HomeMy WebLinkAboutOnline Rule 5 Cert 03-16-22" CONSTRUCTION STORMWATER—
SIGNED CERTIFICATION
cc (Applies to online application submittals only.)
State Form 56679 (4-19)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
OFFICE OF WATER QUALITY
Note: Submission of the Construction Stom water— Signed Certification form Is the final
step to complete online applications for permit coverage and terminations under 3271AC
1&5 (Construction Stormwater General Permit). The signature verification (wet ink) Is
required as part of the application process and consistent with the U.S. Environmental
Protection Agency Cross -Media Electronic Reporting Rule (CROMERR).
For questions regarding the Stormwater Program and
the requirement to complete this form, contact:
IDEM Stormwater Program
100 North Senate Avenue IGCN Room 1255
Indianapolis, Indiana 46204-2251
Telephone: (317) 233-1864 or
(800) 451-6027(within Indiana)
E-mail: Stormwat&dem IN coy
Web Access: httl2://www.IN.govlidem/stormwater/2331.htm
PROJECT INFORMATION
Authorization Number (Begins with INR and six (6) characters. Required forAmendments, Renewals, and Terminations.):
Submission Reference Number (Assigned for each online submission): HPF-VSMPS8Q7
Project name (As it appeared on the ~Notice of Intent): ,Jackson's Grant Village, Section 2
Project Contact to address IDEM Questions (an individuaq:
Telephone: 317-770-1818 E-mail: dwagner@republiodev.com
NOTICE OF INTENT (Complete this Section for NOI Submittals.)
Notice of Intent: ® Initial ❑ Amendment ❑ Renewal
Transmittal and Enclosure Requirements: Check One:
® Fee has been paid online: The application for permit coverage under 327 LAC 15-5 (Construction Stormwater Permit) was
submitted through the IDEM online system and the application fee of $100 was paid at that time (if the application was associated
with an amendment and no fee is required). Mail this completed form to:
IDEM, Office of Water Quality
Stormwater Program
100 N Senate Avenue, IGCN Room 1255
Indianapolis, IN 46204-2251
❑ Fee has not been paid: The application for permit coverage under 327 IAC 15-5 (Construction Stormwater Permit) was submitted
through the IDEM online system and at the time of submittal, the option to pay the application fee of $100 with a check was
selected. The check in the amount of $100, payable to IDEM, OWQ is enclosed. Mail this completed form and payment to:
IDEM, Accounts Receivable
100 N Senate Avenue, IGCN Room 1340
Indianapolis, IN 46204-2251
NOTICE OF TERMINATION (Complete this Section for NOT Submittals.)
Notice of Termination: ❑ Construction Complete ❑ Change of Ownership ❑ Early Release from Permit Coverage
The application to terminate permit coverage under 327 IAC 15-5 (Construction Stormwater Permit) was submitted through the IDEM
online system. Mail this form to:
IDEM, Office of Water Quality
Stormwater Program
100 North Senate Avenue, IGCN Room 1255
Indianapolis, IN 46204-2251
CERTIFICATION AND SIGNATURE
This form is the official certification for the construction stormwater online submittal associated with the Submission Reference Number
referenced above.
By signing this form, I certify under penalty of law, including under penalty of perjury as specified by IC 35-44.1-2-1 and other
penalties specified by IC 13-30-10, that this document, the project information submitted online and all attachments were
prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly
gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment for knowing violations.
Printed name of project site owner (Name of app Lant as defined In 327 IAC 15,5 and submitted online): Doug Wagner
Signature of project site owner (individual):.4a.2 f>, Date (month, day, year): 3116rz2
This "Construction Stormwater— Signature Verification" orm must be signed by an individual meeting the signatory requirements
in 327IAC 15-4-3 . The submittal requires an original wet ink signature; hotoco ies are not acceptable.