Notice of Intent

1 Page 1 of 5 Notice of IntentGP-0-17-004 This is the Notice of Intent f or stormwater Discharges Associated with Industrial Activity under theState pollutant discharge elimination system (SPDES) multi - sector general permit InformationContact Last NameContact First NameO/O Street AddressO/O CityO/O StateO/O Zip-Contact Phone--Contact eMailO/O NameFor Department Use OnlyNYRThe completed Notice of Intent (NOI)should be submitted to:MSGP Coordinator,NYSDEC Division of Water,625 Broadway, 4th FloorAlbany, New York 12233-3505 IMPORTANT- Applicants must read and understand the conditions of the permit prior to submitting this NOI Applicants are responsible for identifying and obtaining other DEC permits that may be Use this NOI to obtain coverage under GP-0-17-004 OR to make revisions to a previously submitted All sections must be completed unless otherwise noted. Incomplete forms will be returned to you, thereby delayingyour coverage under this general Type or print in boxes.

2 Avoid contact with the edge of the Fill in circles completely and do not use check The Owner/Operator must sign the InformationEnter the name of the legally responsible entity and the address of the executive the name and contact information for the individual responsible for communicating with DECregarding the implementation of the MSGP on behalf of the Tax ID #-Save time by filing your NOI electronically using the E-NOI found on the Departments websiteSECTION 16052362228 Facility InformationFacility NameFacility Street AddressFacility CityStateNYFacility Zip-Facility CountyPage 2 of 5 Enter the complete street address of the physical location of the InformationNameStreet AddressCityStateZip-Provide the geographic coordinates in decimal degrees for the latitude & longitude of the facility. The NYSDECS tormwater Interactive Map on the DEC's website can be used to get information is same as Owner/Operator (Do not complete this section)Billing information is different from Owner/Operator (Please complete billing information below) the name of the nearest surface waterbody into which site runoff will discharge .

3 If more than one, list all that apply:6(a).Does site runoff enter a Municipal Separate Storm Sewer system (MS4) including roadside drains, swales, ditches, culverts, If No, go to question 7(a)..YesNo6(b).If Yes, enter the name of the municipality/entity that owns the Municipal Separate Storm Sewer SystemPage 3 of your facility conduct any activities listed in Part of the SPDES multi - sector general Permitwhich would make your facility ineligible for coverage under this general permit ?.. your facility meet all the eligibility requirements listed in Part of the SPDES multi -SectorGeneral permit to gain coverage under this general permit ? No, contact the Department to discuss next steps. If Yes, go to question 2(a).If Yes, contact the Department to discuss next steps. If No, go to question 25(c).Does your SWPPP include measures to address the pollutant (s) of concern as required by of the SPDES multi - sector general permit ? If No, contact the Department to discuss next (b).

4 Is the pollutant (s) causing the impairment a pollutant of concern included in the benchmarks and/or effluent limitations to which the facility is subject to in Part VII of the SPDES multi -SectorGeneral permit ? A list of applicable pollutant (s) of concern for the SPDES multi - sector general Permitcan be found in Appendix G of the permit . If No, go to question 6(a).5(a).Has the surface waterbody in question 4 been identified as an impaired waterbody as defined in MSGP 0-17-004?If No, go to question 6(a).To determine if the waterbody in Question 4 is impaired use the following links available on the Department'spublic web site:MSGP Toolbox with Map of Impaired Waterbodies .. Waters Listings .. (a).Has a stormwater Pollution Prevention Plan (SWPPP) been prepared for this facility in accordancewith the requirements of the SPDES multi - sector general permit GP-0-17-004? If No, you are noteligible for permit (b).How will you make your SWPPP available to the public?

5 Posting a copy online (Provide URL).Maintain copy at the facility address listed in the facility information section of the copy at the following location (Provide address):Street AddressCityStateZip-2883362226 Page 4 of this facility have coal piles that are exposed to precipitation? this facility have salt piles that are exposed to precipitation? this facility discharge stormwater from secondary containment areas for liquid bulk storage ortransfer areas? facility's existing ID is:NYR 0 07(a).Has this facility been assigned a SPDES MSGP ID under previous versions of the MSGP?If No, go to question (b).If Yes, Provide the ID if known (Note: All SPDES MSGP IDs begin with NYR00)SECTION S - Is this facility an airport that uses more than 100,000 gallons of glycol-baseddeicing/anti-icing chemicals and/or 100 tons or more of urea on an average annual basis? a Representative Outfall Waiver being claimed in accordance with Part (If Yes, please submit the Representative Outfall waiver form with the NOI).

6 Each stormwater discharge associated with industrial activity at your facility identify the outfall number ( , 001,002, etc.); the four digit Standard Industrial Classification (SIC) codes, the sector Code, the sector N Subsector, or2-letter Industrial Activity Codes that best represent the principal products or services rendered by the facility for thatdrainage area; and the Benchmark (B) and/or Compliance (C) monitoring required; and the acreage of industrial activityexposed to stormwater for each outfall (round to nearest tenth of an acre):..OutfallNumberIndustrial Activities (SIC or 2-letter Codes) AcreagePrimarySICS econdarySICS ectorSectorMonitoringRequiredMonitoringR equiredTertiarySICS ectorMonitoringRequired5110362222 Page 5 of 5 CertificationI certify under penalty of law that this document and all attachments were prepared under my direction orsupervision in accordance with a system designed to assure that qualified personnel properly gathered andevaluated the information submitted.

7 Based on my inquiry of the person or persons who manage the system , orthose persons directly responsible for gathering the information, the information submitted is, to the best of myknowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submittingfalse information, including the possibility of fine and imprisonment for knowing First Name (please print or type)MIO/O Last Name (please print or type)Date//O/O the facility subject to any of the following EPA Point Source Category Effluent Limitations?(b) sector C - Contaminated runoff from phosphate fertilizer manufacturing facilities?YesNoIf Yes, list Outfall (a) sector A - Discharges resulting from spraydown or intentional wetting of logs at wet deck storageareas?YesNoIf Yes, list Outfall (c) sector D - Runoff from asphalt emulsion facilities?YesNoIf Yes, list Outfall (e) sector J - Mine dewatering discharges at crushed stone, construction sand and gravel, and industrialsand mines?

8 YesNoIf Yes, list Outfall (f) sector L - Runoff from landfills?YesNoIf Yes, list Outfall (h) sector S - Discharges from airport deicing using airfield deicing products that contain urea at anairport with at least 1,000 annual non-propeller aircraft Yes, list Outfall (d) sector E - Runoff from material storage piles at cement manufacturing facilities?YesNoIf Yes, list Outfall (g) sector O - Coal Pile runoff at steam electric power generating facilities?YesNoIf Yes, list Outfall