Date Received: / / / Application/Revenue ID: / Organization ID:
Document ID: / Place ID: / Check ID:
Check Date: / / / Check Number: / Check Amount:
State of Ohio Notice of Intent (NOI) for Coverage under Environmental Protection Agency a General Permit to Install for land application of Division of Surface Water hydro-demolition wastewater
Read accompanying instructions carefully before completing this form
Submission of this NOI constitutes notice that the party identified in Section 3 of this form intends to be authorized to install a treatment works under Ohio EPA’s PTI general permit program. Becoming a permittee obligates a permittee to comply with the terms and conditions of the permit. Complete all required information as indicated by the instructions. Forms transmitted by fax will not be accepted. A check for the proper amount must accompany this form and be made payable to “Treasurer, State of Ohio”.
1. Project Name:2. Brief Project Description:
3. Applicant Information:
Name:
Mailing Address:
City: / State: / Zip:
Contact Name:
Title:
Phone: / () - / Fax: / () - / E-mail :
4. Application/Plans Prepared by:
Name:
Mailing Address:
City: / State: / Zip:
Title:
Phone: / () - / Fax: / () - / E-mail :
5. Project Location:
Hydro-demolition Location:
Land Application Location
County: / Township:
Municipality:
6. Project Details:
Collection system components:
Total length of bridge deck restoration in project:
Is a land application plan attached? / Yes No
Is a schematic diagram attached? / Yes No
Were the design plans developed by a Professional Engineer registered in Ohio? / Yes No
7. Estimated Project Schedule:
Beginning operation date: / // / Ending operation date: / //
8. Fee Calculations:
Permit-to-Install
a. Application fee: / $ 200.00
b. Total Fee (a) / $ 200.00
9. Signature of the Applicant: (see Ohio Administrative Code 3745-42-03)
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and that all the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are substantial penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.
Typed name: / Title:
Signature: / Date: / //
NOTE (Who Must Sign):
Applications for permits to install and plan approvals shall be signed by the person, firm, agency or entity responsible for constructing or funding the construction of the disposal system. In this case, the NOI shall be signed by an authorized representative of the contractor performing hydro-demolition work covered by the General Permit to Install for land application of hydro-demolition wastewater.
General Permit to Install hydro-demolition wastewater / Page 1 of 2