SITE INFORMATION AND CORRESPONDENCE

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VI. ALATORY STATUS • • A. Has a local agency approved a required erosion/sediment control plan?............................................................................................................................. ❑ YES ❑ NO Does the erosion/sediment control plan address construction activities such as infrastructure and structures?.................................................................. ❑ YES ❑ NO Name of local agency: Phone: B. Is this project or any part thereof,subject to conditions imposed under a CWA Section 404 permit of 401 Water Quality Certification?................... ❑ YES ❑ NO If yes,provide details: VII. RECEIVING WATER INFORMATION A. Does the stone water runoff from the construction site discharge to(Check all that apply): 1. ❑ Indirectly to waters of the U.S. 2. ❑ Storm drain system-Enter owner's name: 3. ❑ Directly to waters of U.S.(e.g.,river,lake,creek,stream,bay,ocean,etc.) B. Name of receiving water: (river,lake,creek,stream,bay,ocean): VIII. IMPLEMENTATION OF NPDES PERMIT REQUIREMENTS A. STORM WATER POLLUTION PREVENTION PLAN(SWPPP)(check one) ❑ A SWPPP has been prepared for this facility and is available for review: Date Prepared: Date Amended: ❑ A SWPPP will be prepared and ready for review by(enter date): ❑ A tentative schedule has been included in the SWPPP for activities such as grading,street construction,home construction,etc. B. MONITORING PROGRAM ❑ A monitoring and maintenance schedule has been developed that includes inspection of the construction BMPs before anticipated storm events and after actual storm events and is available for review. If checked above: A qualified person has been assigned responsibility for pre-stone and Dost-stone BMP inspections to identify effectiveness and necessary repairs or design changes........................................................................................................ ❑ YES ❑ NO Name: Phone: C. PERMIT COMPLIANCE RESPONSIBILITY A qualified person has been assigned responsibility to ensure full compliance with the Permit,and to Implement all elements of the Storm Water Pollution Prevention Plan including: 1. Preparing an annual compliance evaluation...................... .................................................❑ YES ❑NO Name: Phone: 2. Elimmatinq all unauthorized discharges.........................................-.................................................................................. YES NO IX. VICINITY MAP AND FEE(must show site location in relation to nearest named streets,intersections,etc.) Have you included a vicinity map with this submittal?...................... ❑ YES NO Have you included payment of the annual fee with this submittal?................................................................................................................... ❑ YES ❑NO X. CERTIFICATIONS "I certify under penalty of law that this document and all attachments were prepared under my direction and 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,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 or imprisonment. In addition, I certify that the provisions of the permit, including the development and implementation of a Storm Water Pollution Prevention Plan and a Monitoring Program Plan will be complied with." Printetl Name: Signature: Date: Title: 2