NOTICE OF INTENT

NPDES GENERAL PERMIT ARG160000

FOR CONSTRUCTION AND DISCHARGE OF UNCONTAMINATED STORMWATER FROM A SANITARY LANDFILL SEDIMENT POND

The attached form can be used by all persons desiring coverage under NPDES general permit ARG160000 (for Construction and Discharge of Uncontaminated Stormwater from a Sanitary Landfill Sediment Pond). The form should be completed and submitted to this Department in accordance with Part 1.3 of the general permit.

Be sure to read the permit (ARG160000), which describes coverage under this permit, effluent requirements, discharge limitations, and other standard conditions that are applicable. A copy of the permit, fact sheet, and other pertinent information can be obtained on the Department’s website:

http://www.adeq.state.ar.us/water/branch_permits/general_permits/default.htm

If you have any questions concerning the ARG160000 permit information or Notice of Intent, please contact General Permits Section of the Water Division at (501) 682-0623.

REMEMBER THE FOLLOWING:

The Notice of Intent (NOI) must be complete. Do not leave any question blank; use "NA" if a question is not applicable. Outfall information must be completed; it cannot be blank or "NA".

A Topographic map showing the location of the discharge points must be attached to the Notice of Intent at the time of submission.

Read the Certification.

A $400.00 Check payable to ADEQ (Re: ARG160000). An additional $500 fee is required if this permit is also covering the construction of a sedimentation pond.

A Disclosure form. Arkansas Code Annotated Section 8-1-106 requires that all applicants for the issuance or transfer of any permit, license, certification or operational authority issued by the Arkansas Department of Environmental Quality (ADEQ) file a disclosure statement with their applications. The filing of a disclosure statement is mandatory. No application can be considered complete without one. A new disclosure statement must be submitted even if one is already on file with the Department. The form may be obtained from ADEQ web site at: http://www.adeq.state.ar.us/disclosure_stmt.pdf

Please call the following number if you have any questions on this Form:

Topic	Contact person	Phone Number

Area Map and	Department of the

USGS Hydrologic	Interior United States	(501)296-1877

Unit Code	Geological Survey

Domestic Drinking	Department of Health	(501)661-2623

Water Supply Intake

General Information	Permits Branch	(501)682-0623

INSTRUCTIONS

How to Determine your Hydrologic Basin Code for the Facility/Outfall:

Locate the county of your facility on the map on Page 6.

Find the numbered segment overlaying the county.

Find the Eight Digit Hydrologic Basin Code located inside the numbered segment.

How to Determine your Stream Segment for the Facility/Outfall:

Locate the county of your facility on the map on Page 6.

Find the numbered Stream Segment overlaying the county. For example 2C overlays most of Saline County. 2C would be the Stream Segment for any facility located within that segment.

III.	How to Determine your Ultimate Receiving Waters:

Locate the county of your facility on the map on Page 6.

Find the numbered segment overlaying the county.

Match the number from the segment to one of the numbered Ultimate Receiving Waters. For example: A facility located in Western Saline County is in segment 2C. The “2" determines that the Ultimate Receiving Water for the project is the Ouachita River.

Signatory Requirements: The information contained in this form must be certified by a Responsible Official as defined in the “signatory requirements for permit applications” (40 CFR 122.22).

Responsible official is defined as follows:

For a corporation: by a responsible corporate officer. For purposes of this section, a responsible corporate officer means:

A president, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation; or

The manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to ensure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

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 or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes:

The chief executive officer of the agency; or

A senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency.

Arkansas Department of Environmental Quality

NOTICE OF INTENT

Landfill sanitary discharge

NPDES GENERAL PERMIT ARG160000

Application Type:	New	Renewal (Permit # ARG16_ __________)

PERMITTEE/OPERATOR INFORMATION

Permittee (Legal Name):	Operator Type:
Permittee Mailing Address:	State	Partnership
Permittee City:	Federal	Corporation*
Permittee State:	Zip:	Sole Proprietorship/Private
Permittee Telephone Number:	*State of Incorporation: _______
Permittee Fax Number:	The legal name of the Permittee must be identical to the name listed with the Arkansas Secretary of State.
Permittee E-mail Address:

II.	INVOICE MAILING INFORMATION

Invoice Contact Person:
City:
Invoice Mailing Company:
State:	Zip:
Invoice Mailing Address:
Telephone:

III.	FACILITY INFORMATION

Facility Name:	Facility Contact Person:
Facility Address:	Telephone Number:
Driving Directions to Facility:
Facility County:	Facility City, State & Zip:
Facility Latitude:	Deg Min Sec	Facility Longitude:	Deg Min Sec
Facility SIC Code:	Facility NAICS:

IV.	DISCHARGE INFORMATION

Outfall Number:	001	Estimated Flow:	MGD (Million Gallons per Day)
Outfall Description:
Stream Segment:	Hydrologic Basin Code:
Outfall Latitude:	Deg Min Sec	Outfall Longitude:	Deg Min Sec
Receiving Stream:
Outfall Number:	Estimated Flow:	MGD (Million Gallons per Day)
Outfall Description:
Stream Segment:	Hydrologic Basin Code:
Outfall Latitude:	Deg Min Sec	Outfall Longitude:	Deg Min Sec
Receiving Stream:

V.	CONSTRUCTION REQUIREMENTS

Yes	No
Is this permit covering the construction of a sedimentation pond?

If yes, have you included Arkansas Form 1 and design, plans and specifications (including the requirements in Part 1.3.2 of the permit) stamped by a Professional Engineer registered in the State of Arkansas?

Is this facility within the area of the Boone or St. Joe formations? Map available at :

http://www.adeq.state.ar.us/water/branch_permits/general_permits/default.htm

VI.	FACILITY PERMIT INFORMATION

NPDES Individual Permit Number (If Applicable):	AR00
NPDES General Permit Number (If Applicable):	ARG
State Construction Permit Number:
NPDES General Construction Stormwater Permit Number (If Applicable):	ARR15
NPDES Industrial Stormwater General Permit Number:	ARR00
Other Department Permits:

OTHER INFORMATION:

Additional Location Description
Additional Comments:
Consultant Contact Name:
Consultant Email Address:
Consultant Address:	City:	State:	Zip:
Consultant Phone Number:	Consultant Fax Number:

CERTIFICATION OF OPERATOR

"I certify that, if this facility is a corporation, it is registered with the Secretary of the State of Arkansas. I certify that the cognizant official designated in this Application is qualified to act as a duly authorized representative under the provisions of 40 CFR 122.22(b). If no cognizant official has been designated, I understand that the Department will accept reports signed only by the Applicant. 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 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."

Responsible Official Printed Name:
Title:
Responsible Official Signature:
Date:
Responsible Official Email:
Cognizant Official Printed Name:
Title:
Cognizant Official Signature:
Telephone:
Cognizant Official Email:

IX.	PERMIT REQUIREMENT VERIFICATION

Please check the following to verify completion of permit requirements. If you answer “NO” to any of questions below the application will be considered incomplete and cause a delay in the permitting process.

Yes	No
Submittal of Complete NOI?
Submittal of Required Permit Fee?
New Permittees Only Check Number:
Submittal of Topographic Map?
Submittal of Disclosure Statement?
Industrial Operator’s License Number:

WATER DIVISION

5301 NORTHSHORE DRIVE / NORTH LITTLE ROCK, ARKANSAS 72118

PHONE 501-682-0623 / FAX 501-682-0880

www.adeq.state.ar.us Revised 8/2014

- 1 -

Ultimate Receiving Waters

Red River

Ouachita River

Arkansas River

White River

St. Francis River

Mississippi River

NOTICE OF INTENT

Mo Shafii

2015-08-03

Berry, Deandra

Arkansas Dept. of Environmental Quality