2017 NPDES Construction General Permit Notice of Intent

2017 CGP Final Appendix J - NOI.pdf

National Pollutant Discharge Elimination System (NPDES) Program (Renewal)

2017 NPDES Construction General Permit Notice of Intent

OMB: 2040-0004

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2040-0004 can be found here:

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2017 Construction General Permit (CGP)

Appendix J - Notice of Intent (NOI) Form and Instructions
Part 1.4.1 requires you to use the NPDES eReporting Tool, or “NeT” system, to prepare and submit
your NOI electronically. However, if the EPA Regional Office grants you a waiver to use a paper
NOI form, and you elect to use it, you must complete and submit the following form.

Page J-1 of 10

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF INTENT FOR THE 2017 NPDES CONSTRUCTION GENERAL PERMIT

NPDES
FORM
3510-9

Form Approved.
OMB No. 2040-0004

Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section III of this form requests authorization to discharge pursuant to
the NPDES Construction General Permit (CGP) permit number identified in Section II of this form. Submission of this NOI also constitutes notice that the operator
identified in Section III of this form meets the eligibility requirements of Part 1.1 CGP for the project identified in Section IV of this form. Permit coverage is
required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in Part 8 of the CGP. To obtain authorization,
you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for
permit coverage. Refer to the instructions at the end of this form.

I. Approval to Use Paper NOI Form
Have you been granted a waiver from electronic reporting from the Regional Office *?

YES

If yes, check which waiver you have been granted, , the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:

The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as
under-served for broadband Internet access in the most recent report from the Federal Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that granted the waiver:
/

Date approval obtained:

* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you must
file this form electronically using the NPDES eReporting Tool (NeT).

II. Permit Information

NPDES ID (EPA Use Only):

Master Permit Number:

(see Appendix B of the CGP for the list of eligible permit numbers)

III. Operator Information
Operator Information
Operator
Name:
Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A?

YES

Mailing Address:
Street:
City:

State:

ZIP Code:

County or Similar Government Division:
Phone:

Ext.

E-mail:
Operator Point of Contact Information:
First Name,
Middle Initial,
Last Name:
Title:
NOI Preparer (Complete if NOI was prepared by someone other than the certifier):
First Name,
Middle Initial,
Last Name:
Organization:

EPA Form 3510-9

Page 1 of 8

Phone:

Ext.

E-mail:

IV. Project/Site Information
Project/Site
Name:
Project/Site Address:
Street/Location:
City:

State:

ZIP Code:

County or Similar Government Subdivision:
For the project/site you are seeking permit coverage, provide the following information:
Latitude/Longitude (Use decimal degrees and specify method):
Latitude:

___ ___. ___ ___ ___ ___° N (decimal degrees)

Latitude/Longitude Data Source:

Map

GPS

Longitude:

___ ___ ___. ___ ___ ___ ___° W (decimal degrees)

Other _______________________

Horizontal Reference Datum:

NAD 27

Is your project/site located in Indian country lands, or located on a property of religious or cultural significance to an Indian tribe?

NAD 83
YES

WGS 84

If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable), or if not in
Indian country, provide the name of the Indian tribe associated with the property:
___________________________________________________________________________________________________________________________________________________
Estimated Project Start Date:

Estimated Area to be Disturbed (to the nearest quarter acre):
Type of Construction Site (check all that apply):

Estimated Project Completion Date:
.

Single-Family Residential
Institutional

Multi-Family Residential

Highway or Road

Will there be demolition of any structure built or renovated before January 1, 1980?

Utility
YES

Commercial

NO
YES

Was the pre-development land use used for agriculture (see Appendix A for definition of “agricultural land”)?
YES

If yes, is your project an “emergency-related project” (see Appendix A)?

Industrial

Other ________________________________________________

If yes, do any of the structures being demolished have at least 10,000 square feet of floor space?

Have earth-disturbing activities commenced on your project/site?

NO
YES

Have stormwater discharges from your project/site been covered previously under an NPDES permit?

YES

If yes, provide the NPDES ID ( if you had coverage under EPA’s 2012 CGP or the NPDES permit number if you had
coverage under an EPA individual permit:

V. Discharge Information
By indicating “Yes” below, I confirm that I understand that the CGP only authorizes the allowable stormwater discharges in Part 1.2.1 and the allowable nonstormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA
section 402(k) by disclosure to EPA, state, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by
the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the
allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must be covered under another NPDES permit.
YES
Does your project/site discharge stormwater into a Municipal Separate Storm Sewer System (MS4)?
Are there any waters of the U.S. within 50 feet of your project’s earth disturbances?

EPA Form 3510-9

YES

Page 2 of 9

Receiving Waters Information: (Attach a separate list if necessary)

For each point of discharge, provide the following receiving water information:
Point of
Discharge ID

Provide the name of the first water of
the U.S. that receives stormwater
directly from the point of discharge
and/or from the MS4 that the point of
discharge discharges to:

If the receiving water is impaired (on
the CWA 303(d) list), list the pollutants
that are causing the impairment:

If a TMDL been completed for this
receiving waterbody, providing the
following information:
TMDL Name and ID: