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<br /> pUBLIC NOTICE TEMPLATE
<br /> (Name af operafor/permitteeJ
<br /> (Address of awner or%represenfative}is seeking coverage under#he Washington�epartmenf of Ecology's
<br /> NPDES Genera! Permit for S#ormwater[7ischarges Assaciafed with Construc#ion Activities.
<br /> The praposed (total acres}prajec#, known as (project name)is focated at (sfreef address,
<br /> infersection, crossroads, or other descriptive sife locafion)in {name of nearesf city). Approximafely
<br /> {number of disturbed acres)wiil be disturbed for construction of (project type).
<br /> (List a/!construction activity, e.g., clearrng, grading, stackpiling(approx yd3. and locafionJ, imporfing/exporfing maferials
<br /> (yd3j, demolifion, grading, stormwater facilities,roads, utilifies, number buildings/homes and type, sidewalks,
<br /> landscaprng.} Stormwater wifl be (Brref descripfion of how fhe stormwater wr!!be cleaned and confrolled)prior to
<br /> discharging (Describe the direcfion of the stormwafer f/ows;include distance to receiving waters. List wetlands,
<br /> unnamed and named receiving waters and storm drains;clearly identify buffer location and widfhs used to protect
<br /> sensitive wafer bodies.)
<br /> Any persons desiring to present their views ta the Department of Ecology concerning this application may notify
<br /> Ecology in wrifing within 30 days from the last date of publicat'son of this notice.
<br /> Comments may be submitted to: Washington Department af Ecology
<br /> WaEer Qualify Program
<br /> Sfarmwater Unit-Cansfruction
<br /> PO Box 47696
<br /> (�fympia,WA 98504-7696
<br /> XI. Certi�cation of Permittees
<br /> "1 cer-iify under penalty uf law that this tlocurneftt and c�tl attuclaments were prepared under my direclion or
<br /> supervision in accordance with a systern designed to assure that qualif ed personnel praperly gather and evaluate
<br /> the infornzaliat submitled. Based on nry inquiry of tlteperson or per,svns who rnanage the system or tl':ase directty
<br /> re.sPoruible fvrgathering the iriformatiort, the irrfor•nratiori submrttecl is, to the besf of n:y krrnwledge and betief,
<br /> true, accurate, c�nd complcte. I am ajvare tlzat tliere are sigizificarrt penalties fvr submiiting false information,
<br /> includittg the possi6ility offine and in:prisonme�at for•knowing violations."
<br /> � �� o�--R.r
<br /> Operator's Pcinted Na * TiUe
<br /> �~ 4��b
<br /> Operator's Signature'' Date
<br /> *�ederaf regulations require this application to be signed as follows:
<br /> A. For a corporatian, by a principal executive officer of at least the level of vice president;
<br /> 8. For a partnership or sale proprietorship,by a genera€partner or the proprietor,respectively;or
<br /> C. For a municipality, state,federal,or other pubfic facility, by either a principal executive afficer or ranking elected
<br /> afficial.
<br /> Please sign anc�return this document to the follawing address: Washington Department of Ecology
<br /> Water Quality Program
<br /> Constructian Stormwater Unit
<br /> PO 8ox 47696
<br /> Olympia, WA 95504-7696
<br /> If yau have any questions, please ca1L
<br /> o {360)407-7453 Charles Gilman for city of Seaftle or counties: Kifsap, Pierce, Thurston
<br /> o (36Q)407-7229 Tamrnie McClure for counties: King, Island, San Juan
<br /> o (360)407-6437 Linda Mat[ock far counties: Whafcom, Skagit, Snohomrsh, �'erry, Sfevens, Pend Oreirle, Lincoln,
<br /> Spokane, Grant,Adams, Whitman, Franklin, Walla Watla, Columbia, Garfield,Asotrn
<br /> o (360)407-6858 Joyce Smith for counties: 4kanogan, Chelan, Douglas, Kiltitas, Yakima, Benton, Klickitat,
<br /> Skamania, CJark, CowJifz, Wahkiakum, Lewis, Pacrfic, Grays Harbor, Mason,Jefferson, ClalJam
<br /> 1(you require fhis document in an alternative formaf,please contact ihe Wafer Quality Program at(360)-Q07-8401.!f you are a person with a
<br /> speeCh or hearing impairment,call 79?for relay service or T-800-833-6388 for 7TY,Ecology is an Equa!Opporfunity Agency.
<br /> EGY 020-85(rev 12/05) ��Page 4��`�,`� .j
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