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HomeMy WebLinkAboutFord Park State Water Discharge Permit.pdf i I I STATEFor Agency Use Only Permit Number Assigned a Dedicated to protecting and Improving the health and anvironment of the people at Wore,& C OR03- 4300 Chaq Creek Or.8. Denver,Colorado 9U240-1$30 * * Oate Received I�l Phone(308)692.2000 Month 'Day Year rt3D line 601-7700 Colamdo.Deparrat ent. Lcoeted in atendaie,Coorad of PublicHealth i httpJhvww.cclphasleta.cc;us nnd�npnrn�n# COLORADO DISCHARGE PERMIT SYSTEM (COPS) 8TORMWATER 0 15CHARGE ASSOCIATED WITH CONSTRUCTION ACTIVITIES APPLICATION PHOTO COPIES, FAXED COPIES,PDF COPIES OR E MAILS WILL NOT BE ACCEPTED, i Please print or type. Original signatures are required. All items must be completed accurately and in their entirety for the application to be deemed complete, Incomplete applications will not be processed until all information is received which will ultimatelydelay the issuance of a permit. If more space is required to answer any question, please attach T additional sheets to the application form. Applications must be submitted by mail or hand delivered to: Colorado Department of Public Health and Environment Water Quality Control Division ;i 4300 Cherry Creek Drive South WQCD-P-B2 Denver,Colorado 80246-1530 Any additional information that you would like the Division to consider in developing the permit should be provided Wth the application.Examples include effluent data and/or modeling and planned pollutant removal strategies. j PERMIT IN'FOR'MATION Reason for Application: NEW CERT RENEW CERT EXISTING CERT# i Applican t is: 0 Property Ovmm er Contractor/Operator I A. CONTACT INFORMATION NOT ALL CONTACT TYPES]MAY APPLY * indicates required *PERMITf.EE {If more than one please add additional pages) *0 RGA N IZATI 0 N FORMAL NAME: j/Ay► V1 I I j 1) *PERMITTEE the person authorized to sign and certify the permit application. This person receives all permit correspondences and is legally responsible for compliance with the permit. I Respons;hle Position(Title): + 3 I'l JA f,. I � Currently Held By(Person): �7 j Telephone Via:. IG ' f5-2— email address- t Organization: hmc F 6VI i i Mailing Address: € City: l_i� State: Zip: 0 This farm tt'tust E?e_siguecl by the Permittee (listed in item 1)to be considered complete. Per Regulation 61 in alt cases,it shall be signed as follows: a) In the case of corporations,by a responsible corporate officer. For the purposes of this section,the responsible corporate officer is responsible for the overall operation of the facility from which the discharge described in the application originates. b) In the case of a partnership,by a general partner. c) Inthe case of a sole proprietorship,by the proprietor. d) In the case of a municipal,state,or other public facility,by either a principal executive officer or ranking elected official page 1 of 5 revised April.2011 a ,9r 2) I1MR COGNIZANT OFFICIAL(i.e.authorized agent)the person or position authorized to sign anti certify reports required by the Division including discharge Monitoring Reports$€7MR°s,Annual Reports,Compliance Schedule submittals, and other Information requested'byt.heDivision. The Divisio.nwi:lltrans pre-printed reports(ie_DMWs)to this person. If more than one,please add additional pages. Satre As 1) Permittee Responsible Position(Title): Currently Held By(Person): Telephone fro: email address Organization: Mailing Address: City: State: Zip: Per Regulation 61:All reports required by permits,and other information requested by the Division shall be signed by the,permittee or by a duly authorized representative of that person.A person is a duly authorized representative only if: (i) The authorization is made in writing by the permittee (ii) The authorization specifies either an individual or a position having responsibilityforthe overall operation of the regulated facility or activity such as the position of plant mana$et',operator of a well or a well field,superintendent; position of equivalent'responsibility,or an individual or position having overall rosponsibilityfor environmental matters for the company.(A duly authorized representative may thus be either a named individual or any individual occupying a named position);and (iii) The written authorization is submitted to the Division 3) SITE CONTACT local contact for questions relating to the facility&discharge authorized by this permit for the facility. ❑ Same As 1) Permittee Responsible Position(Title): Currently Held By(Person): 4 n Telephone Not. email address s Cp i Organization: Mailing Address: . .. .. .......... Tf ................... Zip:. City: ..............._._{..'..........��.� State:.. ... .. p: 4) * BILLING CONTACT if diffe:rentthan the permittee Responsible Position(Title): l Currently Held By(Person):: t]Vitt i Telephone No: email address_�� L�°(- l 1+,�` Organization: MailingAddrep: 40ol. City: At State: zip ___ Page 2 of 5 revised April 2011 i 5) OTHER CONTACTTYPES(check below) Add pages If necessary: ResponsiblePosition(Title): Currently Held By(Person): Telephone No: x email address Organization: j Mailing Address: City State: Zip: o Pretreatment CJ Inspection Facility Contact © StormwaterMS4Responsible Coordinator EJ Consultant Person o Environmental Contact d Compliance Contact 11 5tormwaterAuthorized j o Siosolids Responsible Representative Party El Other * Property Owner i 13. Permitted ProjecV!Facilfty Information w Project/Facility Name Street Address or cross streets I (e.g.,"S.of Park St.between Sth Ave.and 10 Ave.",or"W.side of C4_21,3;.25 miles N.of Hwy IG';A street name without an address, intersection,mile marker,or other identifying information describing the location of the project is M adequate. for linear projects, the route of the project should be described as best as possible with the location more accurately indicated by a map.) City, # Zip Code ��1 [ County we-, Facility Latitude/Longitude—itude— a roxiMate center of site to nearest 15 se ondusin Y 9 � pp g one of following formats j i 001R Latitude ASQongltude _ ��(e.g„39,703°, 104.333©') degrees(to 3 decirnaf places) degrees(to 3 dec€oral places) or 001A Latitude ° " Longitude... ... ° �"(e.g., 39346'11"N, 10405311"W) degrees I notes seconds degrees minutes seconds For the approximate center point of the property,to the nearest 15 seconds. The latitude and longitude must be provided as either degrees,minutes,and seconds,or in decimal degrees with three decimal places. This infnmiation may be obtained from a variety c sources,including: • Surveyors or engineers for the project should have,or be able to calculate,this information, 3 • EPA maintains a web-based siting tool as part of their Toxic Release Inventory program that uses interactive maps and aerial photography to help users get latitude and longitude.The siting tool can be accessed at I www.epa.govltrilreport/alting_tool/tndax.htm • US.Geological Survey topographical map(s),available at area malt stores, .0 Using a Global'.Pasltioning System(GPS)unit tau obtain a direct reading. IV'ote.the latitudellongitude required above is not the directional degrees,minares,anrf seconds provided on a site legal description to define property boundari es. C. MAP Attachment If no maR is submitted ft permit will not be issued, I Map:Attach in map that indicates the site location and that CLEARLY shows the boundaries of the area that will be disturbed. Maps must be no largerthan 11x17 inches. 1 D. LEGAL DESCRIPTION Legal description;If subdivided,provide the legai description:below,or indicate that it is not applicable(do not supply Township/Range/Section or metes and bounds description of site) Subdivision(s): Lot(s): Block(s): OR Not applicable (site has not been subdivided) page 3 of 5 revised April 2011 E. AREA OF CONSTRUCTION SITE........ � Total area of project site(acres): .1 Q Area of project site to undergo disturbance(acres): _ 19� Nate: aside from clearing,grading and excavation activities,disturbed areas also include.areas receiving overburden(e.g.,stockpiles),demolition areas,and areas with heavy equipment/vehicle traffic and storage that disturb existing vegetative cover Total disturbed area of Larger Common Plan of Development or Sale,if applicable: µ (Le.,total,including.all phases,filings,:lots,and infrastructure riot covered by this application) Prr�vide both the total area of the construction site,and the area that will undergo disturbance,in acres, date. aside from clearing,grading and excavation activities,disturbed areas aiso include areas receiving overburden(e.g., stockpiles),demolition areas,and areas with heavy equipment/vehicle traffic and storage that disturb existing vegetative cover(see construction activity description under the APPLICABILITY section on page 1). Ifthe project is part of a larger common plan of development orsale(see the definition tinder the APPLICABILITY section on page 1),the disturbed area of the total plan must also be included. F. MATURE OF CONSTRUCTION ACTIVITY Check the appropriate box(s)or provide a brief description that indicates the general nature:of the construction activities, (The full description of activities must be included in the 5torravurater Management Flan.) 5 ngle'Family Residential Development Multi-Family Residential Development Commercial Development Oil and Gas Production and/or Exploration(including pad sites and associated infrastructure) Highway/Road Development(r o including roadways associated with commercial or residential development) Other—.D escriptio n: G. ANTICIPATED CONSTRUCTION SCHEDULE Construction Start late: ! Final Stabillzatlon Date:. *Construction Start Date-This is the day you expect to begin ground disturbing activities,including grubbing,stockpiling,excavating, demolition,and grading activities. •Final5tabilization Bate-in terms of permit coverage,this is when the site is finally stabilized. This means that all ground surface disturbing activities at the site have been completed,and all disturbed areas have been either built on,paved,or a uniform vegetative cover has been established with an individual plant density of at least 70 percent of pre-disturbance levels.Permit coverage must be maintained until the site is finally stabilized.Even if you are only doing one part of the project,the estimated final stabilization date must be for the overall project, If permit coverage Is still required once your part is completed,the permit certification may be transferred or reassigned to a new responsible entity(s). H. RECEIVING WATERS Ilf discharge is to a ditch or storm sewer,include the name of the ultimatereceivipg waters. Immediate ReceivinglNater(s): ................ ........ € ltimate'Receiving Water(s): Identify the receiving water of the storrnwater from your site. Receiving waters are any waters of the State of Colorado. This includes all watercourses,even if they are usually dry. If stormwater from the construction site enters a ditch or storm sewer system,identify that system and indicate the ultimate receiving water for the ditch or storm sewer. Note:a storrnwaterdischarge permit does io al low a discharge into a ditch or storm sewer system withou t the approval of th e owner/operator of that system. page 4 of 5 revis.edApril 2011 i { i i 1. REQUIRED SIGNATURES(Both parts L and H.must be signed) Signature of Applicant.The applicant must be either the owner and/aro perator oft he construction site.Refer to part$of the instructlonsfor additional information. The application must 6*sl ,nevi by the applicant to be considered complete. In W I c it shall be Signed as follows: (Regulation 61A(I*l) a) In the case of corporations,by the responsible corporate officer Is responsible for the overall operation of the facility from which the discharge descrlbed in the form originates b) Inthe case ofapartnershlp,byagoneralpartner. c) In the case of a sole proprietorship,by th a pro prletor. dj Inthe case ofamunlclpal,state,crotherpublic facility,byeitheraprincipA executive offlccr,ran dng elected offlcial, (a prin cipa I exe cutiv e officer has respo nsib Ility for th a overal I operation of th a fac11lty from which th a discharge originates). STOP', i. STORM WATER MANAGEMENT PLAN CERTIFICATION "I certify under penalty of lava that a complete Stormwater Management Plan,has been prepared for my activity.Based on my inquiry of the person or persons who man age the system,or those persons directly responsible for gathering the information,the Stormwater Management Plan is,to the best of my knowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for falsely certifying the completion of said SWMP, inckr ng t passihi'ty of fine and Im Wrisonni ant for k nowi ng violation s," XX Signature of Legally Responsible Person or Authorized Agent(submission must include origiAl signature) Date Sigrkd Name(printed) Title H. SIGNATURE OF PERMIT LEGAL CONTACT "I certify tinder penalty of lave 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,the information submitted is to the hest of my knowledge and belief,true,accurate and complete.1 am aware th at there are significant penalties for submitting false information,including the possibility of fine and imprisonment for knowing violations." "I understand that submittal of this application is for coverage under the State of Colorado General Permit for Stormwater discharges Associated with Construction Activity for the entirety of the construction site/project described and applied for,until such time as the application is amended or the ce catr n is transferred,Inactivated,or expfred" Signet a of Legal Responsible Person{submission must include original signature) flats igned njat2e Name(printed Title DO NOT INCLUDE A COPY CE THE-STORM WATER MANAGEMENT PLAID DO NOT INCLUDE PAYMENT—AN I lVOICEWII.I.BE SENTAFTER THE CERTIFICATION 15155 UEM page 5 of 5 revised April 2011 I E ;i I i I 530 S Frontage Rd E Vail,CO Satellite Map and View-MapQuest littp://www.niapquest.roiiVprint?a=app.core.e5O865876Ob8a67751616ba3 1 Notes map� r� quest" Ford Park Map of: 530 S Frontage Rd E Vail, CO 81657-4534 O TRAVEL with p�,u t' (877) 577-5766 y I I i 82013 MapQuest,Inc.Use of directions and maps is subject to the MapQuest Terms of Use.We make no guarantee of the accuracy of their content,road conditions or route usability.You assume all risk of use.Vew Terms of Use 4 I II 1 of 1 9/4/2013 3:05 PM