121 E MARINE VIEW DR 2016-01-01 MF Import

� Application for General Permit to � Discharge Stormwater Associated with � Change of Infortnation ,,,,,,,,,, ,,,,, Construction Activity E�C�O�L�O�G �Y (Notice oi Intentl Pertnit A' S03 - IPiease print in ink or type) Please Fiead N01 Instructions Before Flling Out This Form I. Contact Person II. Owner/Representative of Site IAII correspondence will be mailed here) Contact Name Phone No. Owners Name Phonc No. Company ComDany Name Madmg Address Mailing Address City Statt Zip + 4 City State Zip + 4 III. Site Location/Address IV. Billin Address Site Name Contaa Name Phone No. S[reet Address (or Locauon Description) Company Name Gty lor nearest cttyl Zip + 4 Mailing AGdress County City State Zip + 4 Provide legal description if no address tor site lattach separate sheet if necessary) V. Receivin Water Information Icheck all chac applyl A. Does your construttion site discharge stortnwater to: 1. 0 Storm drain system - Owner of stortn drain system (name) 2. O Indirectly or directly to surface waters Ie.g., river, lake, creek, estuary, ocean, wetland) 3. ❑ Directly to ground waters of Washington state. ❑ Dry Well ❑ Dreinfield ❑ Other B. Namels) of receiving water�s) • Initial discharge is to an unnamed receiving water? ❑ Yes ❑ No VI. Construction Activit Information 1. Total area to be disturbed Acres 2. Projected consuuction.startup / ; projected completion date / month year month Yeer VII. Stormwater Polfution Prevention Plan (SWPPP) Hz� a stormwater pollution prevention plan, been developed? ❑ Yes ❑ No If N0, will a plan 6e developed prior to the start of consttuction? ❑ Yes ❑ No Ecology must be notified that a SWPPP will be developed prior to the start of conmuction by checking the I appropriate boxes above or by sending a follow-up letter to Ecology. A stormwater pallution preverttion plan must be develaped prior to tfie start of construetion. ECY 020-85 (Rev. 11l951 /Conunued on Back Page/ (Appendix 1)