NOTICE OF INTENT

NPDES GENERAL PERMIT ARG550000

INDIVIDUAL TREATMENT FACILITIES

The attached form can be used by all persons desiring coverage under NPDES general permit ARG550000 (Individual Treatment Facilities). The form should be completed and submitted to this Department no later than thirty (30) days prior to the date coverage is desired.

All information must be provided. If a question does not apply, place "NA" in that space. Do not leave questions blank.

Be sure to read the Individual Treatment Facilities General Permit, ARG550000. It describes what constitutes coverage under this permit, effluent requirements, discharge limitations, and other standard conditions that are applicable to this permit.

40 CFR 122.22(b) states that all reports required by the permit, or other information requested by the Director, shall be signed by the applicant (or person authorized by the applicant) or by a duly authorized representative of that person. A person is a duly authorized representative only if the authorization is made in writing by the applicant (or person authorized by the applicant); the authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity such as the position of plant manager, superintendent, or position of equal responsibility for environmental matters for the company; the written authorization is submitted to the Director. This Notice of Intent must be signed by a person authorized under the provisions of state and federal law, and who should be familiar with the provisions of 40 CFR 122.22 pertaining to signatory authority. Be sure to read the Certification.

If you have any questions concerning the ARG550000 permit information or Notice of Intent, please contact Permits Branch of this Department at (501) 682-0623. For the purpose of this permit a Home Owner is an individual owning a single residence.

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 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 $200.00 Check payable to ADEQ (Re: ARG550000). (Home owners are exempt.)

A Disclosure form as required by ACA 8-1-106. (Home owners are exempt.)

Written approval from the Arkansas Department of Health (ADH) (EHP-19Form) must be submitted with the NOI.

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 Latitude and Longitude:

If a physical address is known go to www.terraserver-usa.com and proceed with the following steps:

Select Advanced Find

Select Address

Input address

Click on Aerial Photo

Click on the Info link at the top of the page

Note the Latitude and Longitude are in Decimal Coordinates.

Go to www.geology.enr.state.nc.us/gis/latlon.html to convert coordinates to Degrees, Minutes, and Seconds.

NOTE: If a physical address does not exist you may find the coordinates in the Legal Description of the property.

How to Determine the Accuracy, Method, Datum, Scale, and Description for the Facility/Outfall Latitude and Longitude:

Horizontal Accuracy Measure – This indicates the accuracy, in meters, of the latitude/longitude location, or how close the specific latitude/longitude location is guaranteed to be to the real-world location. It is typically a function of the method used to obtain the latitude/longitude.

Horizontal Collection Method - The text that describes the method used to determine the latitude and longitude coordinates for a point on the earth.

Address Matching-House Number	Public Land Survey-Quarter Section
Address Matching-Block Face	Public Land Survey-Section
Address Matching-Street Centerline	Classical Surveying Techniques
Address Matching-Nearest Intersection	Zip Code-Centroid
Address Matching-Digitized	Unknown
Address Matching-Other	GPS-Unspecified
Census Block-1990-Centroid	GPS with Canadian Active Control System
Census Block/Group-1990-Centroid	Interpolation-Digital Map Source (TIGER)
Census Block/Tract-1990-Centroid	Interpolation-SPOT
Census-Other	Interpolation-MSS
GPS Carrier Phase Static Relative Position	Interpolation-TM
GPS Carrier Phase Kinematic Relative Position	Public Land Survey-Eighth Section
GPS Code (Pseudo Range) Differential	Public Land Survey-Sixteenth Section
GPS Code (Pseudo Range) Precise Position	Public Land Survey-Footing
GPS Code (Pseudo Range) Standard Position (SA Off)	Zip+4 Centroid
GPS Code (Pseudo Range) Standard Position (SA On)	Zip+2 Centroid
Interpolation-Map	Loran C
Interpolation-Photo	Interpolation-Other
Interpolation-Satellite

Horizontal Reference Datum - The code that represents the reference datum used in determining latitude and longitude coordinates.

Unknown	WGS84
NAD27	NAD83

Source Map Scale - The scale used to determine the latitude and longitude coordinates.

Not Applicable	1:62,500
Unknown	1:63,000
1:15,840	1:63,350
1:20,000	1:63,360
1:24,000 (1” = 2,000’)	1:100,000
1:25,000	1:250,000

Reference Point Description - The place for which geographic coordinates were established.

Facility/Station Building Entrance or Street Address	Facility Center/Centroid
Boundary Point	Intake Point
Treatment/Storage Point	Release Point
Monitoring Point	Other

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

Locate the county of your facility on the map on Page 4.

Find the numbered segment overlaying the county. For example 2C overlays most of Saline 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 4.

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.

V.	How to Determine your Ultimate Receiving Waters:

Locate the county of your facility on the map on Page 4.

Find the numbered segment overlaying the county. For example 2C overlays most of Saline 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:

Corporation, a principal officer of at least the level of vice president, treasurer

Partnership, a general partner

Sole proprietorship: the proprietor/owner

Municipal, state, federal, or other public facility: principal executive officer, or ranking elected official

Arkansas Department of Environmental Quality

NOTICE OF INTENT

Individual treatment FacilitIES

NPDES GENERAL PERMIT ARG550000

Application Type:	New	Renewal (Permit # ARG55___________)

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 (Home owners are exempt.)

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:
Facility County:	Facility City, State & Zip:
Facility Latitude:	Deg Min Sec	Facility Longitude:	Deg Min Sec
Accuracy:	Method:	Datum:	Scale:	Description:

IV.	DISCHARGE INFORMATION

Outfall Number:	Flow:	gpd (Gallons per Day)
Stream Segment:	Hydrologic Basin Code:
Outfall Latitude:	Deg Min Sec	Outfall Longitude:	Deg Min Sec
Accuracy:	Method:	Datum:	Scale:	Description:
Type of Treatment:
Receiving Stream:

V.	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

OTHER INFORMATION:

Operator Name:
Operator License Number:	License Class:
Consultant Contact Name:
Consultant Email Address:
Consultant Address:	City:	State:	Zip:
Consultant Phone Number:	Consultant Fax Number:

Has this treatment system been approved by AHD? Yes No

Disclosure Statements:

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. You must submit a new disclosure statement even if you have one on file with the Department. The form may be obtained from ADEQ web site at: http://www.adeq.state.ar.us/disclosure_stmt.pdf.

CERTIFICATION OF OPERATOR

_____(Initial) "I certify that, if this facility is a corporation, it is registered with the Secretary of the State of Arkansas."

_____(Initial) "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."

_____(Initial) "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:

X.	PERMIT REQUIREMENT VERIFICATION

Please check the following to verify completion of permit requirements.

Yes	No	* If No is answered for any of the questions, then a permit can not be issued!
Submittal of Complete NOI?
Submittal of Required Permit Fee?
Check Number:
Submittal of AHD Form EHP-19?
Submittal of Site Map?
Submittal of Disclosure Statement?

6

WATER DIVISION

5301 NORTHSHORE DRIVE / NORTH LITTLE ROCK, ARKANSAS 72118

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

www.adeq.state.ar.us

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Ultimate Receiving Waters

Red River

Ouachita River

Arkansas River

White River

St. Francis River

Mississippi River

Yarberry, Katherine

2015-08-03

Berry, Deandra

Arkansas Dept. of Environmental Quality