NOTICE OF INTENT FOR DISCHARGES OF STORM WATER ASSOCIATED WITH MEDIUM OR LARGE CONSTRUCTION ACTIVITY AUTHORIZED UNDER NPDES GENERAL PERMIT ARR150000

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1 NOTICE OF INTENT FOR DISCHARGES OF STORM WATER ASSOCIATED WITH MEDIUM OR LARGE CONSTRUCTION ACTIVITY AUTHORIZED UNDER NPDES GENERAL PERMIT ARR The enclosed form may be used to obtain coverage under NPDES general permit ARR for discharges of storm water associated with construction activity at any site or common plan of development or sale that will result in the disturbance of five (5) or more acres of total land area. Return the completed form to: The following facilities are required to submit the Notice of Intent: (1) Except as provided in paragraphs (2) and (3) below, individuals who intend to obtain coverage for storm water discharges from a medium or large construction site shall submit a Notice of Intent at least two weeks prior to commencement of construction; (2) Upon a pending transfer of ownership of a construction operation with a storm water discharge covered by this general permit, the new owner/operator must submit a Notice of Intent at least two weeks prior to the new owner/operator beginning work at the site; (3) A discharger is not precluded from submitting a Notice of Intent at a later date as provided above. In such instances, the Director may bring an enforcement action for failure to submit a Notice of Intent in a timely manner or for any unauthorized discharge of storm water that have occurred on or after the dates specified in paragraphs (1) or (2) above. The following definitions should be used to determine if the construction activity is a medium or large construction site: Large Construction Sites mean any construction activity that meets one of the following two definitions: (i) Construction sites that will result in the disturbance of ten (10) or more acres of total land area or less than ten (10) acres of total land area that is part of a larger common plan of development or sale if the larger common plan will ultimately disturb ten (10) acres or more located in the following counties: Baxter Garland Newton Sharp Benton Hot Spring Perry Stone Boone Howard Pike Van Buren Carroll Independence Polk Washington Clark Izard Pope White Cleburne Johnson Pulaski Yell Conway Lawrence Randolph Crawford Logan Saline Faulkner Madison Scott Franklin Marion Searcy Fulton Montgomery Sebastian

2 (ii) Construction sites that will result in the disturbance of twenty (20) or more acres of total land area or less than twenty (20) acres of total land area that is part of a larger common plan of development or sale if the larger common plan will ultimately disturb twenty (20) acres or more located in the following counties: Arkansas Crittenden Jefferson Nevada Ashley Cross Lafayette Ouachita Bradley Dallas Lee Phillips Calhoun Desha Lincoln Poinsett Chicot Drew Little River Prairie Clay Grant Lonoke Sevier Cleveland Greene Miller St. Francis Columbia Hempstead Mississippi Union Craighead Jackson Monroe Woodruff Medium Construction Sites mean any construction activity that meets one of the following two definitions: (i) Construction sites that will result in the disturbance of greater than five (5) acres and less than ten (10) acres of total land area or less than five (5) acres of total land area that is part of a larger common plan of development or sale if the larger common plan will ultimately disturb five (5) acres or more located in one of the counties identified in Part (i) of the Large Construction Site definition above. (ii) Construction sites that will result in the disturbance of greater than five (5) acres and less than twenty (20) acres of total land area or less than five (5) acres of total land area that is part of a larger common plan of development or sale if the larger common plan will ultimately disturb five (5) acres or more located in one of the counties identified in Part (ii) of the Large Construction Site definition above. Unless notified by the Director to the contrary, dischargers who submit a complete Notice of Intent in accordance with the requirements of this permit are authorized to discharge storm water from construction sites under the terms and conditions of this permit two weeks after the date the NOI is postmarked. As required by ADEQ Regulation No. 9, an initial permit fee of $ must be submitted with this NOI. Subsequent annual fees of $ per year will be billed by the Department. Failure to remit the required permit fee may be grounds for the Director to deny coverage under this general permit, and to require the owner or operator to apply for an individual NPDES permit. NOTE: A STORM WATER POLLUTION PREVENTION PLAN (SWPPP) SHALL BE PREPARED PRIOR TO SUBMITTAL OF THIS NOI PER PART II.A OF THE GENERAL PERMIT. THE SWPPP MUST BE SUBMITTED FOR APPROVAL ALONG WITH THIS NOI FOR LARGE CONSTRUCTION SITES PER PART I.B.6.a OF THE GENERAL PERMIT. For additional information please contact: Storm Water Runoff Engineer Ph.: (501) Fax: (501) adeq@state.ar.us

3 How to Determine Latitude and Longitude: 1. If a physical address is known go to 2. Select Advanced Find 3. Select Address 4. Input address 5. Click on Aerial Photo 6. Click on the Info link at the top of the page 7. Note the Latitude and Longitude are in Decimal Coordinates. 8. Go to to convert coordinates to Degrees, Minutes, and Seconds. NOTE: If a physical address does not exist you may find the coordinates in the Legal Description of the property. How to Determine your Ultimate Receiving Waters: 1. Locate the county of your project. 2. Find the numbered segment overlaying the county. For example 2C overlays most of Saline County. 3. Match the number from the segment to the one of the numbered Ultimate Receiving Waters. For example: A project located in Western Saline County is in segment 2C. The 2" determines that the Ultimate Receiving Water for the project is the Ouachita River. 6C 6B Ultimate Receiving Waters 1. Red River 2. Ouachita River 3. Arkansas River 4. White River 5. St. Francis River 6. Mississippi River 6A

4 (501) NOTICE OF INTENT FOR DISCHARGERS OF STORM WATER RUNOFF ASSOCIATED WITH MEDIUM OR LARGE CONSTRUCTION ACTIVITY AUTHORIZED UNDER NPDES GENERAL PERMIT ARR Application Type: New Renewal I. PERMITTEE INFORMATION Permittee Name: Permittee Type: Permittee Mailing Address: PRIVATE STATE City: FEDERAL CORPORATION State: Zip: PUBLIC OTHER Permittee Telephone Number: Permittee Fax Number: II. INVOICE MAILING INFORMATION (If different from Permittee Mailing Address above.) Invoice Contact Person: City: Invoice Mailing Company: State: Zip: Invoice Mailing Address: Telephone: III. CONTRACTOR, IF DIFFERENT FROM PERMITTEE (Operator with day to day operational control) Name: State: Zip: Address: Telephone: City: IV. CONSTRUCTION SITE INFORMATION Project Name: Project County: Project Contact Person: Project Physical Address: Directions to the Project: Project City: Zip: Telephone Number: Project Start Date: Total amount of soil to be disturbed (estimate in acres): Project End Date: Project Latitude: degrees minutes seconds Project Longitude: degrees minutes seconds

5 (501) V. DISCHARGE INFORMATION Name of Receiving Stream (i.e. an unnamed tributary of Mill Creek, thence into Mill Creek; thence into Arkansas River): Choose Your Ultimate Receiving Stream: Red River Ouachita River Arkansas River White River St. Francis River Mississippi River VI. FACILITY/SITE PERMIT INFORMATION NPDES Individual Permit Number (If Applicable): NPDES General Permit Number (If Applicable): NPDES General Industrial Storm Water Permit Number (If Applicable): NPDES General Construction Storm Water Permit Number (If Applicable): AR00 ARG ARR00 ARR15 NOTE: A STORM WATER POLLUTION PREVENTION PLAN (SWPPP) SHALL BE PREPARED PRIOR TO SUBMITTAL OF THIS NOI PER PART II.A OF THE GENERAL PERMIT. THE SWPPP MUST BE SUBMITTED FOR APPROVAL ALONG WITH THIS NOI FOR LARGE CONSTRUCTION SITES PER PART I.B.6.a OF THE GENERAL PERMIT. VII. CERTIFICATION OF PERMITTEE (See Part II.B.10, page 29 of the general permit) I certify that, if this facility is a corporation, it is registered with the Secretary of State of Arkansas. I certify that a storm water pollution prevention plan has been prepared for this facility in accordance with Part II.A of this permit, which provides for, or will provide for, compliance with approved state or local sediment and erosion plans, local storm water permits or storm water management plans, in accordance with Part II.A.4.c of this permit. I certify that the cognizant official designated in Part VIII of this Notice of Intent is qualified to act as a dully authorized representative under the provisions of 40 CFR (b). If no cognizant official has been designated, I understand that the Department will accept reports signed by the applicant. 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 persons directly responsible for gathering 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. Also, I certify that as a whole the storm water discharge(s), and the construction and implementation of Best Management Practices (BMP s) to control storm water runoff, are not likely to adversely affect species of critical habitat for a listed species. Typed or Printed Name: Signature: Title: Date:

6 (501) VIII. COGNIZANT OFFICIAL (Person having responsibility for overall operation of project, see Part II.B.9 page 28 of the permit.) Name: Title: Telephone: IX. PERMIT REQUIREMENT VERIFICATION Please check the following to verify completion of permit requirements. Submittal of Complete NOI? Submittal of Required Permit Fee? Check Number: Development of a Construction Site Map? Development of Storm Water Pollution Prevention Plan (SWPPP)? Yes No