Form ECY070-31 "Notice of Intent - Application for Coverage for Non-portable Operations Under the Sand and Gravel General Permit" - Washington

What Is Form ECY070-31?

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 ECY070-31 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

ADVERTISEMENT
ADVERTISEMENT

Download Form ECY070-31 "Notice of Intent - Application for Coverage for Non-portable Operations Under the Sand and Gravel General Permit" - Washington

616 times
Rate (4.8 / 5) 37 votes
Notice of Intent - Application for Coverage for Non-Portable
Operations under the Sand & 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.
– Check and provide your permit number if applicable:
Application Type
1.
Permit Renewal - Permit Number:
New Permit
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:
Cell Phone (Optional):
Fax (Optional):
Mailing Address:
Permittee’s Unified Business Identifier (UBI) – UBI is a
City:
State:
Zip + 4:
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:
– Ecology may contact this person
(Optional) – Fill out this section if the
3. Site Contact
5. Site Owner
regarding site inspections
landowner is different than the Permittee
Site Owner First & Last Name:
Site Contact First & Last Name:
Organization Name:
Organization Name:
Mailing Address:
Mailing Address:
City:
State:
Zip + 4:
City:
State:
Zip + 4:
Cell Phone (Optional):
Business Phone:
Cell Phone:
Business Phone:
E-mail:
E-mail:
6. Facility/Site Information
This Facility / Site’s Ownership Type is:
Private
Public
Mixed
Facility / Site Name:
City:
Zip + 4:
Street Address:
ECY 070-31 (Rev.01/15)
Notice of Intent - Application for Coverage for Non-Portable
Operations under the Sand & 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.
– Check and provide your permit number if applicable:
Application Type
1.
Permit Renewal - Permit Number:
New Permit
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:
Cell Phone (Optional):
Fax (Optional):
Mailing Address:
Permittee’s Unified Business Identifier (UBI) – UBI is a
City:
State:
Zip + 4:
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:
– Ecology may contact this person
(Optional) – Fill out this section if the
3. Site Contact
5. Site Owner
regarding site inspections
landowner is different than the Permittee
Site Owner First & Last Name:
Site Contact First & Last Name:
Organization Name:
Organization Name:
Mailing Address:
Mailing Address:
City:
State:
Zip + 4:
City:
State:
Zip + 4:
Cell Phone (Optional):
Business Phone:
Cell Phone:
Business Phone:
E-mail:
E-mail:
6. Facility/Site Information
This Facility / Site’s Ownership Type is:
Private
Public
Mixed
Facility / Site Name:
City:
Zip + 4:
Street Address:
ECY 070-31 (Rev.01/15)
Record Site Location at front door or site entrance – Provide latitude and longitude, expressed in decimal degrees to
six decimal places, at front door or site entrance.
° N
° W
Latitude:
Longitude:
Acreage of permitted facility – This acreage is the land area permitted for mining over the life of mine or total acreage
of a fully developed site:
acres
Active (Includes reclamation)
Inactive (no activity or only removal of
What is status of the facility?
material from existing stockpiles).
– Indicate what activities take place at the site by checking the appropriate boxes. (See
7. NAICS Information
Appendix A of the Sand & Gravel General Permit or
http:/www.census.gov/eos/www/naics/
for North American
Industry Classification System (NAICS) code descriptions.)
Aggregate Mining, Screening, Crushing, and/ or Washing,
Hot Mix Asphalt Batch Plant:
Recycling Concrete and/or Asphalt:
113110 Timber Tract
212321 Construction
324121 Asphalt Paving Mixture and Block
Operations
Sand and Gravel Mining
Manufacturing
113310 Logging
212322 Industrial
Sand Mining
Will the facility with the above NAICS code operate
212311 Dimension Stone
212324 Kaolin and
Yes
No
for more than 90 days per year?
Mining and Quarrying
Ball Clay Mining
Enter the amount of asphalt produced per year in
212325 Clay and
Tons per Year, for the last three years.
212312 Crushed and Broken
Ceramic and Refractory
Limestone Mining and Quarrying
(For example, if you are filling this form out in 2015 list
Minerals Mining
the amount of asphalt you produced in 2014, 2013, &
2012).
212319 Other
Crushed and Broken
212313 Crushed and Broken
Stone Mining and
Granite Mining and Quarrying
Last year
Year before Last
Three years ago
Quarrying
212399 All Other
Nonmetallic Mineral
327999 All Other
Concrete Batch Plant/ Products:
Mining
Miscellaneous Nonmetallic Mineral
327320 Ready-Mix
327390 Other
Product Manufacturing
Mineral Type:
Concrete Manufacturing
Concrete Product
Manufacturing
327332 Concrete
Recycling Asphalt
Recycling Concrete
Pipe Manufacturing
Will the facility with the above NAICS code(s) and / or
Will the facility with the above NAICS code(s)
activities operate for more than 90 days per year?
operate for more than 90 days per year?
Yes
No
Yes
No
For NAICS codes that include concrete production
Amount of Recycled Concrete (Optional):
or making products from concrete (not including
recycling concrete), enter the amount of concrete
Approximately, how much concrete will be recycled at the site
produced per year in cubic yards per year, for the
in cubic yards per year?
last three years. (For example, if you are filling this
form out in 2015 list the amount of concrete production
3
for your facility in 2014, 2013, & 2012).
yd
/ year
How much cubic yards of fragmented concrete will be stored
onsite at any one time for recycling purposes?
Last year
Year before Last
Three years ago
3
yd
/ year
ECY 070-31 (Rev.01/15)
8. Site Management Plan
Is the site management plan (including the Stormwater Pollution Prevention Plan, Monitoring Plan with map of
monitoring points, Spill Control Plan, and Erosion and Sediment Control Plan) up to date and complete?
Yes
No
– Provide information
10. Regulatory Status
for any existing permits for the facility other than the
– Indicate
9. Storage Activities Conducted On Site
Sand and Gravel Permit.
what activities take place at the site by checking the appropriate
boxes.
State Waste Discharge Permit Number
Store, handle, or use inert waste (concrete, glass, metal, brick,
Air Notice of Construction, Permit or Order,
non-ferrous metal) as fill. Note: Maximum 250 cubic yards of
Agency
inert waste can be used in backfill otherwise an inert waste
landfill permit is required from the jurisdictional Health
City or County Permit Number
Department.
Department of Natural Resources
Reclamation Permit Number
Store, process, or stockpile materials other than concrete or
asphalt for recycle. Note: A Health Department permit may be
UIC Registration Number
required.
Other (List title and permit number)
11. Ground Water Protection Designations
Is site within a Critical Aquifer Recharge Area?
YES
NO
Local cities, counties, and districts designate Critical Aquifer Recharge Areas as areas with a critical recharging effect on
aquifers used for potable water. Critical Aquifer Recharge Area information is available from your local government
planning agency. Internet sites for local governments usually show these areas.
Is site within a designated Wellhead Protection Area?
YES
NO
Wellhead protection information is available from your local government planning agency and the water system operator
in your area. Internet sites for local governments usually show these areas.
Is site within a Sole Source Aquifer?
YES
NO
The United States Environmental Protection Agency designates sole source aquifers. You can find a listing on their web
site at:
http://yosemite.epa.gov/r10/water.nsf/Sole+Source+Aquifers/SSA.
Attach a copy of an 11” x 17”, to scale, facility site map from the Stormwater Pollution
12. Facility Site Map -
Prevention Plan or the Monitoring Plan. See Attachment 2 for an example facility site map.
The map must identify the following information:
Outfall points and outfall point identifier(s)
Outline of the drainage areas for each discharge
point including discharges to ground water All
Monitoring / Sampling points identifier(s)
areas associated with industrial activities
Drainage and discharge structures
Lands adjacent to the site, where helpful in
Nearby and on-site surface water bodies
identifying discharge points or drainage routes
ECY 070-31 (Rev.01/15)
If your stormwater, process water, and/or mine dewatering water will flow through a storm drain system or
13. Storm Sewer Conveyance System -
roadside ditch, provide the name of the operator of the storm sewer system and conveyance system (typically, the operator is the city or county you are located in,
e.g., Kent stormwater drainage system, 145th street ditch). Otherwise leave this blank. Storm Sewer Operator:
14. Discharge to Surface Waterbody -
Skip this section if you discharge to groundwater only.
Fill out the table below for all surface water outfalls related to your site. (Please use an extra sheet of paper if necessary.) Provide the information below for
all the point(s) where your stormwater, process water, and/or mine dewatering water enters (or has the potential to enter) into a surface waterbody. Surface waters
include but are not limited to lakes, rivers, ponds, streams, wetlands, inland waters, salt waters, and all other surface waters and water courses within the jurisdiction
of the state of Washington. See Attachment 3 for an example of how to fill out this section.
Surface Water Outfall Point Identifier: assign a name (up to 4 characters) to identify the outfall point (e.g., S001).
Surface Water Outfall Name: assign a name to identify the outfall point (e.g., Outfall to Duck Creek).
Surface Water Outfall Point Latitude and Longitude: Provide the latitude and longitude, expressed in decimal degrees to six decimal places, of the point where
your stormwater, process water, and/or mine dewatering water enters (or has the potential to enter) into a surface waterbody.
Name of Surface Waterbody: Enter the waterbody name where your stormwater, process water, and/or mine dewatering water enters (or has the potential to enter)
into a surface waterbody; even if the risk of discharge is low or limited to periods of extreme weather.
If the creek or tributary is unnamed, use a format such as “unnamed tributary to Deschutes River.”
If your discharge is to a storm sewer system, enter the name of surface water body that the storm sewer system discharges to.
If the outfall flows into a wetland (which is not a constructed wetland), mark “Wetland”.
Is the Outfall Point a Monitoring Point: Indicate which outfall point(s) from your facility will be sampled to comply with Sections S4.B.1 and S4.B.2 of the permit
monitoring requirements. If it is a monitoring point, mark “Yes”; if it is not, mark “No”.
Type of Discharge: List the discharge type (either process water, mine dewatering water, or stormwater) that apply to the outfall point. Stormwater that mixes with
process water is considered process water.
NAICS Code(s): List all NAICS codes that apply to the outfall point, see Section 7 for a list of codes.
Surface Water
Surface Water
Surface Water
Name of
Is the Outfall
Outfall Point
Outfall Point
Outfall Point
Type of Discharge (Process
Surface
NAICS Code(s)
Surface Water
Point a
Identifier
Latitude
Longitude
Water, Mine Dewatering
Waterbody
Outfall Name
Monitoring
Water, or Stormwater)
(4 characters
(Decimal
(Decimal
Point?
max)
Degrees)
Degrees)
ECY 070-31 (Rev.01/15)
15. Monitoring Point Locations
Fill out the table below for all of the monitoring points (both to surface water and groundwater) on your site. (Please use an extra sheet of paper if
necessary.) Provide the information below for all of the point(s) that you sample to comply with Sections S4.B and S4.C of the permit monitoring requirements.
See Attachment 3 for an example of how to fill out this section.
Monitoring Point Identifier: assign a name (up to 4 characters) to identify the monitoring point (e.g., MP01).
Monitoring Point Name: assign a name to identify the monitoring point (e.g., Stormwater Pond 1).
Monitoring Point Latitude and Longitude: Provide the latitude and longitude, expressed in decimal degrees to six decimal places, of the point where you sample to
comply with Sections S4.B and S4.C of the permit monitoring requirements.
Discharge to Groundwater or Surface Water: Identify if the monitoring point relates to a groundwater or surface water discharge from your site.
Corresponding Surface Water Outfall Identifier: Each monitoring point that discharges to surface water must correspond with a surface water outfall listed in
Section 14. Enter the surface water outfall identifier from Section 14. You can have more than one monitoring point associated with each surface water outfall. If the
monitoring point is related to a groundwater discharge, leave this column blank or enter “N/A”.
Type of Discharge: List the discharge type (either process water, mine dewatering water, or stormwater) that apply to the monitoring point. Stormwater that mixes
with process water is considered process water.
NAICS Code(s): List all NAICS codes that apply to the monitoring point, see Section 7 for a list of codes.
Monitoring
Monitoring
Monitoring
Discharge to
Type of Discharge
Point
Corresponding
Point Identifier
Point Latitude
NAICS Code(s)
Monitoring
Groundwater
(Process Water, Mine
Longitude
Surface Water
Point Name
or Surface
Dewatering Water, or
(4 characters
(Decimal
Outfall Identifier
(Decimal
Water?
Stormwater)
max)
Degrees)
Degrees)
ECY 070-31 (Rev.01/15)
Page of 13