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

VIII. State Environmentai Polic Act (SEPA) If•ihe SEPA process has not been completed at the time of NOI submittal, a foitow-up lener must be sent [o Ecology with the following information prior to Ecology granting permit coverage. Has a SEPA review been completed? ❑ Yes ❑ No ❑ Exempt Type of SEPA document ❑ DNS ❑ Fnal EIS Agency issuing DNS, Fnal EIS, or Exemption ; Date Are you aware af an appeal of the adequaney of tfie SEPA document7 ❑ Yes ❑ No (If yes, please attach explanatory letter.) SEPA requirements must be complied with prio� to ermit issuance. IX. Public Notice The public notice must be published at least once each week for 2 consecutive weeks, in a sinole newspaper which has general circulation in the county in which the construction is to take place. See the NOI instructions for the public notice language reQuirements. Pertnit covera9e will not be granted sooner than 31 davs aher the date ot the second pubiic notice. Note: this NOl must be submitted to Eco%gy on or before the date of the fust pubfrc noGce. ..; Provide the exact dates Imm/dd/yy) that the first and second public notices will appear in the newspaper: '� Date of the first public notice / / ; Date of second public notice / � � Name of the newspaper which will run the public notices Eco%gy is no longer iequiring the subminal o/the aflidavrt of publication. � A cop of the notice to be ublished must be rovided elan with the N01. X. Re ulator Status a L A. ❑ NPDES Permh (e.g., industrial stormwater) C. ❑ Air Notice of Construction, Permit, or Order Permit No. Ageney B. ❑ State Waste Discharge Permit D. ❑ State/USEPA Hazardous Waste ID No. Permit No. • XI. Certification of Permittee(s) 'I�1Y��P�fY oJlaw rhat thi.r doaonau mid al(atrad+ma�ts»ae p�epared imder my di�euion or.nrpotii,nm in atcordanct Hith a rystan d�tigned to auure rhm qudified penmvvl P7OP�h'Bmhu and twlu�e the inJonrmiort svbrm'ncd. �. inJormarion, Uu '�Y�I rhe person or persanr»�w mm�age the sY�4 or�hate perrair 6rocrh'raporznp(�J�8mhering the ,; inJanr�ian subrnraed ir. w 1he 6err oJmY Anm.iedgt m�d bdief, rrue, aaarrme, md cor�lue. I mn awrre thm thtre are.ngnil+�+prnalria Jor subnu'rringJaLre inJonrnnw+. in�lu�'ng�he pasribiliry oJfine m�d ir�n'savnou jor Anm+ing � YIOIB7�07tt.' '� ��a �2 Owner/Representative's Printed Name Trtie � :3 •; Owner/Representative's Signature Date Sign and return this document to the foliowing add�ess; for Questions call (360) 407-6437�ar�gq-gg- Washington Department of Ecology Water �uality Program • Stormwater UnR .� PO Box 47696 Olympia, WA 98504-7696 rhe Deparrmenr of Ecology/s an equal opporruniry ag��y and does nar diserrminate on the basis of race, •reed, colo% disabiliry, age, religion, national o�iyin, sez, mariral status, drsabled veteran's sratus, Vietnam Ere •eteren's status, or sexual oiientation.