Revised January 18, 2002Rainfall Erosivity Waiver Application, Page 1 - PDF document

Revised January 18, 2002Rainfall Erosivi
Revised January 18, 2002Rainfall Erosivity Waiver Application, Page 1See Attached Sheet for InstructionsRainfall Erosivity Waiver Application (REWA)I.OWNER OR OPERATOR ADDRESS & RECORD LOCATION INFORMATIONOwner or Operator’s Name: Owner’s Contact Name: Company Name: Company Name: Owner or Operator’s Phone: Contact Phone: Mailing Address: City: State: Zip Code: City: State: Zip Code: Will permit records be located on site? NIf not, provide an address where records will be kept:Mailing Address: City: State: Zip Code: City: State: Zip Code: II.SITE INFORMATIONA.LOCATIONProject Name: On-Site Contact Name: Street Address: City: State: Zip Code: Contact Phone: Mailing Address: Physical Location:City: State: Zip Code: , , W;County: QTRQTRQTRSectionTownshipRangeFor Official Use Only:ReceivedWaivedReviewerSecretary, Kansas Department of Health and EnvironmentDateRevised January 18, 2002Rainfall Erosivity Waiver Application, Page 2B.Existing Conditions/UsesIs any part of the project located on Indian lands?If yes, contact EPA regarding discharging stormwater runoff from construction activities on Indian lands. Identify the local Municipal Separate Storm Sewer System (MS4) Operator:If stormwater runoff does not flow into an MS4, identify the first receiving water; stream; or lake:Are there any known soil contamination areas which will be disturbed by the construction activity?C.Project descriptionProject Description: Anticipated Start Date: and Completion Date: Completion means final stabilization.Estimated area to be disturbed: AcresTotal area of the site: If a cumulative total of 5 or more acres are disturbed, the project is not eligible for a rainfall erosivity waiver.D.Site PlanAttach a site plan showing the disturbed area. E.Area MapAttach a topographic map showing the project location and significant features in the

surrounding area. III.RAINFALL EROSIVITY
surrounding area. III.RAINFALL EROSIVITY FACTOR (R)To calculate the rainfall erosivity factor (R) for the proposed construction project, the applicant for a waiver must obtain a copy of Fact Sheet3.1 - Storm Water Phase II Final Rule Construction Rainfall Erosivity Waiver and use the calculation procedures therein to determine R forthe project. An operator must certify to KDHE that the construction activity will be completed during a period when the value of the rainfallerosivity factor is less than five. For more information please refer to Fact Sheet 3.1 What is the rainfall erosivity factor (R) for the project: Is the R factor for the project less than 5?IV.APPLICANT CERTIFICATIONSI, the undersigned, certify that I have read and understand the requirements and conditions of the NPDES general permit for StormwaterDischarges from Construction Activity;To the best of my knowledge, the construction activity which will be covered under this rainfall erosivity waiver will begin and end duringthe period stated above; urbing activities, all exposed soils remaining after construction will be vegetated and stabilized; andTo the best of my knowledge, this construction activity qualifies for a rainfall erosivity waiver in accordance with the applicable requirementsand conditions of the NPDES general permit for Stormwater Discharges from Construction Activity.I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance witha system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of theperson or persons who manage the system, or those persons directly responsible for gathering the information, the information submittedis, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting falseinformation, including the pond imprisonment for SignatureDateName and Official Title (Please Print)Name of Project