HomeMy WebLinkAboutAgenda Bill 3B.Attch2 03/03/2003["k1fil I �l
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NOTICE OF INTENT
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State Water Resources Control Board
NOTICE OF INTENT
TO COMPLY WITH THE TERMS OF THE GENERAL PERMIT FOR
STORM WATER DISCHARGESTROM
SMALL MUNICIPAL SEPARATE STORM SEWER SYSTEMS
A. Agency
City of 'Petaluma
City of Petaluma
B. Contact Person
C. Title
Dean H. Ecker
C. Title
Engineering Manager
D. Mailing Address
E. Address (Line 2)'
11 English St -reet
E. Addresi(4ine2)'
F. City
-11 English Street..
State
G'. Zip
H. County
Petaluma
CA
94952
Sonoma
I. Phone
J..,FAX'
K. Email Address
(707') 77- 8- 45`83
1. Phone
0 776 -3635
L. O erator Type (check one)
(707) 778 -4583
1. city 2. County 3. f I
State 4. 1 Federal 5. S ecial:District 6. Government Combination
I. NOI Status
Mark Only One Item 1. [X]New Permittee 2. [ -]Change of Information WDID #:
II. Agency Information
M. Permit Area
City of Petaluma
IV. Boundaries of Coverage (include a map with the submittal)
• Petaluma City Limits
V. Billinty Information
A. Agency
City of Petaluma
B. Contact Person
C. Title
Dean H.. Eckerson
Enaineering Manager
D. Mailing Address
E. Addresi(4ine2)'
-11 English Street..
F. City
State
G. Zip -
H. County _
Petaluma
CA
94952
Sonoma
1. Phone
FAX
K: Email Address
(707) 778 -4583
7 (707) 776 -3635
deCkerson@di.peta1uma.qa.us
[ ] Population,greater=than250 ,000 ..........................
$20,000
L. Population 55,000
[ Population between and 249999 ...............
$17,500
Please check the appropriate box'on the right and [ ] Population between 150;000 and 199,999 ... ..............
$15,000
submit the corresponding,fee. Check(s) should be
[ ] Population- between 100,000 and 149 999 ...............
$12,500
made payable to the SWRCB.
[ ] Population between 75 ',000 and 99,999....; ..............
$10,000
X] Population between 50,000 and. 74,999 ..................
$7,500 - -
SWRCB Tax ID is: 68- 0281986
[ ] Population between 25;000`and 49,999 ..................
$5,000
[ ] Population between 10 000 ;,and ..:...............
$3,000
[ ] Population between 1,000and 9,999 .....................
$2,000
[ ]Population between 0 > and i1 ,000 ............... :..........
$1,000
K — 12 School District ..: ..... :..... ::....... : ........ :......
Exempt
VL Discharg Information (check applicable box(es) and complete. corresponding information)
-' 1. [g] Applying for Individual General PermivCoverage
• 2. Applying fora Pennit with one or more co- _ ermittees
The undersigned agree to work as co- pernuttees in implementing a;corri
plete small MS
Agency
_ 3J-1.-Separate Im lementin °Enti SIE - -
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VII. Storm Water Management Plan (check box)
-- -- —[g] The. SWMP is attached.
VIII. Certification
Lcertifyunder penalty of law that this documentand
Y'g chments were,prepared under mydirection,and supervision in accordance with a system, designed to
- -- -- —
manage Y
assure`thar
qualified ersonnel ro erl ather'andievaluate the information submitted. Based on m y mn q uy person or u' of the. the system, or
9 P P p, P ersons who g
those persons' directly responsible ;for gathering,the information, to the:best ofmy'knowledge and belief, the;information submitted is true, accurate, and
complete. am+,aware that there a,r sigm. icantpenalties for
I submitting false`infommation, including the possibility of fine and,imprisonment. Additionally, I
certify that the provisioiis,of the permit, including' the development and implementation of a Storm Water.Management Program, will be complied with."
A. Printed Name: ;Micha'el . A Bierman
B. Title: City Manager
C. Signature: D. Date:
•
4 storm *water program. The program
must comply with the requirements 'found in,Title 40 of the Code of:Federal'Regulations, parts 122.32. Attach additional sheets
if necessary. Each co- ermittee must complete an NOI.
Lead Agency
Signature
Agency
Signature
- Agency - - --
Signature
G. Zip
Signature
A. Agency
B. Contact Person
C. Title
D. Mailing Address
E. Address (Line 2)
F. City
State
G. Zip
H. County
CA
I. Phone
J.� FAX
K Email Address
H. Operator Type (check one)
1. City 2. County 3. State 4. 1 Federal 5. Special District 6. Government Combination
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Minimum Control Measures being implemented by the SIE (check allthatapply)
[ ] Public Education _ [ ],Public Involvement [ )Illicit Discharge/Elimination
—[- ] Construction _ -
[ ]' Post Construction' [ ] Good Housekeeping
"I agree to coordinate with the agency identified in Section.Il of this =form and comply -with =its qualifying•storm.water. program. I certify under penalty of law that
this document and all attachments were prepared'under my direction and`supervisionin accordance with a system designed to assure that qualified personnel
properly gather and evaluate the informadon_ 'Based on,my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, to the of my knowledge and belief, "the; information subrutted is true;,accurate, and complete. I am aware that there
are significant penalties for submitting false' information „ncluding'the,possibility of fine and'imprisonment. Additionally, I certify that the provisions of the
permit, including, the development and irriplementation of a Storm Water:ManagementPr`ogmm, will.be complied with.”
N. Si afore of Official Date
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