ADEM Form 24 "Notice of Intent - General Permit Number Alr100000" - Alabama

What Is ADEM Form 24?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 24 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

ADVERTISEMENT
ADVERTISEMENT

Download ADEM Form 24 "Notice of Intent - General Permit Number Alr100000" - Alabama

Download PDF

Fill PDF online

Rate (4.8 / 5) 82 votes
A
D
E
M
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– G
P
N
ALR100000
OTICE OF
NTENT
ENERAL
ERMIT
UMBER
Instructions: This form should be used to submit a Notice of Intent for coverage under NPDES Permit Number ALR100000, which is the general permit
authorizing discharges associated with construction activities that result in a total land disturbance of one (1) acre or greater and sites less than one (1)
acre but are part of a larger common plan of development or sale. Please complete all questions. Incomplete or incorrect answers, or missing
signatures will delay processing. Attach CBMPP and other information as needed.
P
T
NOI
URPOSE OF
HIS
Initial NOI for New Facility
Reissuance of General Permit ALR__________
Modification of General Permit No. ALR__________
Other____________________________________________________________
Transfer of General Permit No. ALR__________
I. P
I
ERMITTEE
NFORMATION
Permittee Name (Legal Name)
Responsible Official Phone Number (Provide at least one)
Responsible Owner/Operator or Official Name
Responsible Official Title
Responsible Official Email Address
Responsible Official (RO) Mailing Address
Mailing City, State, and Zip Code
Responsible Official (RO) Location Street/Physical Address
Location City, State, and Zip Code
Corporation
Individual
Sole Proprietorship
Partnership
LLC
LLP
Government Agency
Other
II. F
I
ACILITY
NFORMATION
Facility/Site Name
Facility/Site Contact Name
Facility/Site Contact Title
Facility/Site Street Address or Location Description
Facility/Site Contact Company Name
City
Zip Code
Facility/Site Contact Phone Number (Provide at least one)
Office:
Cell:
County(s)
Facility/Site Contact Email Address
Facility Latitude and Longitude (Decimal or Deg. Min. Sec.) [Provide the set of coordinates below appropriate for the project type, non-linear vs. linear]
Front Gate Coordinates
Non-Linear
Latitude
Longitude
Project
Beginning Point Coordinates
Ending Point Coordinates
Linear Project
Latitude
Longitude
Latitude
Longitude
Detailed Directions to Facility/Site
III. A
D
CTIVITY
ESCRIPTION
Brief Description of Construction / Land disturbance activity(s):
(For Modifications Only) Brief description of the action/change that has resulted in the request for permit modification:
Primary SIC Code:
Primary NAICS Code:
IV. P
S
ROPOSED
CHEDULE
Commencement Date:
Completion Date:
Anticipated Activity Schedule:
Total Site Area in Acres:
Total Disturbed Area in Acres:
Area of Permitted Facility/Site:
ADEM Form 24 m2 04/2020
Page 1 of 2
A
D
E
M
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– G
P
N
ALR100000
OTICE OF
NTENT
ENERAL
ERMIT
UMBER
Instructions: This form should be used to submit a Notice of Intent for coverage under NPDES Permit Number ALR100000, which is the general permit
authorizing discharges associated with construction activities that result in a total land disturbance of one (1) acre or greater and sites less than one (1)
acre but are part of a larger common plan of development or sale. Please complete all questions. Incomplete or incorrect answers, or missing
signatures will delay processing. Attach CBMPP and other information as needed.
P
T
NOI
URPOSE OF
HIS
Initial NOI for New Facility
Reissuance of General Permit ALR__________
Modification of General Permit No. ALR__________
Other____________________________________________________________
Transfer of General Permit No. ALR__________
I. P
I
ERMITTEE
NFORMATION
Permittee Name (Legal Name)
Responsible Official Phone Number (Provide at least one)
Responsible Owner/Operator or Official Name
Responsible Official Title
Responsible Official Email Address
Responsible Official (RO) Mailing Address
Mailing City, State, and Zip Code
Responsible Official (RO) Location Street/Physical Address
Location City, State, and Zip Code
Corporation
Individual
Sole Proprietorship
Partnership
LLC
LLP
Government Agency
Other
II. F
I
ACILITY
NFORMATION
Facility/Site Name
Facility/Site Contact Name
Facility/Site Contact Title
Facility/Site Street Address or Location Description
Facility/Site Contact Company Name
City
Zip Code
Facility/Site Contact Phone Number (Provide at least one)
Office:
Cell:
County(s)
Facility/Site Contact Email Address
Facility Latitude and Longitude (Decimal or Deg. Min. Sec.) [Provide the set of coordinates below appropriate for the project type, non-linear vs. linear]
Front Gate Coordinates
Non-Linear
Latitude
Longitude
Project
Beginning Point Coordinates
Ending Point Coordinates
Linear Project
Latitude
Longitude
Latitude
Longitude
Detailed Directions to Facility/Site
III. A
D
CTIVITY
ESCRIPTION
Brief Description of Construction / Land disturbance activity(s):
(For Modifications Only) Brief description of the action/change that has resulted in the request for permit modification:
Primary SIC Code:
Primary NAICS Code:
IV. P
S
ROPOSED
CHEDULE
Commencement Date:
Completion Date:
Anticipated Activity Schedule:
Total Site Area in Acres:
Total Disturbed Area in Acres:
Area of Permitted Facility/Site:
ADEM Form 24 m2 04/2020
Page 1 of 2
V. P
C
S
RIORITY
ONSTRUCTION
ITE
Is this a Priority Construction Site as defined by Part V of the construction stormwater general permit?
Yes
No
If yes, attach/submit a copy of the CBMPP that meets or exceeds the requirements of Parts III A. and E. of the construction stormwater general permit.
VI. T
M
S
OPOGRAPHIC
AP
UBMITTAL
Attach a recent 7.5 minute series USGS topographic map(s) no larger than 11 by 17 inches (several pages may be necessary), showing the location of the Facility
including site boundaries, area of disturbance, a 1 mile radius, perennial, intermittent, and ephemeral streams, lakes/springs/wells/wetlands and contour lines. The map
should also show the point(s) at which stormwater runoff will exit (outfall) the facility and the point(s) where stormwater runoff from the site will enter the receiving
water.
VII. R
W
ECEIVING
ATERS
Does your project discharge stormwater into a Municipal Separate Storm Sewer System (MS4)?
Yes
No
Are there any surface waters within 25 feet of your project’s earth disturbances?
Yes
No
List name of receiving water(s), latitude & longitude (Decimal degrees or Degrees Minutes Seconds) of location(s) that run-off enters the receiving water, and the
waterbody classification. Please refer to ADEM Admin. Code 335-6-11 for a detailed list of water use classifications. (Attach a separate list if necessary)
Receiving Water
Latitude
Longitude
Waterbody Classification
VIII. General Information
Will flocculants or other chemical stabilization products be used on site?
Yes
No
IX. Q
C
P
(QCP) C
UALIFIED
REDENTIALED
ROFESSIONAL
ERTIFICATION
“I certify under penalty of law that a comprehensive Construction Best Management Practices Plan (CBMPP) for the prevention and minimization of all sources of
pollution in stormwater and authorized related process wastewater runoff has been prepared under my supervision for this site/activity, and associated regulated
areas/activities. The CBMPP meets the requirements of this permit and if properly implemented and maintained by the operator, discharges of pollutants in stormwater
runoff can reasonably be expected to be effectively minimized to the maximum extent practicable according to the requirements of ADEM Administrative Code
Chapter 335-6-6-.23 and this Permit. The CBMPP describes the erosion and sediment control measures that must be fully implemented and regularly maintained as
needed at the permitted site in accordance with sound sediment and erosion control practices to ensure the protection of water quality.”
QCP Designation/Description:
Name:
Title:
Registration/Certification #
Address:
Phone Number:
Email:
Signature
Date Signed:
O
/R
O
S
X.
PERATOR
ESPONSIBLE
FFICIAL
IGNATURE
Pursuant to ADEM Administrative Code Rule 335-6-6-.09, this NOI must be signed by a Responsible Official of the permittee who is the operator, owner, the sole
proprietor of a sole proprietorship, a general/controlling member or partner, a ranking elected official or other duly authorized representative for a unit of government;
or an executive officer of at least the level of vice-president for a corporation, having overall responsibility and decision making for the site/activity.
“I certify under penalty of law that this form, the CBMPP, and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the qualified credentialed professional (QCP) and
other 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, correct, and complete. I am aware that there are significant penalties for submitting false information including the possibility of
fine or imprisonment for knowing violations. I certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to
the ADEM approved form. I further certify that the proposed discharges described in this registration have been evaluated for the presence of any non-construction
and/or coal/mineral mining stormwater, or process wastewaters have been fully identified.”
Name
Official Title
Signature
Date Signed:
ADEM Form 24 m2 04/2020
Page 2 of 2
Page of 2