NOTICE OF INTENT

FOR DISCHARGES OF STORMWATER

ASSOCIATED WITH REGULATED SMALL MUNICIPAL SEPARATE STORM SEWER SYSTEMS

AUTHORIZED UNDER NPDES GENERAL PERMIT ARR040000

The enclosed form may be used to obtain coverage under NPDES general permit ARR040000 for discharges of stormwater associated with Regulated Small Municipal Separate Storm Sewer Systems (MS4). Only a copy of the attached authorized Notice of Intent form will be accepted by this Department.

Return the completed form to:

Arkansas Department of Environmental Quality

Permits Branch, Water Division

5301 Northshore Drive

North Little Rock, AR 72118

NOTE:	DO NOT LEAVE BLANK SPACES IN THE NOTICE OF INTENT. IF ANY QUESTION DOES NOT APPLY, MARK “N/A” IN THE SPACE PROVIDED.

For additional information please contact:

General Permit Section, Water Division
Ph.: (501) 682-0623
Fax: (501) 682-0880
Web: www.adeq.state.ar.us

NOTICE OF INTENT

FOR DISCHARGERS OF STORMWATER RUNOFF

ASSOCIATED WITH REGULATED SMALL MUNICIPAL SEPARATE STORM SEWER SYSTEMS

AUTHORIZED UNDER NPDES GENERAL PERMIT ARR040000

PERMITTEE INFORMATION	New Renewal (Permit Tracking Number ARR04_________)

Regulated Small MS4 Name:	Owner Type:
Mailing Address:	FEDERAL	STATE
Actual Street Address:	PUBLIC	OTHER
City:	Urbanized Area
State:	Zip:	County(ies):
Enter the Latitude and Longitude of the approximate center of the Small MS4 (A map must be included.):
Small MS4 Latitude:	degrees	minutes	seconds
Small MS4 Longitude:	degrees	minutes	seconds

II.	PERMITTEE CONTACT INFORMATION

Name:	Telephone:
Title:	Email Address:

INVOICE MAILING INFORMATION

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

CERTIFICATION OF PERMITTEE (See Part 5.7 of the general permit)

For a municipality, State, Federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of Part VI.H of the general permit, a principal executive officer of a Federal agency includes (i) the chief executive officer of the agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrator of EPA).

“I certify that the cognizant official designated in this Notice of Intent is qualified to act as a dully 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 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 who manage the system, or those persons directly responsible for gathering 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:

COGNIZANT OFFICIAL DESIGNATION (Optional)

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

PERMIT REQUIREMENT VERIFICATION

Submittal of Complete NOI?	Yes	No

Submittal of Complete Stormwater Management Program?	Yes	No
Submittal of MS4 map?	Yes	No

ADEQ Water Division / 5301 NORTHSHORE DRIVE / NORTH LITTLE ROCK, ARKANSAS 72118 / PHONE 501-682-0623 / FAX 501-682-0880

www.adeq.state.ar.us

MS4 NOI / Revision date 10/22/2012

NOTICE OF INTENT

Kim Fuller

2015-07-30

Berry, Deandra

Arkansas Dept. of Environmental Quality