ~pamte s~ ~r ly~m ~). en~r
~e fll~ of ~e o~mtor of ~e MS4 (e.g.. mun~pal~ ~, ~un~ fll~)
or system of ~fl~yafl~s (including made ~ drainage syste~, mun~l
~t~ basins. ~s. gu~e~, a~es. ~fl~de ~anflels. or
~ed or operated by a sets. ~, ~. ~mugh. ~ufl~. pe~h,
or offier publ~ ~y ~ ~ des~nad or u~ for ~g
E~e f~ dilates s~ water dim~ ~ ~g
~ you am ~ing as a ~ee and a s~ ~r Oenamf
~ued, enter ~at flum~r ~ ~e spa~ pm~ed.
~n~dng mquim~fl~. Ind~ ~e ~n~dng
following:
1 = Not Subp~ ~ ~fl~oHng mquim~fl~ under
2 = $ub~m ~ ~fl~dflg ~uim~n~ ~ mqui~ ~ subm~ da~.
3 ~ $ub~ ~ ~fl~odng mquim~n~ but ~ required ~ subm~ da~.
4 = Sub~ ~ ~n~dng mquim~fl~ b~ sub.fig
e~us~n.
Federal statutes proMde for severe penalbea for submiUing tam In~rmation on this
&pplioaUon form, Federal regutaUons require this app#caUon to be si0ned as foaows:
For · co,,poredon: by a m~ponaible coq)orate Mflcer, which means: (1) president.
eecrete~, tTeSsumr, or vlce-presid2nt af the corporation in charge of ·
business lunches, or any other peruse Who pedo~'ns ~11hr policy or decision making
func~ona, or (ii) the manager of one or mom manufac~ring, pmcluc~on, or operaling
lactates emp~y~g nme than 250 pemena or hav~ng gm~ annual seJes or
expenditures exceeding $25 million (in second-quarter 1080 doAirs), if aumor~y to sign
documents has been ii, geed or delegaMd to the ffmneger ~n eacordance
corporate procedures:
For · p~p or f~e pmp~ea~/p: by i 0enarel perMor or the proprJe~c or
For f municipally. E~t~, Federal. or o~)er pubic fea~. by either a principal executive
oftfcer or ranking elacWd official.
Paperwork RedugUon ALt NoUce
PulMic reporlmg bun:lea for this application is ealJrnated to average O.S beura per
appl'ca'don, including time for reviewing instruc~ons, seafl:~ing exJst~g dam semcos,
gathering and maintaining the data neeae~, ina Gon~p;ednG ~,n,~ reviewing the c:~c~X~n
of infestation. Send comments rebinding the b~rclen estimate, any other asp~c~ of~e
ccglaction of information, or luggesttons ~ knprovtng this .fi)rm..i~uding any
luggesliona whic~ may increase or reduce thee I~len to: Chief, Irlfommti~n Pulley
Branch, 2136. U.S. Environmental Protection Agent, 401 M Street, aW, Washingt=n.
DC 20460. or Director, Ofhce of Infon'natien Ind Regulito~ Afflim, cifrK:e of
Management -,nd Budget, Washington. DC 20503.