W E S T V I R G I N I A	General Permit Registration	Department of Environmental Protection	NO. WVR _______________

Division of Water and Waste Management	(Official use only)

REVISED: October 2009

Site Registration Application Form Construction Storm Water WV/NPDES General Permit (Three Acres Or Greater)

Project:	name:

state Number:

federal number:

County:

Applicant’s name:	Mr. Gregory L. Bailey, P.E.

Director – Engineering Division

FEDERAL EMPLOYER IDENTIFICATION NUMBER*: 556000813001

*Required For Application Processing

ADDRESS:	West Virginia Division of Highways

Building 5, Room A-317

1900 Kanawha Boulevard, East

Charleston, West Virginia 25305-0430

TELEPHONE:	(304) 558-2885

E-MAIL CONTACT ADDRESS: anna.m.vanderlaan@wv.gov

OPERATOR OR CONTRACTOR: Will notify after award of contract.

PREPARER’S NAME:	DOH Project Manager

Division/District

ADDRESS:

TELEPHONE:

E-MAIL CONTACT ADDRESS: anna.m.vanderlaan@wv.gov

ACRES DISTURBED:

RAINFALL ZONE:

APPLICATION FEE:

LATITUDE: º ’ ”

LONGITUDE: º ’ ”

TOPOGRAPHIC MAP WITH SITE LOCATED (ATTACH COPY): USGS Topo Map Name

NEAREST TOWN:

COUNTY:

COUNTY ROUTE:

RECEIVING STREAM(S):

BASIN:

MUNICIPAL SYSTEM OPERATOR:

PROJECT DESCRIPTION: Please see the attached pertinent plan sheets. A complete set of the plans is available to the DEP upon request and is available to the public for review or purchase at the DOH’s Central Office at the Capitol Complex.

ESTIMATED START & COMPLETION DATES FOR PROJECT:

CUBIC YARDS OF EXCAVATION (CUT/FILL) & WASTE/BORROW SITES

(ATTACH SOILS REPORT)

EXCAVATION - CY	WASTE - CY	BORROW - CY

RELATIVE TIME LINE OF CONSTRUCTION ACTIVITIES: Contractor’s Critical Path Method (CPM) of construction activities will be available at the WVDOH Field Office.

NOTE: IF ANY OF THE FOLLOWING CONDITIONS APPLY, SUBMIT A NOTARIZED, SIGNED STATEMENT FOR BILLING SO THAT THE PROJECT CAN BE SENT OUT TO PUBLIC NOTICE.

GRADING PHASE OF CONSTRUCTION WILL LAST FOR 1 YEAR OR LONGER

DISTURBANCE OF 100 ACRES OR MORE

DISCHARGE TO OR UPSTREAM OF TIER 2.5 OR TIER 3 WATERS

SEE INSTRUCTIONS FOR DETAILS AND NOTICE PROCESS

NARRATIVE DESCRIPTION OF EROSION AND SEDIMENT CONTROLS: As per Project Plans, the WVDOH Erosion and Sediment Control Manual, the WVDOH Standard Specifications, and supplements, which are available to the DEP upon request and are available to the public for review or purchase at the DOH’s Central Office at the Capitol Complex. The Contractor’s Erosion and Sediment Control Plan will be submitted to the DOH and the DEP for approval prior to the start of construction.

SEQUENCE OF CONSTRUCTION: Contractor’s Erosion and Sediment Control Plan, including sequence of construction, will be submitted to the DOH and the DEP for approval prior to the start of construction.

DETAILED SITE MAP(S) OF EROSION AND SEDIMENT CONTROLS (ATTACH): As per Project Plans, the WVDOH Erosion and Sediment Control Manual, the WVDOH Standard Specifications, and Supplements.

SITE MAP OF THE FINAL CONDITIONS SHOWING THE STORM WATER MANAGEMENT FACILITIES (ATTACH): As per the Project Plans, the pertinent sheets of which are attached.

PRE- AND POST-DEVELOPMENT DRAINAGE AREA MAPS IDENTIFYING DISCHARGE POINTS AND SUPPORTING CALCULATIONS (ATTACH):

Discharge Point: Station Offset

PRE-DEVELOPMENT PEAK DISCHARGE FOR 1 YR/24 HOUR STORM:

POST-DEVELOPMENT PEAK DISCHARGE FOR 1 YR/24 HOUR STORM:

See attachment 17

NARRATIVE DESCRIPTION OF THE FINAL STORM WATER MANAGEMENT AND POLLUTION PREVENTION: As per the Project Plans, the pertinent sheets of which are attached.

DO YOU HAVE A PERMANENT STORMWATER MANAGEMENT FACILITY ON THIS PROJECT? CHECK THE APPROPRIATE BOX. IF YES, COMPLETE 19.A.

Yes.

No.

WHICH OF THE FOLLOWING BEST MANAGEMENT PRACTICES (BMPS) WILL BE UTILIZED FOR THIS PROJECT? ALSO, WHAT IS THE AMOUNT OF DRAINAGE ACREAGE (IN ACRES) THAT WILL FLOW THROUGH THESE BMPS WHILE ACTING AS PERMANENT STORMWATER MANAGEMENT FACILITIES?

*LIST COORDINATES AND DRAINAGE FOR EACH POND SEPARATELY*

Dry Detention Ponds	Acres Drained:

Latitude:	Longitude:

Dry Extended Detention Ponds	Acres Drained:

Latitude:	Longitude:

Urban Infiltration Practices	Acres Drained:

Urban Filtering Practices	Acres Drained:

Wet Ponds and Wetlands	Acres Drained:

Latitude:	Longitude:

Definitions for the above list of BMPs may be found on Page 17 of the Instructions for Completing the Site Registration Application Form.

PUBLIC NOTICE SIGN (See instructions and Section G.4.b.6 of the General Permit). ALL APPLICANTS ARE REQUIRED TO POST A PUBLIC NOTICE SIGN ONSITE WITHIN 24 HOURS OF SUBMITTING AN APPLICATION. ATTACH SITE SPECIFIC TEMPLATE.

BY COMPLETING AND SUBMITTING THIS APPLICATION, I HAVE REVIEWED AND UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THE GENERAL PERMIT ISSUED ON NOVEMBER 5, 2007. I UNDERSTAND THAT PROVISIONS OF THE PERMIT ARE ENFORCEABLE BY LAW. VIOLATION OF ANY TERM AND CONDITION OF THE GENERAL PERMIT AND/OR OTHER APPLICABLE LAW OR REGULATIONS CAN LEAD TO ENFORCEMENT ACTION.

I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND AM FAMILIAR WITH THE INFORMATION SUBMITTED ON THIS FORM AND ALL ATTACHMENTS AND THAT, BASED ON MY INQUIRING OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING 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.

OFFICIAL SIGNATURE: ___________________________________ DATE ______________

PRINT NAME:	Gregory L. Bailey, P.E.

Director, Engineering Division

PRIOR TO FILING THIS APPLICATION, YOU MAY WISH TO OBTAIN A COPY OF THE LEGISLATIVE RULES OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION, TITLE 47, SERIES 26, WATER POLLUTION CONTROL PERMIT FEE SCHEDULE IN ORDER TO DETERMINE THE APPROPRIATE PERMIT APPLICATION FEE REQUIRED TO ACCOMPANY YOUR SUBMISSION OF THIS APPLICATION. YOU CAN OBTAIN A COPY OF THE REGULATION FROM THE SECRETARY OF STATE’S OFFICE, STATE CAPITOL BUILDING, CHARLESTON, WV 25305. HOWEVER, YOU MAY WISH TO USE THE TABLE FOUND IN ITEM V. OF THE ATTACHED INSTRUCTIONS.

YOUR CHECK OR MONEY ORDER FOR THE APPROPRIATE APPLICATION FEE MUST BE MADE PAYABLE TO THE WEST VIRGINIA DEPARTMENT OF ENVIRONMENTAL PROTECTION.

We will process your personal information (email address, mailing address and/or telephone number) in accordance with the State of West Virginia’s Privacy Policy for appropriate and customary business purposes. Your personal information may be disclosed to other State agencies or third parties in the normal course of business or as needed to comply with statutory or regulatory requirements, including Freedom of Information Act requests. The Division of Water and Waste Management will appropriately secure your personal information. If you have any questions about our use of your personal information, please contact the DEP’s Chief Privacy officer at depprivacyofficer@wv.gov.

ALL SPILLS OR ACCIDENTAL DISCHARGES ARE REQUIRED TO BE REPORTED IMMEDIATELY TO THE EMERGENCY RESPONSE SPILL ALERT SYSTEM TOLL FREE TELEPHONE NUMBER 1-800-642-3074. CALLS FROM OUT OF STATE SHOULD BE MADE TO 304-348-8899.