Form M "Application for Wv/Npdes Water Pollution Control Permit Modification" - West Virginia

What Is Form M?

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

Form Details:

  • Released on January 1, 2010;
  • The latest edition provided by the West Virginia Department of Environmental Protection;
  • 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 Form M by clicking the link below or browse more documents and templates provided by the West Virginia Department of Environmental Protection.

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Download Form M "Application for Wv/Npdes Water Pollution Control Permit Modification" - West Virginia

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General Instructions - Form M
1)
Where to file:
Four (4) copies of the application form and one (1) completed wasteload allocation form
(if applicable) should be mailed to:
Division of Water & Waste Management
Attention: Permitting Section
th
601 57
Street SE
Charleston, WV 25304-2345
2)
Fees:
A permit modification application fee by check or money order shall accompany the
application. The check or money order shall be made payable to the “Department of
Environmental Protection”. A modification fee is required each time an application is submitted.
Refer to §47-26-6. Permit Modification Application Fees to determine the amount of this fee.
If the director determines that a submitted application is incomplete and must be returned
to the applicant for additional information, a modification application resubmission fee shall
accompany the refiled application. This fee shall be either a sum equivalent to five percent (5%)
of the modification application fee or fifty dollars ($50), whichever is greater.
The construction stormwater general permit modification fee will vary depending on
acreage and the precipitation zone in which the construction is taking place.
3)
Form Instructions
Item I - Enter the permittee’s official or legal name; enter the facility name. (Do not use
colloquial name).
Item II - Give the name, title, and work telephone number of a person who is thoroughly
familiar with the operation of the facility and with the facts reported in the application and who
can be contacted by reviewing offices if necessary.
Item III - Give the complete mailing address where correspondence should be sent.
Item VI. A. State statute provides for severe penalties for submitting false information on this
application form. State regulations require this application to be signed as follows:
• For a corporation: by a principal executive officer of at least the level of vice-president.
• For a partnership or sole proprietorship: by a general partner or the proprietor,
respectively.
• For a municipality, State, Federal, or other public agency: by either a principal executive
officer or ranking elected official.
B. Signature of cognizant official.
C. Date application signed.
D. Email address of applicant and preparer/consultant – Mod approval will be sent
electronically.
General Instructions - Form M
1)
Where to file:
Four (4) copies of the application form and one (1) completed wasteload allocation form
(if applicable) should be mailed to:
Division of Water & Waste Management
Attention: Permitting Section
th
601 57
Street SE
Charleston, WV 25304-2345
2)
Fees:
A permit modification application fee by check or money order shall accompany the
application. The check or money order shall be made payable to the “Department of
Environmental Protection”. A modification fee is required each time an application is submitted.
Refer to §47-26-6. Permit Modification Application Fees to determine the amount of this fee.
If the director determines that a submitted application is incomplete and must be returned
to the applicant for additional information, a modification application resubmission fee shall
accompany the refiled application. This fee shall be either a sum equivalent to five percent (5%)
of the modification application fee or fifty dollars ($50), whichever is greater.
The construction stormwater general permit modification fee will vary depending on
acreage and the precipitation zone in which the construction is taking place.
3)
Form Instructions
Item I - Enter the permittee’s official or legal name; enter the facility name. (Do not use
colloquial name).
Item II - Give the name, title, and work telephone number of a person who is thoroughly
familiar with the operation of the facility and with the facts reported in the application and who
can be contacted by reviewing offices if necessary.
Item III - Give the complete mailing address where correspondence should be sent.
Item VI. A. State statute provides for severe penalties for submitting false information on this
application form. State regulations require this application to be signed as follows:
• For a corporation: by a principal executive officer of at least the level of vice-president.
• For a partnership or sole proprietorship: by a general partner or the proprietor,
respectively.
• For a municipality, State, Federal, or other public agency: by either a principal executive
officer or ranking elected official.
B. Signature of cognizant official.
C. Date application signed.
D. Email address of applicant and preparer/consultant – Mod approval will be sent
electronically.
FORM M
Existing Permit No.
WEST VIRGINIA DIVISION OF ENVIRONMENTAL PROTECTION
Division of Water and Waste Management
Application For WV/NPDES Water Pollution Control Permit Modification
Revised 1/10
Please print or type in the unshaded area only.
I. PERMITTEE’S NAME
NAME OF FACILITY
II. FACILITY CONTACT
A. Name and Title (last, first and title)
B. Phone (area code & number)
III. FACILITY MAILING ADDRESS
A. Street or Post Office Box
B. City or Town
C. State
D. Zip Code
IV. FACILITY LOCATION
A. Street, Route No. Or other specific identifier
B. City, Town or nearest Post Office
C. County
D. Zip Code
V. MODIFICATION OF EXISTING PERMIT
A. The applicant must present a detailed description with supporting drawings, water analyses, etc. as to exactly what
modification is being applied for. A schedule of compliance (completion of final plans, commencement and
completion
of construction, operational level date, etc.), beginning at the time of permit modification issuance must
also be provided
where applicable.
B. Description of proposed modification
VI. CERTIFICATION (see instructions)
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 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.
A. NAME AND OFFICIAL TITLE (type or print)
B. SIGNATURE
C. DATE SIGNED
D.
Applicant’s Email Address
Consultant/Preparer E-Mail Address
We will process your personal information (email address, mailing address and/or telephone number) in accordance with the State of West Virginia’s Privacy Policy for
appropriate and customary business purposes. Your personal information may be disclosed to other State agencies or third parties in the normal course of business or as
needed to comply with statutory or regulatory requirements, including Freedom of Information Act requests. The Division of Water and Waste Management will
appropriately secure your personal information. If you have any questions about our use of your personal information, please contact the DEP’s Chief Privacy officer at
depprivacyofficer@wv.gov.
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