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HomeMy WebLinkAbout013 - Bozeman Discount Tire - MDEQ SWPPP FormFinal Permit: 2018-2022 Form SWPPP Page 1 of 10 AGENCY USE ONLY PERMIT NO.: Date Rec’d.: Amount Rec’d.: Check No.: Rec’d By: WATER PROTECTION BUREAU FORM SWPPP 2018 Storm Water Pollution Prevention Plan (SWPPP) Form Storm Water Discharge Associated With Construction Activity MTR100000 READ THIS BEFORE COMPLETING FORM: The Form SWPPP is intended to assist operators in developing a SWPPP which complies with Part 3 of the General Permit for Storm Water Discharges Associated with Construction Activity (General Permit). It is the permittee’s responsibility to ensure all required items in the General Permit are adequately addressed and that the SWPPP is developed, implemented, and maintained. Additional information may be needed to supplement the Form SWPPP. For additional information, please call: (406) 444-3080 or visit: http://deq.mt.gov/wqinfo/mpdes/stormwaterconstruction.mcpx Section A - SWPPP Status: (Check one) New No prior SWPPP submitted for this site. Modification Permit Number: MTR10 __ __ __ __ (Please specify these four numbers) Section B - Facility or Site Information: Site Name ________________________________________________________________________________ Site Location Nearest City or Town County Section C - Applicant (Owner/Operator) Information: Owner or Operator Name Mailing Address City, State, and Zip Code Phone Number Section D SWPPP Preparer and SWPPP Administrator SWPPP Preparer: Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________ Final Permit: 2018-2022 Form SWPPP Page 2 of 10 Primary SWPPP Administrator: ☐Same as above Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________ Section E – Site Description (Part 3.3) 1.Describe the nature of the construction activity and what is being constructed. 2.Describe all support activities and associated storm water discharges dedicated to the construction activity including but not limited to: material borrow areas, material fill areas, concrete or asphalt batch plants, equipment staging areas, access roads/corridors, material storage areas, and material crushing/recycling /processing areas. 3.Provide an estimate of the total area of the site, and an estimate of the area of the site expected to undergo construction-related disturbance (including all construction-related support activities). Total Site Area (acres): ____________ Area of Construction-Related Disturbance (acres): ____________ 4. Describe the character and erodibility of soil(s) and other earth material to be disturbed at the site, including cut/fill material to be used. Secondary SWPPP Administrator: Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________ Final Permit: 2018-2022 Form SWPPP Page 3 of 10 6.For a storm water discharge associated with construction activity with construction-related disturbance of fiveacres or more of total land area (based on the acreage provided in item E.3 above): a.Provide an estimate of the runoff coefficient of the site, both before and after construction, and describe what supporting information this determination is based upon: Runoff coefficient before construction: ____________ Runoff coefficient after construction: ____________ Supporting Information Source: b.Provide an estimate of the increase in impervious area after the construction activity is completed: ________ Percent. Outfall Number Receiving Surface Water Size (acres) ofSize of Drainage Area Associated with each Outfall Each Outfall Type of Discharge Latitude and Longitude of Outfall Discharge to Municipal Storm Sewer System Sewer System001Choose an item.Choose an item. 002 Choose an item.Choose an item. 003 Choose an item.Choose an item. 004 Choose an item.Choose an item. 005 Choose an item.Choose an item. 006 Sheet 007 008 009 010 7. In the Outfall table below, identify the name(s) of the first state surface water(s) that receives storm water from the construction project. Provide a description of the size, type, location of each outfall, and if the discharge is to a storm sewer system. To properly identify the state receiving water, locate the drainage(s) into which the construction project discharges. If additional outfalls are applicable, please include an attachment. 5.Provide a brief description of the existing vegetation at the site and an estimate of the percent density of vegetative ground cover. Specify Percent Density of Existing Vegetation: _________________ a. List the impaired receiving surface waters from the table above. Yes No No Yes No No No No Yes No Yes No Yes No Yes No ConcentratedSheet Concentrated et Concentrated Sheet Concentrated Sheet Concentrated Sheet ConcentratedSheet Concentrated Sheet Concentrated Sheet Concentrated Concentrated Sheet Sheet 001 002 003 004 Yes Yes Yes Yes Final Permit: 2018-2022 Form SWPPP Page 4 of 10 Section F – Identification and Summary of Potential Pollutant Sources (Part 3.4) Select the pollutants expected to be present on the construction project: Additional Pollutants List any additional pollutants likely to be present at the construction project. Non-Storm Water Discharges Select the types of allowable non-storm water discharges likely to be present at the construction project. Type of Allowable Non-Storm Water Discharge Present at Construction Project Irrigation Drainage Landscape Watering Pavement Wash Waters Routine Building Wash Down Uncontaminated spring or ground water Water used for dust control Emergency fire-fighting activities Foundation or footing drains Incidental windblown mist from cooling towers Uncontaminated condensate from air conditioners, coolers, or other compressors Other Explain ___________________________ Soils ☐Areas of Shallow Grade ☐Areas of Steep Grade ☐Slopes ☐Ditch ☐Stockpiles ☐Contaminated Soils ☐Import and Export Operations ☐Entrance / Exit Locations ☐Other Explain_______________________ Materials ☐Loading and Unloading Operations ☐Storage of building materials ☐Storage of chemicals ☐Portable Toilets ☐Concrete Batch Plant ☐Asphalt Batch Plant ☐Worker Trash ☐Demolition Materials / Debris ☐ Other Explain ____________________ Activities ☐Concrete Truck Washout ☐Masonry - Stone / Brick / Concrete ☐Spray / Wand Applications ☐Finish Work – Dry wall / Painting ☐Equipment Washing ☐Washing of Buildings ☐Maintenance of Equipment ☐Refueling Operations ☐Application of herbicides, pesticides, fertilizers ☐Application of solvents or detergents ☐Construction Dewatering ☐Other Explain_____________________ YesYesYesYesYesYesYesYesYes YesYes NoNoNoNo NoNoNoNoNoNoNo Final Permit: 2018-2022 Form SWPPP Page 5 of 10 Section G – Selection of Best Management Practices (BMPs) (Part 3.5) Select the BMPs to be used during the construction project. All selected BMPs are required to have a specification provided in the SWPPP. The specifications do not have to be submitted to DEQ. The specifications are required to be maintained by the SWPPP Administrator(s) and provided to DEQ, EPA, or other local permitting authority upon request. Additional BMPs List any additional BMPs likely to be used at the construction project. Erosion Control BMPs ☐Surface Roughening ☐Diversion Ditches ☐Velocity Checks / Check Dams ☐Preservation of Existing Vegetation ☐Minimizing Ground Disturbance ☐Mulch – Straw / Compost ☐Tackifiers / Soil Binders ☐Temporary Seeding ☐Erosion Control Blankets ☐Rough Cut Street Controls / Water Bars ☐Channel Liner ☐Stream Crossing ☐Terracing ☐Culvert ☐Outfall / Outlet Protection (Rip Rap) ☐Other ______________________ Run On / Runoff Control BMPs ☐Temporary Slope Drain ☐Rock Run Down ☐Clean Water Diversion ☐Drainage Swales ☐Other ______________________ Sediment Control BMPs ☐Silt Fence ☐Straw Wattles ☐Rock Wattles / Rock Socks ☐Curb Socks ☐Straw Bales ☐Earthen Berms ☐Vegetative Buffers ☐Drainage Ditch / Ditch Berm ☐Gravel Pack ☐Tarps, Plastic, Visqueen ☐Compost Socks ☐Brush Barrier ☐Sandbag Barrier ☐Inlet Protection ☐Vehicle Tracking Control Pad ☐Stabilized Vehicle Entrance ☐Stabilized Parking Area ☐Stabilized Construction Roadway ☐Street Sweeping ☐Sediment Trap ☐Sediment Basin ☐Other ________________________ Administrative Controls ☐Concrete and Liquid Waste Washouts ☐Worker Toilets ☐Construction Fencing ☐Dust Control ☐Secondary Containment ☐Dumpsters / Waste Receptacles ☐Stabilized Staging Area ☐Material Storage and Stockpile Area ☐Paving and Painting Controls ☐Saw Cutting and Grinding Controls ☐Spill Prevention and Response Procedures ☐Traffic Control ☐Back Charging / Penalties ☐Other __________________________ Post Construction BMPs ☐Detention Pond(s) ☐Retention Pond(s) ☐Drainage Swales ☐Infiltration System(s) ☐Dry Well(s) ☐Other __________________________ Final Permit: 2018-2022 Form SWPPP Page 6 of 10 Local Erosion and Sediment Controls Describe applicable local erosion and sediment control requirements. Dewatering Activities (Part 3.6) Describe dewatering activities associated with the construction project. Identify the BMPs to be used to control dewatering activities and prevent discharges to state waters. If a separate authorization is obtained under the Construction Dewatering General Permit, include the dewatering plan with the SWPPP. ☐ Dewatering activities will be controlled on-site with no discharge to state waters. Provide a description of BMPs to be used to control dewatering activities on-site. ☐Separate authorization obtained under the Construction Dewatering General Permit. MPDES Permit Authorization Number: MTG07__ __ __ __ ☐Dewatering plan is attached to the SWPPP for the separate authorization. Section H: Major Construction Activity and BMP Phasing (Part 3.7) Identify the total number of major construction activities associated with the project: ______________________ Complete the table below by listing the major construction activities in the top row. List the selected BMPs to be used for the construction project in the first column. Select the box in the row and column that will represent when the BMP will be used for each major construction activity. For additional major construction activities and BMPs, complete another sheet using this page. Major Construction Activity BMPs ☐☐☐☐☐☐☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Final Permit: 2018-2022 Form SWPPP Page 8 of 10 Major Construction Activity Schedule (Part 3.7) List the major construction activities identified in the table above and provide an estimated timeframe for each major construction activity. For each major construction activity, identify all construction activities that will occur during the proposed major construction activity. Section I – Final Stabilization (Part 3.8) Identify the BMPs that will be used to achieve final stabilization. Information to be included is seed mix selection and application methods, soil preparation and amendments, soil stabilization practices, and any temporary BMPs. Section J – Post-Construction Storm Water Management (Part 3.9) Identify BMPs that will be used to control storm water discharges that will occur after the major construction activities are complete. Include a description of applicable local requirements. Final Permit: 2018-2022 Form SWPPP Page 9 of 10 Section K – Site Map (Part 3.10) Develop and attach the required SWPPP site maps and plans with the SWPPP. The site maps or plans must clearly indicate all the required information in Part 3.10 of the General Permit. This means SWPPP site maps must be of sufficient size, scale, and legibility. Section L – Inspection and BMP Maintenance Procedures (Part 3.11) Select the inspection schedule for the construction project: ☐Once every 7 calendar days ☐Once every 14 calendar days, and a post-storm event inspection within 24 hours of the end of a rainfall event of 0.25 inches or greater, and/or within 24 hours of runoff from snowmelt. Check one: The rainfall event will be determined by either ☐ a rain gage on site or ☐the following weather service:____________________________________________. Describe the inspection and maintenance procedures that will be used to maintain all erosion, sediment control, and other BMPs in good and effective operating condition. Identify how changes to the SWPPP will occur per Part 3.12 of the General Permit. If post construction BMPs will be used during major construction activities, include a maintenance plan that will transition the BMP from active construction to post construction. Section M – Water Quality Controls for Discharges to Impaired Water bodies (Part 2) Describe BMPs that target and reduce discharges of identified pollutants of impairment to impaired waterbodies. The permittee should only describe additional BMPs based on their construction activities pollutant sources. Include any applicable TMDL condition, goal, requirement, implementation intent, or specific controls or requirements as directed by the Department. Final Permit: 2018-2022 Form SWPPP Page 10 of 10 Section O - CERTIFICATION Permittee Information: This SWPPP must be completed, signed, and certified as follows: •For a corporation, by a principal officer of at least the level of vice president; •For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or •For a municipality, state, federal, or other public facility, by either a principal executive officer orranking elected official. Alternatively, this SWPPP may be signed by a duly authorized representative of the person above. A person is a duly authorized representative only if: •The authorization is made in writing by a person described above; •The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, position of equivalent responsibility, or an individual or position havingoverall responsibility for environmental matters for the company (a duly authorized representative maythus be either a named individual or any individual occupying a named position); •The written authorization is submitted to the department. All Permittees Must Complete the Following Certification: 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 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 and imprisonment for knowing violations. [75-5- 633, MCA] A. Name (Type or Print) B. Title (Type or Print)C. Phone No. D. Signature E. Date Signed The Department will not process this form until all of the requested information is supplied, and the appropriate fees are paid. Return this form and the applicable fee to: Department of Environmental Quality Water Protection Bureau PO Box 200901 Helena, MT 59620-0901 (406) 444-3080 Section N – Miscellaneous Information Use this space to identify miscellaneous information that is to be included in the SWPPP.