Form ECY070-35 "Sand and Gravel General Permit - Application for Coverage for Portable Operations" - Washington

What Is Form ECY070-35?

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

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Washington State Department of Ecology;
  • 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 fillable version of Form ECY070-35 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY070-35 "Sand and Gravel General Permit - Application for Coverage for Portable Operations" - Washington

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Notice of Intent - Application for Coverage for Portable
Operations under the Sand and Gravel General Permit
You can fill out and submit this application online. Visit
http://www.ecy.wa.gov/programs/wq/sand/forms.html
for more information.
Please print in ink or type all sections of this application. All fields are required unless
otherwise marked.
1. Application Type
– Check and provide your permit number if applicable:
New Permit
Permit Renewal - Permit Number:
Permit Modification - Permit Number:
Describe Modification:
2. Permittee Contact Information
4. Billing Contact
Organization Name – Provide the legal name of the
Billing Contact First & Last Name:
business or company (Permittee) that is applying for permit
coverage:
Organization Name:
Legal Responsible Party – Provide the first and last name
E-mail:
Business Phone:
of the person who has the legal authority to represent the
permittee and commit to the terms and conditions of the
Mailing Address:
permit:
E-mail:
Business Phone:
City:
State:
Zip + 4:
Mailing Address:
Cell Phone (Optional):
Fax (Optional):
City:
State:
Zip + 4:
Permittee’s Unified Business Identifier (UBI) – UBI is a
nine-digit number used to identify a business entity (also
called Washington State Tax Identification Number, Labor
Cell Phone (Optional):
Fax (Optional):
and Industries Identification Number, or Licensing
Number). Mark “none” if you do not have a UBI number.
UBI Number:
3. Site Contact
5. Site Owner
– Ecology may contact this person
(Optional) – Fill out this section if the
regarding site inspections
landowner is different than the Permittee
Site Contact First & Last Name:
Site Owner First & Last Name:
Organization Name:
Organization Name:
Mailing Address:
Mailing Address:
City:
State:
Zip + 4:
City:
State:
Zip + 4:
Business Phone:
Cell Phone (Optional):
Business Phone:
Cell Phone:
E-mail:
E-mail:
ECY 070-35 (Rev.01/15)
+
Notice of Intent - Application for Coverage for Portable
Operations under the Sand and Gravel General Permit
You can fill out and submit this application online. Visit
http://www.ecy.wa.gov/programs/wq/sand/forms.html
for more information.
Please print in ink or type all sections of this application. All fields are required unless
otherwise marked.
1. Application Type
– Check and provide your permit number if applicable:
New Permit
Permit Renewal - Permit Number:
Permit Modification - Permit Number:
Describe Modification:
2. Permittee Contact Information
4. Billing Contact
Organization Name – Provide the legal name of the
Billing Contact First & Last Name:
business or company (Permittee) that is applying for permit
coverage:
Organization Name:
Legal Responsible Party – Provide the first and last name
E-mail:
Business Phone:
of the person who has the legal authority to represent the
permittee and commit to the terms and conditions of the
Mailing Address:
permit:
E-mail:
Business Phone:
City:
State:
Zip + 4:
Mailing Address:
Cell Phone (Optional):
Fax (Optional):
City:
State:
Zip + 4:
Permittee’s Unified Business Identifier (UBI) – UBI is a
nine-digit number used to identify a business entity (also
called Washington State Tax Identification Number, Labor
Cell Phone (Optional):
Fax (Optional):
and Industries Identification Number, or Licensing
Number). Mark “none” if you do not have a UBI number.
UBI Number:
3. Site Contact
5. Site Owner
– Ecology may contact this person
(Optional) – Fill out this section if the
regarding site inspections
landowner is different than the Permittee
Site Contact First & Last Name:
Site Owner First & Last Name:
Organization Name:
Organization Name:
Mailing Address:
Mailing Address:
City:
State:
Zip + 4:
City:
State:
Zip + 4:
Business Phone:
Cell Phone (Optional):
Business Phone:
Cell Phone:
E-mail:
E-mail:
ECY 070-35 (Rev.01/15)
3. NAICS Codes and Portable Status
– Indicate the type and status of the portable by checking the appropriate
boxes. (See Appendix A of the Sand & Gravel General Permit or
http:/www.census.gov/eos/www/naics/
for code
descriptions.)
Active (Must have submitted a
What is the status of the portable?
Inactive
Notification of Intent to Begin Operation)
Will the portable operate for more than 90 days per year?
Yes
No
Rock Crusher for crushing:
Asphalt Batch Plant (NAICS 324121)
Bag House
Gravel (NAICS 212321)
Wet Scrubber
Limestone (NAICS 212312)
Other Stone (NAICS 212319)
Concrete Batch Plant (NAICS 327320)
Granite (NAICS 212313)
Concrete Recycle
Dry Batch
Wet Batch
Asphalt Recycle
Is rock washing part of the operation?
Yes
No
4. Major Components
– List the major components (equipment and materials) typically associated with this
portable (e.g., feeder hopper, drum dryer, batch tower, load-out silo, fuel tanks, and admixture tank). Please use an extra
sheet of paper if necessary.
5. Certification of Permittees
“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 person or persons who manage the system or those 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.”
/
.
Printed Name / Company (Permittee)
Title
.
Signature of Responsible Person*
Date
* Federal regulations require this application is signed by one of the following:
A. For a corporation: By a principal executive officer of at least the level of vice president.
B. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility: By either a principal executive officer or ranking elected
official.
ECY 070-35 (Rev.01/15)
6. Mailing Address -
Mail your completed application to the appropriate Ecology Regional Office listed below,
based on the county in which the facility is located:
Regional Office Address
Counties
Attn: WQ Sand & Gravel Permit Coordinator
Washington State Department of Ecology
Benton, Chelan, Douglas, Kittitas, Klickitat, Okanogan, or
Central Regional Office
Yakima Counties
15 West Yakima Avenue Suite 200
Yakima, WA 98902-3463
Attn: WQ Sand & Gravel Permit Manager
Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant,
Washington State Department of Ecology
Lincoln, Pend Oreille, Spokane, Stevens, Walla Walla, or
Eastern Regional Office
Whitman Counties
4601 North Monroe Street Suite 202
Spokane, WA 99205-1295
Attn: WQ Sand & Gravel Permit Coordinator
Washington State Department of Ecology
Island, King, Kitsap, San Juan, Skagit, Snohomish, or
Northwest Regional Office
Whatcom Counties
3190 160th Avenue S.E.
Bellevue, WA 98008-5452
Attn: WQ Sand & Gravel Permit Coordinator
Washington State Department of Ecology
Clallam, Clark, Cowlitz, Grays Harbor, Lewis, Mason,
Southwest Regional Office
Pacific, Pierce, Skamania, or Wahkiakum Counties
300 Desmond Drive
PO Box 47775
Olympia, WA 98504-7775
Accommodation Requests:
To request ADA accommodation including materials in a format for the visually impaired, call Water Quality Reception at
Ecology, 360-407-6600. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech
disability may call TTY at 877-833-6341.
ECY 070-35 (Rev.01/15)
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