2017 Construction General Permit – Appendix J

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2017 Construction General Permit (CGP)

Appendix J - Notice of Intent (NOI) Form and Instructions
Part 1.4.1 requires you to use the NPDES eReporting Tool, or “NeT” system, to prepare and submit
your NOI electronically. However, if the EPA Regional Office grants you a waiver to use a paper
NOI form, and you elect to use it, you must complete and submit the following form.

Page J-1 of 10

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF INTENT FOR THE 2017 NPDES CONSTRUCTION GENERAL PERMIT

NPDES
FORM
3510-9

Form Approved.
OMB No. 2040-0004

Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section III of this form requests authorization to discharge pursuant to
the NPDES Construction General Permit (CGP) permit number identified in Section II of this form. Submission of this NOI also constitutes notice that the operator
identified in Section III of this form meets the eligibility requirements of Part 1.1 CGP for the project identified in Section IV of this form. Permit coverage is
required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in Part 8 of the CGP. To obtain authorization,
you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for
permit coverage. Refer to the instructions at the end of this form.

I. Approval to Use Paper NOI Form
Have you been granted a waiver from electronic reporting from the Regional Office *?

YES

NO

If yes, check which waiver you have been granted, , the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:

The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that
is identified as under-served for broadband Internet access in the most recent report from the Federal
Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that granted the waiver:
/

Date approval obtained:

/

* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you must
file this form electronically using the NPDES eReporting Tool (NeT).

NPDES ID (EPA Use Only):

II. Permit Information
Master Permit Number:

(see Appendix B of the CGP for the list of eligible permit numbers)

III. Operator Information
Operator Information
Operator Name:
Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A?

YES

NO

Mailing Address:
Street:
City:

State:

ZIP Code:

-

County or Similar Government Division:
Phone:

-

-

Ext.

E-mail:
Operator Point of Contact Information:
First Name, Middle
Initial, Last Name:
Title:
NOI Preparer (Complete if NOI was prepared by someone other than the certifier):
First Name, Middle
Initial, Last Name:
Organization:
Phone:

-

-

Ext.

E-mail:

EPA Form 3510-9

Page 1 of 8

IV. Project/Site Information
Project/Site Name:
Project/Site Address:
Street/Location:
City:

State:

-

ZIP Code:

County or Similar Government Subdivision:
For the project/site you are seeking permit coverage, provide the following information:
Latitude/Longitude (Use decimal degrees and specify method):
Latitude:

___ ___. ___ ___ ___ ___° N (decimal degrees)

Latitude/Longitude Data Source:

Map

GPS

Longitude:

___ ___ ___. ___ ___ ___ ___° W (decimal degrees)

Other _______________________

Horizontal Reference Datum:

NAD 27

Is your project/site located in Indian country lands, or located on a property of religious or cultural significance to an Indian tribe?

NAD 83
YES

WGS 84

NO

If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable), or if not in
Indian country, provide the name of the Indian tribe associated with the property:

Estimated Project Start Date:

/

/

Estimated Area to be Disturbed (to the nearest quarter acre):
Type of Construction Site (check all that apply):

/

Estimated Project Completion Date:
.

Single-Family Residential
Institutional

Multi-Family Residential

Highway or Road

Will there be demolition of any structure built or renovated before January 1, 1980?

Utility
YES

Commercial

NO
YES

Was the pre-development land use used for agriculture (see Appendix A for definition of “agricultural land”)?
YES

If yes, is your project an “emergency-related project” (see Appendix A)?

Industrial

Other

If yes, do any of the structures being demolished have at least 10,000 square feet of floor space?

Have earth-disturbing activities commenced on your project/site?

/

NO
YES

NO

NO
YES

NO

Have stormwater discharges from your project/site been covered previously under an NPDES permit?

YES

NO

If yes, provide the NPDES ID ( if you had coverage under EPA’s 2012 CGP or the NPDES permit number if you had
coverage under an EPA individual permit:

V. Discharge Information
By indicating “Yes” below, I confirm that I understand that the CGP only authorizes the allowable stormwater discharges in Part 1.2.1 and the allowable nonstormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA
section 402(k) by disclosure to EPA, state, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by
the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the
allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must be covered under another NPDES permit.
YES
Does your project/site discharge stormwater into a Municipal Separate Storm Sewer System (MS4)?
Are there any waters of the U.S. within 50 feet of your project’s earth disturbances?

EPA Form 3510-9

YES

YES

NO

NO

Page 2 of 9

Receiving Waters Information: (Attach a separate list if necessary)

Point of
Discharge
ID

For each point of discharge, provide the following receiving water information:
Provide the name of the first water of
the U.S. that receives stormwater
If the receiving water is impaired (on
directly from the point of discharge
the CWA 303(d) list), list the pollutants
and/or from the MS4 that the point of
that are causing the impairment:
discharge discharges to:

If a TMDL been completed for this
receiving waterbody, providing the
following information:
TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

EPA Form 3510-9

Page 3 of 9

TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

TMDL Name and ID:

Pollutant(s) for which
there is a TMDL:

Are any of the waters of the U.S. to which you discharge designated by the state or tribal authority under its antidegradation policy as a Tier 2 (or Tier 2.5) water
(water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water) or as a Tier 3 water
(Outstanding National Resource Water)? (See Appendix F).
YES

NO

If yes, name(s) of receiving water(s) and its designation (Tier 2, Tier 2.5 or Tier 3):

VI. Chemical Treatment Information
Will you use polymers, flocculants, or other treatment chemicals at your construction site?
If yes, will you use cationic treatment chemicals at your construction site*?

YES

YES

NO

NO

If yes, have you been authorized to use cationic treatment chemicals by your applicable EPA Regional Office in advance of filing your NOI*?
YES
NO
If you have been authorized to use cationic treatment chemicals by your applicable EPA Regional Office, attach a copy of your authorization letter and
include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals
will not lead to a violation of water quality standards.
Please indicate the treatment chemicals that you will use:

* Note: You are ineligible for coverage under this permit unless you notify your applicable EPA Regional Office in advance and the EPA office authorizes
coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic
treatment chemicals will not lead to a violation of water quality standards.

VII. Stormwater Pollution Prevention Plan (SWPPP) Information
Has the SWPPP been prepared in advance of filing this NOI, as required?

YES

NO

SWPPP Contact Information:
First Name,
Middle Initial Last
Name:
Professional Title:
Phone:

-

-

Ext.

E-mail:

EPA Form 3510-9

Page 4 of 9

VIII. Endangered Species Protection
Using the instructions in Appendix D of the CGP, under which criterion listed below are you eligible for coverage under this permit? Check only 1 box, include
the required information and provide a sound basis for supporting the criterion selected. You must consider Endangered Species Act listed threatened or
endangered species (ESA-listed) and/or designated critical habitat(s) under the jurisdiction of both the U.S. Fish and Wildlife Service (USFWS) and National
Marine Fisheries Service (NMFS) and select the most conservative criterion that applies.
A

No ESA-listed species and/or designated critical habitat present in action area. Using the process outlined in Appendix D of this permit, you certify
that ESA-listed species and designated critical habitat(s) under the jurisdiction of the USFWS or NMFS are not likely to occur in your site’s “action area”
as defined in Appendix A of this permit. [Basis statement content: A basis statement supporting the selection of this criterion should identify the USFWS
and NMFS information sources used. Attaching aerial image(s) of the site to this NOI is helpful to EPA, USFWS, and NMFS in confirming eligibility under
this criterion. Please Note: NMFS’ jurisdiction includes ESA-listed marine and estuarine species that spawn in inland rivers.]

B

Eligibility requirements met by another operator under the 2017 CGP. The construction site’s discharges and discharge-related activities were already
addressed in another operator’s valid certification of eligibility for your “action area” under eligibility Criterion A, C, D, E, or F of the 2017 CGP and you
have confirmed that no additional ESA-listed species and/or designated critical habitat under the jurisdiction of USFWS and/or NMFS not considered
in the that certification may be present or located in the “action area.” To certify your eligibility under this criterion, there must be no lapse of NPDES
permit coverage in the other CGP operator’s certification. By certifying eligibility under this criterion, you agree to comply with any conditions upon
which the other CGP operator's certification was based. You must include in your NOI the NPDES ID from the other 2017CGP operator’s notification of
authorization under this permit. If your certification is based on another 2017 CGP operator’s certification under criterion C, you must provide EPA with
the relevant supporting information required of existing dischargers in criterion C in your NOI form. [Basis statement content: A basis statement
supporting the selection of this criterion should identify the eligibility criterion of the other CGP NOI, the authorization date, and confirmation that the
authorization is effective.]
If you select criterion B, provide the NPDES ID from the other operator’s notification of authorization under this permit:

C

Discharges not likely to adversely affect ESA-listed species and/or designated critical habitat. ESA-listed species and/or designated critical habitat(s)
under the jurisdiction of the USFWS and/or NMFS are likely to occur in or near your site’s “action area,” and you certify to EPA that your site’s
discharges and discharge-related activities are not likely to adversely affect ESA-listed threatened or endangered species and/or designated critical
habitat. This certification may include consideration of any stormwater controls and/or management practices you will adopt to ensure that your
discharges and discharge-related activities are not likely to adversely affect ESA-listed species and/or designated critical habitat. To certify your
eligibility under this criterion, indicate 1) the ESA-listed species and/or designated habitat located in your “action area” using the process outlined in
Appendix D of this permit; 2) the distance between the site and the listed species and/or designated critical habitat in the action area (in miles); and
3) a rationale describing specifically how adverse effects to ESA-listed species will be avoided from the discharges and discharge-related activities.
You must also include a copy of your site map from your SWPPP showing the upland and in-water extent of your “action area” with this NOI. [Basis
statement content: A basis statement supporting the selection of this criterion should identify the information resources and expertise (e.g., state or
federal biologists) used to arrive at this conclusion. Any supporting documentation should explicitly state that both ESA-listed species and designated
critical habitat under the jurisdiction of the USFWS and/or NMFS were considered in the evaluation.]
What ESA-listed species and/or designated critical habitat are located in your “action area”:

Distance between your site and the ESA-listed species and/or designated critical habitat within the action area (in miles, state “on site” if the ESAlisted species and/or designated critical habitat is within the area to be disturbed):

D

Coordination with USFWS and/or NMFS has successfully concluded. Coordination between you and the USFWS and/or NMFS has concluded. The
coordination must have addressed the effects of your site’s discharges and discharge-related activities on ESA-listed species and/or designated
critical habitat under the jurisdiction of USFWS and/or NMFS, and resulted in a written concurrence from USFWS and/or NMFS that your site’s
discharges and discharge-related activities are not likely to adversely affect listed species and/or critical habitat. You must include copies of the
correspondence with the participating agencies in your SWPPP and this NOI. [Basis statement content: A basis statement supporting the selection of
this criterion should identify whether USFWS or NMFS or both agencies participated in coordination, the field office/regional office(s) providing that
coordination, and the date that coordination concluded.]

E

ESA Section 7 consultation has successfully concluded. Consultation between a Federal Agency and the USFWS and/or NMFS under section 7 of the
ESA has concluded. The consultation must have addressed the effects of the construction site’s discharges and discharge-related activities on ESAlisted species and/or designated critical habitat under the jurisdiction of USFWS and/or NMFS. To certify eligibility under this criterion, Indicate the
result of the consultation:
biological opinion from USFWS and/or NMFS that concludes that the action in question (taking into account the effects of your site’s
discharges and discharge-related activities) is not likely to jeopardize the continued existence of listed species, nor the destruction or adverse
modification of critical habitat; or
written concurrence from USFWS and/or NMFS with a finding that the site’s discharges and discharge-related activities are not likely to
adversely affect ESA-listed species and/or designated critical habitat.
You must include copies of the correspondence between yourself and the USFWS and/or NMFS in your SWPPP and this NOI. [Basis statement
content: A basis statement supporting the selection of this criterion should identify the federal action agencie(s) involved, the field office/regional
office(s) providing that consultation, any tracking numbers of identifiers associated with that consultation (e.g., IPaC number, PCTS number), and the
date the consultation was completed.]

EPA Form 3510-9

Page 5 of 9

F

Issuance of section 10 permit. Potential take is authorized through the issuance of a permit under section 10 of the ESA by the USFWS and/or NMFS,
and this authorization addresses the effects of the site’s discharges and discharge-related activities on ESA-listed species and designated critical
habitat. You must include copies of the correspondence between yourself and the participating agencies in your SWPPP and your NOI. [Basis
statement content: A basis statement supporting the selection of this criterion should identify whether USFWS or NMFS or both agencies provided a
section 10 permit, the field office/regional office(s) providing permit(s), any tracking numbers of identifiers associated with that consultation (e.g.,
IPaC number, PCTS number), and the date the permit was granted.]

Provide a brief summary of the basis for criterion selection listed above [the necessary content for a supportive basis statement is provided under the criterion
you selected.].

IX. Historic Preservation
Are you installing any stormwater controls as described in Appendix E that require subsurface earth disturbance? (Appendix E, Step 1)

YES

NO

If yes, have prior surveys or evaluations conducted on the site have already determined historic properties do not exist, or that prior disturbances have
precluded the existence of historic properties? (Appendix E, Step 2)
YES
NO
If no, have you determined that your installation of subsurface earth-disturbing stormwater controls will have no effect on historic properties?
(Appendix E, Step 3)
YES
NO
If no, did the SHPO, THPO, or other tribal representative (whichever applies) respond to you within the 15 calendar days to indicate whether the
subsurface earth disturbances caused by the installation of stormwater controls affect historic properties? (Appendix E, Step 4)
YES
NO
If yes, describe the nature of their response:
Written indication that no historic properties will be affected by the installation of stormwater controls.
Written indication that adverse effects to historic properties from the installation of stormwater controls can be mitigated by
agreed upon actions.
No agreement has been reached regarding measures to mitigate effects to historic properties from the installation of
stormwater controls.
Other:

X. Certification Information
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed
to assure that qualified personnel properly gathered and evaluated 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 have no personal knowledge that the information submitted is other than 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.
First Name, Middle
Initial, Last Name:
Title:
Signature:

Date:

/

/

Email:

EPA Form 3510-9

Page 6 of 9

Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)

This Form Replaces Form 3510-9 (02/12)

Who Must File an NOI Form
Under the provisions of the Clean Water Act, as amended (33
U.S.C. 1251 et. seq.; the Act), federal law prohibits stormwater
discharges from certain construction activities to waters of the U.S.
unless that discharge is covered under a National Pollutant
Discharge Elimination System (NPDES) permit. Operators of
construction sites where one or more acres are disturbed, smaller
sites that are part of a larger common plan of development or
sale where there is a cumulative disturbance of at least one acre,
or any other site specifically designated by the Director, must
obtain coverage under an NPDES general permit. For coverage
under the 2017 CGP, each person, firm, public organization, or
any other entity that meets either of the following criteria must file
a Notice of Intent form: (1) they have operational control over
construction plans and specifications, including the ability to
make modifications to those plans and specifications; or (2) they
have day-to-day operational control of those activities at the
project necessary to ensure compliance with the permit
conditions. If you have questions about whether you need a
NPDES stormwater permit, or if you need information to determine
whether EPA or your state agency is the permitting authority,
contact your EPA Regional Office.
Completing the Form
Obtain and read a copy of the 2017 CGP, viewable at
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#cgp. To complete this form, type or print
uppercase letters, in the appropriate areas only. Please place
each character between the marks (abbreviate if necessary to
stay within the number of characters allowed for each item). Use
one space for breaks between words, but not for punctuation
marks unless they are needed to clarify your response. If you have
any questions on this form, telephone EPA’s NOI Processing Center
at (866) 352-7755. Please submit the original document with
signature in ink - do not send a photocopied signature.
Section I. Approval to Use Paper NOI Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper NOI form unless the EPA
Regional Office has approved its use. Where you have obtained
approval to use this form, indicate the waiver that you have been
granted, the name of the EPA staff person who granted the
waiver, and the date that approval was provided.
See https://www.epa.gov/npdes/contact-usstormwater#regional
for a list of EPA Regional Office contacts.
Section II. Permit Number
Provide the master permit number of the permit under which you
are applying for coverage (see Appendix B of the general permit
for the list of eligible master permit numbers)
Section III. Operator Information
Provide the legal name of the person, firm, public organization, or
any other entity that operates the project described in this NOI.
Refer to Appendix A of the permit for the definition of “operator”.
Indicate whether you are seeking coverage under this permit as
a “federal operator” as defined in Appendix A.

EPA Form 3510-9

Form Approved OMB No. 2040-0004

Also provide a point of contact, the operator’s mailing address,
county, telephone number, and e-mail address (to be notified via
e-mail of NOI approval when available). Correspondence for the
NOI will be sent to this address.
If the NOI was prepared by someone other than the certifier (for
example, if the NOI was prepared by the facility SWPPP contact
or a consultant for the certifier’s signature), include the full name,
organization, phone number, and email address of the NOI
preparer.
Section IV. Project/Site Information
Enter the official or legal name and complete street address,
including city, state, ZIP code, and county or similar government
subdivision of the project or site. If the project or site lacks a street
address, indicate the general location of the site (e.g.,
Intersection of State Highways 61 and 34). Complete site
information must be provided for permit coverage to be granted.
Provide the latitude and longitude of your facility in decimal
degrees format. The latitude and longitude of your facility can be
determined in several different ways, including through the use of
global positioning system (GPS) receivers, U.S. Geological Survey
(U.S.G.S.) topographic or quadrangle maps, and web-based
siting tools, among others. For consistency, EPA requests that
measurements be taken from the approximate center of the
construction site. For linear construction sites, the measurement
should be taken midpoint of the site. If known, enter the horizontal
reference datum for your latitude and longitude. The horizontal
reference datum is shown on the bottom left corner of USGS
topographic maps; it is also available for GPS receivers.
Indicate whether the project is in Indian country lands or located
on a property of religious or cultural significance to an Indian tribe,
and if so, provide the name of the Indian tribe associated with the
area of Indian country (including name of Indian reservation, if
applicable), or if not in Indian country, provide the name of the
Indian tribe associated with the property.
Enter the estimated construction start and completion dates using
four digits for the year (i.e., 10/06/2012). Indicate to the nearest
quarter acre the estimated area to be disturbed.
Indicate the type of construction site, if demolition is occurring,
and if so, if the structure has at least 10,000 square feet of floor
space. Indicate whether the pre-development land use of the site
was used for agriculture Appendix A defines “agricultural land” as
cropland, grassland, rangeland, pasture, and other agricultural
land, on which agricultural and forest-related products or
livestock are produced and resource concerns may be
addressed. Agricultural lands include cropped woodland,
marshes, incidental areas included in the agricultural operation,
and other types of agricultural land used for the production of
livestock.
Indicate whether earth-disturbing activities have already
commenced on your project/site. If earth-disturbing activities
have commenced on your site because stormwater discharges
from the site have been previously covered under a NPDES permit,
you must provide the 2012 CGP NPDES ID or the NPDES permit
number if coverage was under an individual permit.
Section V. Discharge Information
You must confirm that you understand that the CGP only
authorizes the allowable stormwater discharges listed in Part 1.2.1
and the allowable non-stormwater discharges listed in Part 1.2.2.

Page 7 of 9

Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)

This Form Replaces Form 3510-9 (02/12)

Any discharges not expressly authorized under the CGP are not
covered by the CGP or the permit shield provision of the CWA
Section 402(k) and they cannot become authorized or shielded
by disclosure to EPA, state, or local authorities via the NOI to be
covered by the permit or by any other means (e.g., in the SWPPP
or during an inspection). If any discharges requiring NPDES permit
coverage other than the allowable stormwater and nonstormwater discharges listed in Parts 1.2.1 and 1.2.2 will be
discharged, they must either be eliminated or covered under
another NPDES permit.
Indicate whether discharges from the site will enter into a
municipal separate storm sewer system (MS4), as defined in
Appendix A.
Also, indicate whether any waters of the U.S. exist within 50 feet from
your site. Note that if “yes”, you are required to comply with the
requirement in Part 2.2.1 of the permit to provide natural buffers or
equivalent erosion and sediment controls.
For each unique point of discharge you list, you must specify the
name of the first water of the U.S. that receives stormwater directly
from the point of discharge and/or from the MS4 that the point of
discharge discharges to. You must specify whether any waters of
the U.S. that you discharge to are listed as ”impaired” as defined in
Appendix A, and the pollutants for which the water is impaired. You
must identify any Total Maximum Daily Loads (TMDL) that have
been completed for any of the waters of the U.S. that you discharge
to.
Indicate whether discharges from the site will enter into a water of
the U.S. that is designated as a Tier 2, Tier 2.5, or Tier 3 water. A list
of Tier 2, 2.5, and 3 waters is provided as Appendix F. If the answer
is “yes”, name all waters designated as Tier 2, Tier 2.5, or Tier 3 to
which the site will discharge.
Section VI. Chemical Treatment Information
Indicate whether the site will use polymers, flocculants, or other
treatment chemicals. Indicate whether the site will employ
cationic treatment chemicals. If the answer is “yes” to either
question, indicate which chemical(s) you will use. Note that you
are not eligible for coverage under this permit to use cationic
treatment chemicals unless you notify your applicable EPA
Regional Office in advance and the EPA office authorizes
coverage under this permit after you have included appropriate
controls and implementation procedures designed to ensure that
your use of cationic treatment chemicals will not lead to a
violation of water quality standards. If you have been authorized
to use cationic treatment chemicals by your applicable EPA
Regional Office, attach a copy of your authorization letter and
include documentation of the appropriate controls and
implementation procedures designed to ensure that your use of
cationic treatment chemicals will not lead to a violation of water
quality standards. Examples of cationic treatment chemicals
include, but are not limited to, cationic polyacrylamide (C-PAM),
PolyDADMAC (POLYDIALLYLDIMETHYLAMMONIUM CHLORIDE),
and chitosan.
Section VII. Stormwater Pollution Prevention Plan (SWPPP)
Information
All sites eligible for coverage under this permit are required to
prepare a SWPPP in advance of filing the NOI, in accordance with
Part 7. Indicate whether the SWPPP has been prepared in
advance of filing the NOI.

EPA Form 3510-9

Form Approved OMB No. 2040-0004

Indicate the street, city, state, and ZIP code where the SWPPP can
be found. Indicate the contact information (name, organization,
phone, and email) for the person who developed the SWPPP for
this project.
Section VIII. Endangered Species Information
Using the instructions in Appendix D, indicate under which
criterion (i.e., A, B, C, D, E, or F) of the permit the applicant is
eligible with regard to protection of ESA-listed endangered and
threatened species and designated critical habitat. A description
of the basis for the criterion selected must also be provided.
If criterion B is selected, provide the NPDES Number for the other
operator who had previously certified their eligibility for the CGP
under criterion A, C, D, E, or F. The Tracking Number was assigned
when the operator received coverage under this permit, and is
included in the notice of authorization.
If criterion C is selected, you must attach copies of your site map.
See Part 7.2.4 of the permit for information about what is required
to be in your site map. You must also specify the federally-listed
species and/or federally-designated critical habitat that are
located in the “action area” of the project, and provide the
distance between the construction site and any listed
endangered species and/or their designated critical habitat.
If criterion D, E, or F is selected, attach copies of any
communications between you and the U.S. Fish and Wildlife
Service and National Marine Fisheries Service and identify the
participating agencies and Field Offices/Regional Offices you
worked with in the basis statement of this NOI.
Section IX. Historic Preservation
Use the instructions in Appendix E to complete the questions on
the NOI form regarding historic preservation.
Section X. Certification Information
The NOI must be signed as follows:
For a corporation: By a responsible corporate officer. For the
purpose of this Section, a responsible corporate officer means:
(i) a president, secretary, treasurer, or vice-president of the
corporation in charge of a principal business function, or any
other person who performs similar policy- or decision-making
functions for the corporation, or (ii) the manager of one or more
manufacturing, production, or operating facilities, provided, the
manager is authorized to make management decisions which
govern the operation of the regulated facility including having
the explicit or implicit duty of making major capital investment
recommendations, and initiating and directing other
comprehensive measures to assure long-term environmental
compliance with environmental laws and regulations; the
manager can ensure that the necessary systems are established
or actions taken to gather complete and accurate information
for permit application requirements; and where authority to sign
documents has been assigned or delegated to the manager in
accordance with corporate procedures.
For a partnership or sole proprietorship: By a general partner or the
proprietor, respectively; or
For a municipality, state, federal, or other public agency: By either
a principal executive officer or ranking elected official. For
purposes of this Part, a principal executive officer of a federal
agency includes (i) the chief executive officer of the agency, or

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Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)

This Form Replaces Form 3510-9 (02/12)

(ii) a senior executive officer having responsibility for the overall
operations of a principal geographic unit of the agency (e.g.,
Regional Administrator of EPA). Include the name and title of the
person signing the form and the date of signing. An unsigned or
undated NOI form will not be considered eligible for permit
coverage.
Modifying Your NOI
If you have been granted a waiver from your Regional Office
from electronic reporting, and if after submitting your NOI you
need to correct or update any fields on this NOI form, you may
do so by indicating changes on this same form. Paperwork
Reduction Act Notice
Public reporting burden for this NOI is estimated to average 3.7
hours. This estimate includes time for reviewing instructions,
searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send
comments regarding the burden estimate, any other aspect of
the collection of information, or suggestions for improving this
form, including any suggestions which may increase or reduce this
burden to: Chief, Information Policy Branch 2136, U.S.
Environmental Protection, Agency, 1200 Pennsylvania Avenue,
NW, Washington, D.C. 20460. Include the OMB control number on

EPA Form 3510-9

Form Approved OMB No. 2040-0004

any correspondence. Do not send the completed form to this
address.
Submitting Your Form
Submit your NOI form by mail to one of the following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2017 CGP
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2017 CGP
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#ereporting

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