Type of Submittal (Check Appropriate Box): Initial Amendment Renewal Permit Number: RULE 5 - NOTICE OF INTENT (NOI) State Form 47487 (R5 / 10-05) Indiana Department of Environmental Management Office of Water Quality Approved by State Board of Accounts, 2005 (Note: The initial submittal does not require a permit number; the Department will assign a number. A permit number is required when filing an amendment, applying for renewal, or correspondence related to this permit). Note: Submission of this Notice of Intent letter constitutes notice that the project site owner is applying for coverage under the National Pollutant Discharge Elimination System (NPDES) General Permit Rule for Storm Water Discharges Associated with Construction Activity. Permitted project site owners are required to comply with all terms and conditions of the General Permit Rule 327 IAC 15-5 (Rule 5). Project Name and Location Project Name: County: Brief Description of Project Location: Project Location: Describe location in Latitude and Longitude (Degrees, Minutes, and Seconds or Decimal representation) and by legal description (Section, Township, and Range, Civil Township) Longitude: Latitude: Quarter: Section: Township: Range: Civil Township: Does all or part of this project lie within the jurisdictional boundaries of a Municipal Separate Storm Sewer System (MS4) as defined in 327 IAC 15-13? Yes No If yes, name the MS4(s): Project Site Owner and Project Contact Information Company Name (If Applicable): Project Site Owner’s Name: (An Individual) Title/Position: Address: City: State: Phone: FAX: ZIP Code: E-Mail Address: (If Available) Ownership Status (check one): Governmental Agency: Federal State Local Non-Governmental: Contact Person: Public Private Other: (Explain) Company Name: (If Applicable) Affiliation to Project Site Owner: Address: (if different from above) City: Phone: State: FAX: ZIP Code: E-Mail Address: (If Available) Project Information Project Description: Residential-Single Family Residential-Multi-Family Commercial Industrial Other: (Explain) Name of Receiving Water: (Note: If applicable, name of municipal operator of storm sewer and the ultimate receiving water. If a retention pond is present on the property, the name of the nearest possible receiving water receiving discharge must be provided). Project Acreage Total Acreage: Proposed Land Disturbance: (in acres) Total Impervious Surface Area: (in square feet, estimated for completed project) Project Duration Estimated Start Date: Estimated End Date for all Land Disturbing Activity: (Continued on Reverse Side) American LegalNet, Inc. www.FormsWorkflow.com Construction Plan Certification By signing this Notice of Intent letter, I certify the following: A. The storm water quality measures included in the Construction Plan comply with the requirements of 327 IAC 15-5-6.5, 327 IAC 15-5-7, and 327 IAC 155-7.5; B. the storm water pollution prevention plan complies with all applicable federal, state, and local storm water requirements; C. the measures required under 327 IAC 15-5-7 and 327 IAC 15-5-7.5 will be implemented in accordance with the storm water pollution prevention plan; D. if the projected land disturbance is One (1) acre or more, the applicable Soil and Water Conservation District or other entity designated by the Department, has been sent a copy of the Construction Plan for review; E. storm water quality measures beyond those specified in the storm water pollution prevention plan will be implemented during the life of the permit if necessary to comply with 327 IAC 15-5-7; and F. implementation of storm water quality measures will be inspected by trained individuals. In addition to this form, I have enclosed the following required information: Verification by the reviewing agency of acceptance of the Construction Plan. Proof of publication in a newspaper of general circulation in the affected area that notified the public that a construction activity is to commence, including all required elements contained in 327 IAC 15-5-5 (9). The Proof of Publication Must include company name and address, project name, address/location of the project, and the receiving stream to which storm water will be discharged. Following is a sample Proof of Publication: “XERT Development Inc. (10 Willow Lane, Indianapolis, Indiana 46206) is submitting a Notice of Intent to the Indiana Department of Environmental Management of our intent to comply with the requirements of 327 IAC 15-5 to discharge storm water from construction activities associated with Water Garden Estates located at 24 Washout Lane, Indianapolis, Indiana 46206. Runoff from the project site will discharge to the White River. Questions or comments regarding this project should be directed to Walter Water of XERT Development Inc.” $100 check or money order payable to the Indiana Department of Environmental Management. A permit fee is required for all NOI submittals (initial and renewal). A fee is not required for amendments. Project Site Owner Responsibility Statement By signing this Notice of Intent letter, 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 or violating the provisions of 327 IAC 15-5, including the possibility of fine and imprisonment for knowing violations. Printed Name of Project Owner: ____________________________________________________________ Signature of Project Owner: ______________________________________ Date: ___________________ This Notice of Intent must be signed by an individual meeting the signatory requirements in 327 IAC 15-4-3(g). All NOI submittals must include an original signature (FAX and photo copies are not acceptable). Note: Within 48 hours of the initiation of construction activity, the project site owner must notify the appropriate plan review agency and IDEM, Office of Water Quality of the actual project start date if it varies from the date provided above. Note: A permit issued under 327 IAC 15-5 is granted by the commissioner for a period of five (5) years from the date coverage commences. Once the five (5) year permit term duration is reached, a general permit issued under this rule will be considered expired, and as necessary for construction activity continuation, a new Notice of Intent letter (Renewal) is required to be submitted ninety (90) days prior to the termination of coverage. The submittal must include the NOI Letter, Proof of Publication, Fee, and verification that the plan for the project was approved (original verification of plan approval is acceptable provided the scope of the project has not changed from the original submittal). Mail this form to: Indiana Department of Environmental Management Cashiers Office - Mail Code 50-10C 100 North Senate Avenue Indianapolis., IN 46204-2251 327 IAC 15-5-6 (a) also requires a copy of the completed Notice of Intent letter be submitted to the local Soil and Water Conservation District or other entity designated by the Department, where the land disturbing activity is to occur. Questions regarding the development or implementation of the Construction Plan/Storm Water Pollution Prevention Plan should be directed to the local county Soil and Water Conservation District (SWCD). If you are unable to reach the SWCD or have other questions please direct those inquiries to the IDEM Rule 5 Coordinator at 317/233-1864 or 800/451-6027 ext.3-1864. For information and forms visit:http://www.in.gov/idem/permits/water/wastewater/wetwthr/storm/rule5.html American LegalNet, Inc. www.FormsWorkflow.com