1. PERMIT SUMMARY SHEET
      2. FOR GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMITS FOR STORMWATER
      3. DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
      4. INSTRUCTIONS
      5. FOR A GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMIT FOR
      6. STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
      7. * * * * *

3150-PM-BWEW0035
Rev. 8/2016
COMMONWEALTH OF PENNSYLVANIA
Instructions
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
- 1 -
PERMIT SUMMARY SHEET
FOR GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMITS FOR STORMWATER
DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
Please read this Summary Sheet prior to reading the
instructions or completing the permit application. Provide all
of the information required on the appropriate application
checklist including
required
Worksheets 1 through 5
(located after Appendix C of the Permit Application
Checklist) and other applicable worksheets that may be
used.
Submittal of these items will result in your permit
being processed and issued in a more expedient
manner.
Earth disturbance activities may not commence
until permit authorization has been received.
Many of the definitions and regulatory requirements for this
Permit Package are contained under
Pa. Code
Title 25.
These include, but are not limited to, Chapters 92, 93, 96,
102, and 105.
The link to these regulations is
www.pacode.com
.
What Do I Need To Know Prior To Applying For A
Permit?
It is important to know what other types of permits or
authorizations are needed prior to receiving NPDES Permit
authorization.
Persons applying for stormwater permits
should demonstrate consistency with county and local plans
that
regulate
development,
i.e.
county
stormwater
management plans.
Stormwater management options
impact other project planning and design decisions. Initial
stormwater
management
planning
should
be
done
concurrent with the Plot Plan and Act 537 Sewage Facilities
Plan Development.
This will insure that stormwater
management is integrated into the project design process.
537 Plan approval (if applicable) is required prior to initiation
of earth disturbance activity. It is also important to know
what your site restrictions are, location of flood plain and
wetland areas, and prior land use.
Information on other potential permit requirements can be
found at
www.dep.pa.gov
, keyword: Permits.
Additional
departmental permits, approvals and coordination could
include, but not be limited to, Water Obstruction and
Encroachments Permit, Chapter 105 general permits, and
Brownfields Remediation. Failure to apply for and obtain all
necessary permits and approvals may result in the delay of
your permit being issued.
Who Needs To Apply For A Permit?
This permit applies to earth disturbance activities
that
disturb equal to or greater than one (1) acre of earth
disturbance, or an earth disturbance on any portion, part, or
during any stage of, a larger common plan of development
or sale that involves equal to or greater than one (1) acre of
earth disturbance.
This permit does not apply to agricultural plowing and tilling,
animal heavy use areas, timber harvesting activities, and
road maintenance activities and oil and gas activities.
If applying for a general permit, applicants should
review the general permit conditions and requirements
to ensure that they are met.
Construction activities
which are not eligible for coverage under the General
Permit as referenced in 25
Pa. Code
Chapter 92, must
utilize the Individual NPDES Permit Application for
Stormwater Discharges Associated with Construction
Activities.
These activities include, but are not limited to,
earth disturbance activities that are located in “special
protection” watersheds (high quality, exceptional value, and
exceptional value wetlands), or may affect existing water
quality standards or threatened or endangered species and
habitat, or have the potential for hazardous or toxic
discharges.
What are the Major Components of a NPDES Permit
Application?
?
Erosion and Sediment (E&S) Control Plan
?
Pennsylvania Natural Heritage Program (PNHP) Search
?
Post Construction Stormwater Management (PCSM)
Plan
?
Thermal Impact Analysis
?
Antidegradation Analysis
Additional details on these and other requirements are
located in the instruction form.
Is a General Information Form (GIF) required?
For purposes of this permit a GIF is only required for
Individual NPDES Permit Applications. To access the GIF,
go to
www.dep.pa.gov
, click on comments then click on
department wide permit authorization package, then click on
general
information
form
which
is
document
number 1300-PM-BIT001.
What Is A Surface Water?
Surface waters are defined in Chapter 92 Section 92.1 as
perennial and intermittent streams, rivers, lakes, reservoirs,
ponds, wetlands, springs, natural seeps and estuaries,
excluding water at facilities approved for wastewater
treatment such as wastewater treatment impoundments,
cooling water ponds and constructed wetlands used as part
of a wastewater treatment process.
What is A Water of This Commonwealth?
Waters of this commonwealth are defined in Chapter 102
Section
102.1 as
rivers, streams, creeks, rivulets,
impoundments, ditches, watercourses, storm sewers, lakes,
dammed water, wetlands, ponds, springs and other bodies
or channels of conveyance of surface and underground
water, or parts thereof, whether natural or artificial, within or
on the boundaries of this commonwealth.
What is the regulatory standard for Post Construction
Stormwater Management?
Applicants must follow the PCSM Plan Stormwater Analysis
as outlined in 102.8(g) to include:
?
Do not increase the post-development total runoff
volume for all storms equal to or less than the two
year/24-hour event

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 2 -
?
Existing (pre-development) non-forested pervious
areas must be considered meadow in good
condition or its equivalent
?
Twenty (20) percent of existing impervious area to
be disturbed must be considered meadow in good
condition or better
Use of Control Guidance-1 is recommended where site
conditions offer the opportunity to reduce the increase in
run-off volume.
Thermal Impacts Analysis
The temperature of a stream could become elevated when
riparian and project site vegetation is removed or when
stormwater exposed to surfaces with elevated temperature
prior to reaching the surface water, especially when
pavements and rooftops are exposed to high temperatures
and high intensity, short duration storm events. Thermal
impacts are particularly important for surface waters that
have a fishery classification of Cold Water Fishes or Trout
Stocking. This includes waters that are HQ waters due to an
existing or designated use as a Class A wild trout stream
and EV waters.
Increasing impervious areas can, by
increasing
water
temperatures,
lead
to
significant
degradation of surface waters. Applicants must evaluate
such potential impacts associated with their project, and
avoid,
minimize,
and/or
mitigate
such
changes
in
temperature through site development design which utilizes
BMP’s that address temperature such as reductions in the
impervious footprint of the project, capturing and treating the
“first flush” and preservation/installation of riparian buffers.
There are additional BMPs identified in the PA Stormwater
Best Management Practices (BMP) Manual which may also
be utilized to manage anticipated thermal impacts.
The
applicant must provide a summary of how thermal impacts
are avoided, minimized, or mitigated.
Preparedness, Prevention & Contingency (PPC) Plan
(aka
Environmental
Emergency
Response
Plan)
Requirements
If the operator will be storing, using or transporting
hazardous wastes and materials, fuels, chemicals, or
solvents
onto, on, or from
the project site during
construction, a PPC Plan must be prepared by the operator
and available at the site at all times. “Guidelines for the
Development
and
Implementation
of
Environmental
Emergency Response Plans” (document #400-2200-001)
can be found at
www.dep.pa.gov
. Under the heading “Quick
Access” on the left side of the screen, click on forms and
publications
and
then
click
on
technical
guidance
documents-final.
Notice of Termination
Upon permanent stabilization of the earth disturbance
activity under Section 102.22, and upon completion of
proper installation of PCSM BMPs, the person who obtains
permit coverage under this Chapter must submit a Notice of
Termination and record drawings with a final certification
statement from a licensed professional in accordance with
102.8(l) to the appropriate DEP regional office or county
conservation district (appropriate processing entity). This
form is found on the DEP website.
Licensed Professional Seal Requirements
The seal of a licensed professional (Professional Engineer,
Land Surveyor, Geologist or Landscape Architect) licensed
to practice in the Commonwealth of Pennsylvania is
required on erosion and sediment control plans and post
construction stormwater management plans for engineered
structural BMP calculations and specifications.
Future Phases of a Project
See Application, Section B, Part 3, page 1
Plans for future phases should be submitted in accordance
with the most recent version of the “Permit Guidelines for
Phased NPDES Stormwater Discharges Associated with
Construction Activity Permits” documents #363-2134-013. A
copy of this policy is available online at
www.dep.pa.gov
.
Under the heading Quick Access on the left side of the
screen, click on “Forms and Publications.” On the left side
of the screen click on “Technical Guidance Documents –
final.”
Then type the document 363-2134-013 into the
search window and conduct the search. For submission of
subsequent phases for approval, the applicant shall utilize
the appropriate application checklist located after Section I
in the Permit Application Form.
Potential Pollution
See Application, Section D, Part 6, page 6
As referenced in 25
Pa. Code
Chapter 92, Section 92.81 (a)
(5), if you have provided data confirming that there is a
potential for toxic or hazardous pollutants to be discharged
from this site during construction, you may not qualify for
General Permit coverage and may need to resubmit your
application for coverage under an Individual NPDES permit.
If the applicant has determine through environmental due
diligence that the site’s past or present land use, or
suspected soil contaminants provide a potential for
contaminated runoff from the project site, the applicant must
provide the requested data for the concerned geologic
features, soil conditions or existing stormwater discharges.
Fill Material
See Application, Section C, Part 3, page 2
If the site will need to have fill imported from an off site
location, the responsibility for performing environmental due
diligence and the determination of clean fill will in most
cases reside with the Operator. The designer must include
a note on the drawings to identify the Operator’s
responsibility and provide the definition of Clean Fill and
Environmental Due Diligence. If the site will have excess fill
that will need to be exported to an offsite location, the
responsibility of clean fill determination and environmental
due diligence rests on the applicant.
This information
should be completed prior to submitting a permit application.
If all cut and fill materials will be used on the site, a clean fill
determination is not required by the operator unless there is
a belief that a spill or release of a regulated substance
occurred on site.
Applicants and/or operators must use environmental due
diligence to ensure that the fill material associated with this
project qualifies as Clean Fill. Definitions of Clean Fill and
Environmental Due Diligence are provided below. All fill
material must be used in accordance with the department’s
policy
“Management
of
Fill,”
document
number
258-2182-773. A copy of this policy is available online at

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 3 -
www.dep.pa.gov
. Under the heading Quick Access on the
left side of the screen, click on “Forms and Publications.”
On the left side of the screen click on “Technical Guidance
Documents – Final.”
Then type the document number
258-2182-773 into the search window and conduct the
search. Click on “Management of Fill.”
Clean Fill
is defined as:
Uncontaminated, non-water
soluble, non-decomposable, inert, solid material. The term
includes soil, rock, stone, dredged material, used asphalt,
and brick, block or concrete from construction and
demolition activities that is separate from other waste and is
recognizable as such. The term does not include materials
placed in or on the waters of the commonwealth unless
otherwise authorized. (The term “used asphalt” does not
include milled asphalt or asphalt that has been processed
for re-use.)
Clean Fill affected by a spill or release of a regulated
substance:
Fill materials affected by a spill or release of a regulated
substance still qualifies as clean fill provided the testing
reveals that the fill material contains concentrations of
regulated substances that are below the residential limits in
Tables FP-1a and FP-1b found in the Department's policy
“Management of Fill.”
Any person placing clean fill that has been affected by a spill
or release of a regulated substance must use Form FP-001
to certify the origin of the fill material and the results of the
analytical testing to qualify the material as clean fill.
Form FP-001 must be retained by the owner of the property
receiving the fill and must be kept on site and made
available upon request by the Department or authorized
conservation district.
Failure to produce the form upon
request may result in the revoking, suspension or
termination of your permit coverage. A copy of Form FP-001
can be found at the end of these instructions.
Environmental Due Diligence:
Investigative techniques, including, but not limited to, visual
property inspections, electronic data base searches, review
of property ownership, review of property use history,
Sanborn maps, environmental questionnaires, transaction
screens, analytical testing, environmental assessments or
audits
.
Analytical testing is not a required part of due
diligence unless visual inspection and/or review of the
past land use of the property indicates that the fill may
have been subjected to a spill or release of regulated
substance.
If the fill may have been affected by a spill or
release of a regulated substance, it must be tested to
determine if it qualifies as clean fill.
Testing should be
performed in accordance with Appendix A of the
department's policy
“Management of Fill.”
Fill material that does not qualify as clean fill is regulated fill.
Regulated fill is waste and must be managed in accordance
with
the department's municipal or residual
waste
regulations based on 25
Pa. Code
Chapters 287 Residual
Waste Management or 271 Municipal Waste Management,
whichever is applicable.
Antidegradation Analysis Module
See Application, Section E, page 7
Maintaining and protecting existing water quality for High
Quality (HQ), Exceptional Value (EV) waters or watersheds,
and Exceptional Value (EV) Wetlands and protecting
designated and existing uses for all surface waters is critical.
These performance standards must be met by following the
process set out in 25
Pa. Code
Section 93.4c(b) (relating to
implementation of antidegradation requirements).
The
Antidegradation Analysis outlines that process.
In circumstances where a discharge cannot be avoided an
applicant must utilize ABACT BMPs in their E&S and PCSM
Plans to demonstrate that any discharge will maintain and
protect the existing quality and water uses of receiving
surface waters. ABACT means environmentally sound and
cost effective treatment, land disposal, pollution prevention
and stormwater reuse BMPs that individually or collectively
manage the difference in the net change in stormwater
volume, rate, and quality for storm events up to and
including the 2-year/24-hour storm when compared to the
stormwater rate, volume and quality prior to the earth
disturbance activities to maintain and protect the existing
quality
of
the
receiving
surface
waters
of
this
commonwealth.
To satisfy the antidegradation implementation requirements
the applicant should refer to 102.4(b)(6) and ensure they
(1) evaluate and include non-discharge alternatives in the
E&S plan, and; (2) If non-discharge alternatives do not exist
the E&S plan must include ABACT BMPs.
Where ABACT BMPs will be utilized, the applicants pre to
post comparative analysis must demonstrate no net change
in stormwater will be managed utilizing ABACT BMPs that
will protect and maintain water quality and uses.
Alternatives to riparian buffers or riparian forest buffers -
Identify any and all best management practices, design
standards and alternatives that collectively are substantially
equivalent to a riparian buffer or riparian forest buffer in
effectiveness, to minimize the potential for accelerated
erosion and sedimentation and to protect, maintain, reclaim
and restore water quality and for existing and designated
uses of a perennial or intermittent river, stream or creek or
lake, pond or reservoir of this Commonwealth to ensure
compliance with 25
Pa. Code
Chapter 93 (relating to water
quality standards).

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 4 -
INSTRUCTIONS
FOR A GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMIT FOR
STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
GENERAL INFORMATION
The Department requires that you use the most up-to-date
Notice of Intent (NOI) application package available. Please
type or print clearly when completing the form. If information
needed is more than space allows, attach additional sheets.
If a question is not applicable to you or your project, check
N/A in the appropriate box.
Persons proposing stormwater discharges associated with
construction activities shall file an administratively complete
and acceptable application no later than 60 days prior to the
proposed commencement of earth disturbance activities for
General Permits, and no later than 120 days for Individual
Permits. Any construction activities, including clearing and
grubbing, may not commence until the permit is authorized.
Persons who have not obtained NPDES permit coverage
(General or Individual permit) and undertake earth
disturbance activities are subject to possible enforcement
actions by the Department, conservation district or to third
party litigation.
Permit Application Filing Fees
The administrative filing fee for a general permit is $500.00
made payable to the appropriate county conservation district
“Clean Water Fund” or Commonwealth of Pennsylvania
“Clean Water Fund,” whichever is the processing entity. The
Individual NPDES permit administrative filing fee is
$1,500.00 made payable as indicated above.
For both
individual and general permits, a $100.00 fee per each
disturbed acre is required, payable to the “Commonwealth of
Pennsylvania Clean Water Fund.” The number of disturbed
acres should be rounded to the nearest whole number. The
check is to be dated within ten days of the application
submittal date.
Only certain State Government Agencies
are exempt from the filing fee.
A federal or state agency
or independent state commission that provides funding for
program administration by the Department through terms
and conditions of a mutual agreement may be exempt from
fees.
Operator Requirement
.
When the operator/contractor and owner/developer of the
facility or activity are not the same individual, corporation,
partnership, or other entity, the Department requires in
102.5(h) that both the owner and operator apply for
coverage
under
a
permit
as
co-permittees. If
no
operator/contractor has been selected at the time of permit
application, then once selected, the operator/contractor
must either be made a co-permittee or the permit must be
transferred to the contractor. Failure of the operator to be
added to the permit is a violation of federal law, and
Department
regulations
at
25
Pa. Code
Chapter 102,
Erosion and Sediment Control.
Erosion and Sediment (E&S) Plan Requirement.
An E&S Plan should contain BMPs designed to minimize
point source discharges to surface waters, preserve the
integrity of stream channels and protect the physical,
biological and chemical qualities of the receiving water. The
plan must be developed utilizing guidelines and BMP
information provided in the Erosion and Sediment Control
BMP Manual and submitted to the “reviewing entity”
(Department or authorized county conservation district)
along with the completed application. Complete and attach
the appropriate BMP worksheet(s) as part of your
administrative completeness check.
If the construction
activities are located in a high quality or exceptional value
watershed pursuant to Chapter 93 of the Department’s
regulations, the required E&S Control Plan must address the
antidegradation
requirements
in
the
Department’s
regulations at Chapter 102, Erosion and Sediment Control,
Section 102.4(b)(6) for activities in such waters.
NOTE:
All Program Manuals, technical guidance,
application forms and instructions related to the E&S,
NPDES, and Post Construction Stormwater Management
Programs can be found at
www.dep.pa.gov
. On the upper
left side of the screen, click on the keyword “stormwater.”
BMP’s not included in the departments manual will
require documentation to support the effectiveness of
the BMP.
Post Construction Stormwater Management (PCSM)
Plans.
A PCSM Plan identifying Best Management Practices
(BMPs) to be installed, which manage and treat the
stormwater discharges to protect water quality after
construction, should be prepared and implemented in
accordance with DEP’s Stormwater Best Management
Practices Manual.
Such BMPs should be designed to
maximize replication of the natural hydrologic cycle, to
protect the structural integrity of the stream, and to protect
and maintain existing and designated uses of the
Commonwealth waters.
Technical references for both E&S control and stormwater
BMPs can be found on the DEP website referenced in the
Summary
Sheet.
Pennsylvania’s
Comprehensive
Stormwater Management Policy is also available at
www.dep.pa.gov
.
After clicking on the DEP keyword
stormwater, click on “Technical Information” then click on
Post Construction Stormwater Management and look for the
“Comprehensive Stormwater Management Policy.”
BMP’s
not included in the Department’s manual will require
documentation to support the effectiveness of the BMP.
Municipal Notification Requirement.
Acts 67, 68 and 127 require permit applicants to notify local
governments of planned land development activities and to
provide local governments the opportunity to identify any
land use planning or zoning ordinance conflicts associated
with the proposed project before the department or
authorized county conservation district completes its review
of the NOI/permit application.
The Department may
consider
and
under
certain
conditions
rely
upon
comprehensive planning and zoning ordinances in our
decision making process or authorizations related to
facilities and infrastructure. Written notice must be received
by the municipality and county government in which the
activity is located at least 30 days before the Department
may issue or deny an NPDES Permit. The written notice

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 5 -
(letter) must also include either a completed DEP General
Information Form (GIF) or answers to the 5 Land Use
Information questions found in Appendix A.
A sample
notification letter and the list of Land Use Questions are
included as appendices A, B, and C in the permit application
form.
For Permit Application Submission – The permit applicant
must submit the following along with the application/NOI:
(1) A copy of correspondence (Appendix B and C) notifying
the municipality and county government of your
intention to discharge under this permit; and
(2) Evidence that the municipality and county government
has received your notification. Acceptable forms of this
evidence include certified mail receipt or written
acknowledgement
of
the
notification
from
the
municipality.
(3) Applicants are encouraged to submit copies of local
zoning approvals with their permit authorization
application.
Failure to provide a copy of the notification correspondence
and evidence of municipal receipt of your notification with
the application will delay processing of your application.
Failure to comply with municipal notification will result in the
return of the application as incomplete.
Pennsylvania Natural Heritage Program (PNHP) &
Pennsylvania Natural Diversity Inventory (PNDI)
Coordination with the Pennsylvania Natural Heritage
Program (PNHP) regarding the presence of State and
Federal threatened and endangered (T&E) species on the
project site is a regulatory requirement for this permit
application. Early coordination (prior to submission) with the
appropriate
jurisdictional
agencies
using
the
PA
Conservation
Explorer,
previously
known
as
the
Pennsylvania
Natural
Diversity
Inventory
(PNDI)
Environmental Review Tool (PNDI ER Tool), is the most
effective
means
of
timely
permit
decisions.
The
PA Conservation
Explorer
can
be
accessed
at
www.naturalheritage.state.pa.us
, first time users will have to
register at the website before conducting the review. Upon
completion of the review, a PNDI receipt, valid for a period
of two years from the date the search was conducted, is
automatically available for printing. To provide proof of
coordination with PNHP and PNDI, applicants must submit a
signed PNDI receipt as part of the permit application.
PNDI reviews can still be obtained free-of-charge for users
without access to a computer using the standard process of
requesting a project review directly from each jurisdictional
agency—PA Department of Conservation and Natural
Resources (DCNR), PA Game Commission (PGC), PA Fish
and Boat Commission (PFBC) and the U.S. Fish and
Wildlife Service (USFWS) instead of generating a PNDI
receipt instantly through the PA Conservation Explorer. The
standard PNDI review process user is responsible for
securing PNDI receipts from each jurisdictional agency—
DCNR, PGC, PFBC and the USFWS.
?
PNDI receipts from each jurisdictional agency,
signed as appropriate, will be included with the
application package. The PNDI review is not
complete or satisfied unless PNDI receipts are
included from all four jurisdictional agencies listed
above. Applicants are encouraged to use the
PA Conservation Explorer because using this tool
is the most effective means of a timely permit
decision.
If the review determines there are potential impacts to a T&E
species, the PNDI receipt will provide an explanation of the
potential impact(s) and instructions on how to resolve the
potential
impact(s).
READ
AND
FOLLOW
THESE
INSTRUCTIONS CAREFULLY.
Following the procedure
outlined by the Department of Environmental Protection
(DEP) in the
Policy for Pennsylvania Natural Diversity
Inventory (PNDI) Coordination During Permit Review and
Evaluation
, No. 021-0200-001
(PNDI Policy)
will allow
applicants to meet regulatory requirements.
There are two options available to applicants for handling
PNDI coordination in conjunction with DEP’s Permit Review
Process: sequential review and concurrent review.
Sequential Review:
o
The applicant runs the PNDI search and completes
all coordination with the appropriate jurisdictional
agencies prior to submitting the permit application.
The applicant will include with the application a
signed PNDI receipt, and clearance letter(s) from
the jurisdictional agency(ies) if the PNDI receipt
shows potential impact(s).
o
If selecting sequential review, different items are
required to be included as part of the permit
application package based on the search results:
o
If the PNDI receipt shows “No Known Impact”,
please provide a copy of the signed PNDI
receipt.
o
If the PNDI receipt contains “Avoidance
Measures”, the PNDI review is not complete or
satisfied unless the applicant has signed
where required on the PNDI receipt, indicating
he/she can and will fulfill the Avoidance
Measure(s) for the project. The applicant
should include the Avoidance Measures in the
project description. Please provide a copy of
the PNDI receipt signed as explained above
and in the certification section.
o
If the applicant cannot or chooses not to
meet the Avoidance Measure(s), he/she
must follow the same process for PNDI
receipts
showing
“Potential
Impact”,
outlined below.
?
If the PNDI receipt shows "Potential Impact”,
DEP and the jurisdictional agencies require
that
the
applicant
provides
additional
information, outlined in the PNDI receipt, to the
agencies noted on the receipt for further
review. Please provide a copy of the signed
PNDI receipt showing “Potential Impact” AND
the additional information outlined in the PNDI
receipt along with proof of delivery to the
appropriate jurisdictional agency(ies) where
further
coordination
is
required.
If
this
coordination was not complete prior to
submitting the permit application package, the
application will be subject to the concurrent
review process as outlined below.

3150-PM-BWEW0035
Rev. 8/2016
Instructions
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Concurrent Review:
o
The applicant runs the PNDI search and will
engage
in
consultation
with
the
applicable
jurisdictional agency(ies). DEP will allow technical
review of the permit to occur concurrently with the
T&E species consultation with the jurisdictional
agency(ies).
o
If selecting a concurrent review, the applicant will
include with the permit application a signed PNDI
receipt processed through the PA Conservation
Explorer
OR
PNDI receipts from each jurisdictional
agency if the standard process of requesting a
project review was used.
o
It is important to note, however, that the
concurrent review option carries certain risks
and consequences to the applicant, including:
?
The permit may not be issued until each
potential impact is resolved.
See DEP’s
Permit
Review
Process and
Permit
Decision Guarantee Policy, Document No.
021-2100-001 (PRP/PGD Policy).
?
The proposed activity subject to the permit
application may need to be redesigned as
a result of the PNDI consultation (
PNDI
Policy
pages 7-8).
Note: Any substantive
project
or
design
changes
to
the
application will require a new application
and fee to be submitted.
INFORMATION
REQUIRED
TO
BE
DETERMINED
COMPLETE PERMIT APPLICATION
The Reviewing Entity will give the applicant written
notification of permit approval or denial. If the Department
or conservation district determines the NOI/application is
incomplete or contains insufficient information, the applicant
will be notified in writing. The applicant will have 60 days to
provide the necessary information along with any required
fees. If the requested information is not submitted within
60 days, the application will be considered withdrawn, and
no fees will be refunded. The following information must be
submitted in order for the application to be considered
complete.
Section A. Applicant Information
Check the appropriate box for a general or individual
NPDES permit.
New – a new application for a project that has not yet
been permitted.
Renewal – An application to renew an existing permit
that is nearing expiration.
This renewal should be
submitted a minimum of 180 days prior to expiration.
NOTE: An expired permit cannot be renewed.
Major Modifications – An application that will modify an
existing permit, which could include such activities as:
expanding the total disturbed area or permit boundary,
adding a new discharge, or substantial changes to
BMPs. The reviewing entity should be consulted for
discussion prior to submittal of this type of application.
Phased – An application where an additional phase of
construction is being added to an already existing permit
that was established as a phased project at the time of
original permit issuance.
Applicant Name.
If the applicant is an individual use the
individual’s name.
If the applicant is a corporation,
partnership, or municipal, state, federal or other public
agency use the name of the corporation, partnership, or
public agency.
Mailing Address.
The physical mailing address of the
Owner/Operator (applicant) identified above is required.
P.O. Box is not acceptable.
City, State, ZIP+4.
Do
not
use abbreviations for the city
name. Use the two-character abbreviation for the state.
Include the four-digit extension to the ZIP code.
Employer ID Number (EIN).
Also referred to as “Federal
Tax ID Number,” the EIN aids the Department in identifying
the organization and prevents duplicate data entry.
Email Address.
Primary E-mail address of the applicant.
Contact Information.
If the applicant is not an individual,
provide the name, title, phone number, and email address
for the site contact. This contact must be an employee of
the applicant, not a consultant.
Section B. Project Information
All questions must be answered.
1.
Project Name.
Provide the name by which this project
is or will be known.
2.
Total Project Site.
Includes the entire area of activity,
development or sale currently planned and proposed in the
future. This includes areas that are not subject to an earth
disturbance activity. Enter the size of the area in acres to
the nearest tenth of an acre.
3.
Total Disturbed Area.
Includes that portion of the total
project area where earth disturbance activities are planned
to occur. Enter the size of the area in acres to the nearest
tenth of an acre.
3.a.
For phased projects, the total disturbed area
should include only the initial phase(s) for which
complete E&S and PCSM plans have been developed
and are being submitted with this application.
4.
Project Description.
Provide a brief description of the
project.
5.
Project Location.
Provide the physical address of the
location where the permitted activities will occur. No PO
Box Numbers will be accepted for site location information.
If a physical address is not available for the project site,
provide the name of the road along which primary access to
the site is located in the Address box and the number of
miles east or west of an intersection in the Supplemental
Address box. Provide the city (or municipality), state, and
the ZIP+4. For linear projects which do not have a physical
address and cross municipal boundaries, find the project
center point and provide the name of the nearest road, city
(or municipality), state and the ZIP+4.
6.
Project County and Municipality.
If more than two
municipalities or counties are affected, please list them on
an attached separate sheet.
7.
Type of Ownership.
Provide the unique description
identifying the type of facility located at the project site.

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 7 -
8.
Project Latitude and Longitude.
Provide the latitude
and longitude coordinates for the approximate center of the
project area or facility.
The coordinates should be in
degrees, minutes and seconds, rounded to the nearest tenth
of a second.
Check the appropriate box matching the
collection method used. Check the appropriate box
matching the Horizontal Reference Datum (or projection
datum) employed in the latitude and longitude collection
process.
Identify the date of collection (mm/dd/yyyy) if
latitude and longitude coordinates were collected via GPS,
WAAS and LORAN.
8.a. Description of collection methods.
EMAP
:
Method based on eMAP Pa program.
(
http://www.depgis.state.pa.us/emappa/
).
HGIS
:
Method based on the Pennsylvania Natural
Heritage Program database (formerly known as PNDI).
The
database
is
located
at
www.naturalheritage.state.pa.us
.
GISDR
: Method based on the use of GIS and Digital
Raster Graphic 1:24,000 scale USGS 7.5 minute
quadrangle maps.
ITPMP
: Method based on map interpolation of USGS
7.5 minute quadrangle maps.
GPS
:
Global Positioning method with unspecified
parameters.
WAAS
:
Method base on GPS WAAS differentially
correct.
LORAN
: Method based on Loran C.
8.b.
Types of Horizontal Reference Datum
(or
projection datum)
NAD27
: North American Datum of 1927
NAD83
: North American Datum of 1983
WGS84
: World Geodetic System of 1984 (GEO84)
9.
U.S.G.S. Quad Map Name
.
Locate the project
boundaries on a photocopy of the U.S.G.S. topo map area.
The map must include the name of the appropriate 1:24,000
scale U.S.G.S. 7.5 minute series quadrangle map where the
project is located.
10. Primary NAICS Code.
Provide the appropriate six-digit
North American Industry Classification System (NAICS
pronounced nākes) code that represents the primary
economic activity of the project site. If none of the provided
codes represent the primary economic activity, choose
“other,” and specify a primary NAICS code found on the
NAICS website (part of the US Census Bureau) at
http://www.census.gov/eos/www/naics/
,
(the “Downloads”
list on the left side of the screen contains the most recent
list).
11. Additional NAICS Code(s).
Provide any additional six-
digit North American Industry Classification System code(s)
that represents the economic activity of the project site.
More than one six-digit code may be entered into the box
provided.
Section C. Site Analysis
1.
Existing and Historic Uses.
Check all appropriate
boxes and provide appropriate information.
1.a. Existing land uses
are the dominant land uses of
the project site for the five (5) years preceding the
planned project, not just the zoning of the land. If
checking “other,” provide description of land use.
1.b. Historic land uses
are the actual land use(s) of
the project site for the past 50 years, or longer if known,
not just the zoning of the land.
Descriptions of Land Use Types.
Agriculture
: cropland, pasture, orchards, vineyards,
nurseries, horticulture areas, confined animal feeding
operations,
fallow
fields,
reverting
cropland
or
pasture/field.
Forest/Woodland
: deciduous, evergreen or mixed
forestland, woodlots in suburban or urban areas.
Barren
:
beaches, sandy areas other than beaches,
bare exposed rock (bedrock, talus or fill), strip mines,
quarries, transitional zones (refers to areas previously
bare but becoming vegetated).
Urban
: cities, towns, residential areas, institutional
areas, commercial areas, industrial areas, suburban or
built-up
areas,
transportation
corridors,
railways,
airports, ports, utilities; water, sewer, electric, petroleum,
communications, etc.
Brownfield
: land that is presently contaminated is being
remediated or has been remediated under PA DEP’s
Land Recycling program.
“A property, the expansion, redevelopment, or reuse of
which may be complicated by the presence or potential
presence of a hazardous substance, pollutant, or
contaminant.”
Other:
provide a brief description of land use or cover.
2.
Potential Pollutants.
Identify
the
pollutants
that
were
analyzed,
their
concentrations, present source (where the samples were
taken), the sample type, and the date(s) and number of
samples that were taken.
Use separate sheets as
necessary.
If no potential pollutants exist, check N/A.
3.
Fill Materials
The NPDES Permit covers the “moving, depositing,
stockpiling, or storing of soil rock or earth materials.” Use
the check boxes to identify the fill activities for the project
site.
4.
Estimated Timetable for Phased Project Buildout.
Large projects requiring a period of years for total
development can be phased. The entire anticipated project
plan should be identified in the initial permit application with
specific site plans for individual phases being submitted for
review and approval as they are developed. Do
not
provide
construction sequencing information. Below is an example
of what should be documented:
Example: Phase I – 20 acre residential lots with roads and
other supporting infrastructures – Time span: 2 years.

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 8 -
5.
Stormwater Discharges.
Receiving Water/Watershed Name And Chapter 93
Receiving Water Classification.
Receiving water designated use information can be obtained
from
Pa. Code
Chapter 93 at
www.pacode.com
. Existing
use information is listed at
www.dep.pa.gov
.
Click DEP
keywords then click “Existing Use.”
?
If the discharge will be to surface waters identified as
impaired waters according to Category 4 or 5 of the
Integrated Water Quality Monitoring and Assessment
Report, there may be no net change (pre-condition to
post condition) in volume or rate or water quality of the
stormwater discharge to use the General (PAG-02)
NPDES Permit.
The applicants may use the
recommended control guidelines as listed in the
Pennsylvania Stormwater Best Management Practices
Manual (Stormwater BMP Manual) Commonwealth of
Pennsylvania, Department of Environmental Protection,
No. 363-0300-002 (December 2006), as amended and
updated, or other alternative BMP or design standards
that achieve the regulatory standards.
?
If there will be a net change (pre- to post-construction)
in volume, rate or water quality, the applicant may use
worksheets 11 through 13 to document how water
quality protection is being achieved through the use of
BMPs.
If the applicant’s discharge meets the water
quality treatment criteria, the applicant may use the
General (PAG-02) NPDES permit.
?
Persons are not eligible for coverage under the PAG-02
general permit for discharges of pollutants of concern to
waters for which there is a total maximum daily load
(TMDL) established or approved by EPA unless the
E&S
and
PCSM
Plans
include
implementation
measures or controls that are consistent with the
assumptions and requirements of such TMDL. To be
eligible for coverage under this general permit, persons
must
implement
conditions
applicable
to
their
discharges
necessary
for
consistency
with
the
assumptions and requirements of such TMDL.
If a
specific wasteload allocation has been established that
would apply to the discharge, persons must implement
necessary steps to meet that allocation. Any questions
on how to comply with a TMDL should be directed to
the appropriate DEP regional office.
If the project discharges to waters other than surface waters,
you check “Other.” This category includes off-site discharges
which may require the applicant to obtain the legal right to
discharge. See Section D(5) for further guidance.
Municipal Storm Sewer or Private Storm Sewer
Operator.
Provide storm sewer operator names.
If the discharge is to something other than those listed
above, provide a description of where the stormwater is
discharged (a separate sheet may be attached).
Section D.
Erosion and Sediment (E & S) Pollution
Control and Post Construction Stormwater Management
(PCSM) Plan
See attachment for corrections to the section below;
Worksheets 1 through 5 and 10 or 11 through 13, as
applicable, are required when applicants have utilized
the Stormwater Best Management Practices (BMP)
Manual to meet design standards.
Complete and attach
the appropriate worksheets.
A separate Section D is
required for each point of discharge. Three copies of the
E&S and PCSM plans must be provided. The PCSM Plan
must be a separate, stand alone final plan. The plan should
address rate, volume, and water quality impacts to each
drainage area. The Chapter 102 regulations require that the
design standards be based on a 2-year/24-hour frequency
storm unless the applicant demonstrates to the Department
that an alternative approach will be more protective, or will
protect and maintain existing and designated uses. The
Permit application allows the use of other design standards
provided that certain criteria is adhered to. The PCSM Plan
should be designed to maximize volume reduction
technologies, eliminate (where possible) or minimize point
source discharges to surface waters, preserve the integrity
of stream channels, and must protect the physical, biological
and chemical qualities of the receiving surface water. DEP
recommends the use of CONTROL GUIDANCE-1 to
accomplish this goal. If the PCSM Plan is consistent with a
DEP approved and current County Act 167 Plan, and meets
applicable local Stormwater ordinances without variance or
exemptions (from 2005 and after), and/or if the Plan is
consistent with existing local ordinances that satisfy the
requirements of an MS4 (NPDES Permit to discharge
stormwater through a municipal separate storm sewer
system) permit, a letter should be provided by the municipal
or county planning engineer that states this. If neither of
these is applicable, the PCSM plan should be consistent
with the practices contained within the DEP Stormwater Best
Management Practices (BMP) Manual. In addition to these
water quality features, all PCSM plans must comply with
local water quantity and/or flood control requirements.
Permittees and co-permittees are responsible for proper
installation of the PCSM Plan BMPs prior to the submission
of the Notice of Termination for this permit.
BMP’s not
included in the Department’s manual will require
documentation to support the effectiveness of the BMP.
1.
E & S BMPs.
Provide a brief summary of proposed
BMPs and their performance to manage E & S on site.
If these BMPs and their application do not follow the Pa.
Erosion and Sediment Pollution Control Program
Manual
Guidelines,
provide
documentation
to
demonstrate performance equivalent to, or better than,
the Manual’s BMPs.
2.
PCSM Plan Information.
Check all applicable boxes.
3.
Summary Table for Supporting Calculation and
Measurement Data.
Please provide this summary data
from the calculations and measures submitted as part
of the PCSM Plan. For a project involving multiple point
of discharge boundaries, please submit a complete
separate Section D for each additional point of
discharge. If choosing other design standards,
do not
fill out the summary table
only
check off the appropriate
box(es) and provide supporting documentation in the
PCSM narrative. This documentation must include:
?
A summary of the alternative approach’s
design criteria for rate, volume and water
quality.
?
Calculations
demonstrating
that
the
criteria were met.

3150-PM-BWEW0035
Rev. 8/2016
Instructions
- 9 -
?
A statement and demonstration that the
alternative approach will either be more
protective than the requirements under
102.8(g)(2)(i-iii) and 102.8(g)(3)(i-ii),or will
protect
and
maintain
existing
and
designated uses.
If the PCSM Plan is consistent with a DEP approved
Act 167 plan from 2005 or later and the Act 167 plan
differs from 102.8(g) in any way
do not
fill out the
summary table,
only
check off the appropriate box(es)
and provide supporting documentation in the PCSM
narrative. This documentation must include:
?
A summary of the PCSM requirements for rate,
volume and water quality.
?
Calculations demonstrating that rate, volume,
and water quality were met in accordance with
the ACT 167 plan. A separate demonstration
and summary should be done for each plan in
the project area.
?
A statement indicating that the PCSM Plan is
consistent with the DEP approved and current
Act 167 plan and meets the requirements
without variance or exemptions
If the PCSM Plan is consistent with a DEP approved
Act 167 plan from 2005 or later and the Act 167 plan is
consistent without variance with the standard design
criteria from the 25 Pa. Code Chapter 102.8(g)(2) and
(3) then utilizing applicable worksheets and the
summary table are recommended.
If none are applicable, the PCSM plan should be
consistent with the Chapter 102 regulations and
practices contained within the DEP Stormwater Best
Management Practices (BMP) Manual. If choosing this,
reference the Stormwater Methodology used, and check
off
the
appropriate
volume
measurement
used
(acre-feet or cubic feet).
4.
Summary
Description
of
Post
Construction
Stormwater BMPs.
Please check all the appropriate
boxes. If there is no check box for a planned BMP,
check the box for “other” and list the BMP. Do
not list
erosion and sediment control BMPs.
5.
Off-site Discharge Analysis.
If an applicant proposes
off-site discharges of stormwater from E & S or PCSM
to areas other than surface waters, documentation must
be provided to demonstrate that the discharge will not
cause erosion, damage, or a nuisance to off-site
properties. It is the applicant’s responsibility to obtain a
legal right to discharge onto adjacent properties.
Please check the appropriate box in this block.
6.
Potential Naturally Occurring Pollution-Causing
Materials.
If an applicant proposes a project that is
located where naturally occurring geologic or soil
formations exist that may cause or contribute pollution
to receiving waters or contribute to the development of
sinkholes, the applicant must identify the potential
pollutant or sinkhole hazard and identify BMPs they
intend to utilize to avoid or minimize pollution and/or
sinkhole development.
7.
Riparian
Buffer
Information.
Check
off
the
appropriate
boxes
and
provide
information
as
applicable.
If an applicant is required to provide a
riparian buffer or a riparian forest buffer as part of the
project they may (a) protect, convert, or establish a
riparian buffer or riparian forest buffer as required in
Section 102.14; or (b) use other BMPs which will be
functionally equivalent to either a riparian buffer or a
riparian forest buffer whichever is applicable to the
project.
If choosing this option the applicant must
complete an equivalency demonstration that shows that
the alternative BMPs implemented will be functionally
equivalent to either a riparian buffer or riparian forest
buffer, whichever is applicable to the project. If the
applicant chooses option (b) and the earth disturbance
is within 100 feet of a surface water they must provide
an offset riparian buffer. This offset must equal “the
reduction in the total square footage of the buffer zone
that would have been utilized as a BMP, with a
replacement buffer elsewhere along special protection
waters in the same drainage list and as close as
feasible to the area of disturbance at a ratio of
one-to-one.”
8.
Thermal Impact Analysis.
This analysis must be
completed as part of the NPDES General and Individual
Permit Application.
The applicant shall provide a
summary of how thermal impacts are avoided,
minimized,
or
mitigated.
Some
examples
are:
minimizing impervious surfaces, green roofs, porous
pavement, shading and discharging from the bottom of
surface impoundments, subsurface impoundments, and
maximum use of vegetated areas. Please see page 2
of the summary sheet for additional guidance.
9.
Critical PCSM plan stages.
Identify the critical stages
of implementation of the PCSM plan for which a
licensed professional or designee shall be present on
site. The critical stages may include the installation of
underground treatment or storage BMPs, structurally
engineered BMPs or other BMPs as deemed
appropriate by the Department or conservation district.
Section E.
Antidegradation Analysis Module (this
section must be completed for all Individual NPDES
Permit Applications where activities will be conducted
in special protection waters.)
Part 1. Non-Discharge Alternative Evaluation
Project designs and BMP selections that do not accomplish
non-discharges should be reconsidered.
All reasonable
efforts should be made to reduce and eliminate discharges.
Non-discharge Alternative is environmentally sound and
cost-effective BMPs that individually or collectively eliminate
the net change in stormwater volume, rate and quality for
storm events up to and including the 2-year/24-hour storm
when compared to the stormwater rate, volume and quality

3150-PM-BWEW0035
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Instructions
- 10 -
prior to the earth disturbance activities to maintain and
protect the existing quality of the receiving surface waters of
this Commonwealth.
Part 2. Antidegradation Best Available Combination of
Technologies (ABACT)
Choose the E&S and PCSM BMPs that will manage the net
change during and after construction.
Erosion and Sediment Control ABACT
ABACT BMPs and their design standards are listed in the
Erosion and Sediment Control BMP Manual.
Post Construction Stormwater Management ABACT
BMPs listed in the Pa. Stormwater BMP Manual may qualify
as ABACT BMPs.
For ABACT BMPs not listed in the
Department’s manuals, the applicant must provide data to
support the BMPs, including a demonstration that they will
maintain and protect the existing quality of receiving surface
waters.
?
Riparian Buffer and Riparian Forest Buffer Alternatives
Identify any and all best management practices, design
standards and alternatives that collectively are substantially
equivalent to a riparian buffer or riparian forest buffer in
effectiveness, to minimize the potential for accelerated
erosion and sedimentation and to protect, maintain, reclaim
and restore water quality and for existing and designated
uses of a perennial or intermittent river, stream or creek or
lake, pond or reservoir of this Commonwealth to ensure
compliance with 25
Pa. Code
Chapter 93 (relating to water
quality standards).
Part 3. Social or Economic Justification (SEJ)
The SEJ can only be used in HQ waters after the applicant
has exhausted all reasonable non-discharge alternatives
and ABACT approaches.
If the applicant intends to
demonstrate that a degrading discharge to a High Quality
water is necessary to accommodate important economic or
social development in the area in which the waters are
located, the procedure identified in Chapter 10 of the Water
Quality
Antidegradation
Implementation
Guidance,
Document #391-0300-002, must be fully and accurately
completed. Check Yes or No if project will be completing
SEJ analysis.
Section F. Consultant For This Project
If this application was prepared by a consultant, agent, or
someone other than the applicant, that individual should
complete this section of the form.
The plans and
specifications for engineered structural BMPs
must
be
sealed by a qualified professional engineer. Qualified
professional land surveyors, professional geologist or
landscape architects may seal applications, plans and
specifications for nonstructural and the following structural
stormwater BMP’s that may involve engineering which they
are qualified to perform Vegetated Swales, Vegetated Filter
Strips, Infiltration Berms and Retentive Grading, Riparian
Buffer Restoration, Landscape Restoration, and Soil
Amendment and Restoration. Licensed professionals who
use engineered structural BMPs must provide their seal in
Section F of the application.
Section G. Compliance History Review
List any violations of any permits issued by DEP or any
regulated activities within the past five years. List each
permit or project that is/was in violation and provide
compliance status update and steps taken to achieve
compliance.
Section H. Permit Coordination
Answer all permit coordination questions and indicate if you
have, have pending, or require any additional permits or
approvals for this project.
Section I. Certification
The applicant(s) must complete the required certification to
include the printed applicant name and title. The application
shall be signed as follows:
a.
Corporations:
(1) 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
(2) The manager of one or more manufacturing,
production or operating facilities if authority to sign
documents has been assigned or delegated to the
manager in accordance with corporate procedures.
b.
Partnerships or sole proprietorships - a general partner
or the proprietor, respectively.
c.
Municipalities, State, Federal or other public agencies -
either a principal executive officer or ranking elected
official:
(1) The chief executive officer of the agency; or
(2) A senior executive officer having responsibility for
the overall operations of a principal geographic unit
of the agency (e.g., Regional Administrators of
EPA).
d.
For individuals, no indication of title is necessary.
If anyone else signs on behalf of a corporation, partnership,
or public agency, documentation supporting delegation of
contracting authority must be provided.
The application shall be notarized in the space provided.
General NPDES Application Checklist
Individual NPDES Application Checklist
Complete the appropriate Application Checklist attached to
the NOI/Application and return it with the General Permit
NOI and/or the Individual permit application.
Appendix A. Land Use Information Questions
When applying for General Permit coverage, please detach
this page, complete the information and submit along with
your municipal notification letter to the appropriate
municipality and county. (For further information please see
page 6 of the instructions.)
Appendix B and C.
Sample Notice Letters to
Municipality and County
Municipal notification is required and evidence of municipal
receipt of your notification.

3150-PM-BWEW0035
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Instructions
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Appendix D. Worksheet Attachments
All Worksheets are located in Appendix D of the permit
application form. Worksheets 1-5 and 10 or 11 through 13,
as applicable, are required when applicants have utilized the
Stormwater Best Management Practices (BMP) Manual to
meet design standards). Additional worksheets should be
used if applicable.
Please complete and submit all
additional
applicable
worksheets
referenced
in
the
application checklist.
Completion of all items referenced
in the application checklist will result in your permit
being processed and issued in a more expedient
manner.

2500-FM-BWM0008 Rev. 8/2010
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
- 1 -
FORM FP-001 - CERTIFICATION OF CLEAN FILL
Prior to completing this form and signing this certification, please review the entire Management of Fill
policy (#258-2182-773), including the certification requirements. Please note that historic fill, as defined in
the Management of Fill policy, may meet the definition of clean fill if the material is limited to
uncontaminated soil, rock, stone, dredged material, used asphalt, and brick, block or concrete from
construction and demolition activities that is separate from other waste and recognizable as such.
Instructions:
Sections 1 and 2 of this form must be completed by the person making the determination of clean fill
at the site of origin. Section 3 must be completed by the person using the material as clean fill. Both the person
determining clean fill and the user of the clean fill are responsible for maintaining copies of this completed form on
site for a period of five (5) years for Department inspection.
Section 1: Person Determining Clean Fill
Name (Print):
Title:
Date:
Company Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:
E-mail Address:
Clean Fill Material originated on the following property:
Site Name:
Street Address:
City:
State:
Zip Code:
Section 2: Site Characterization
Check the following that applies:
A. IF the site of origin for the fill material has undergone or is undergoing cleanup or remediation
pursuant to a local state or federal regulatory program that requires site characterization, provide the
following information along with a copy of the entire site characterization and laboratory analysis for
the material to be used as clean fill.
Name of local, state, or federal agency:
Identification number assigned to the project:
Name of the local, state, or federal contact person:
Telephone Number:
E-mail Address:
Name of the Laboratory that conducted the analysis:
Laboratory Accreditation Number:
B. IF the material proposed to be used as clean fill has otherwise been subject to analytical testing or
other procedure identified in the definition of “environmental due diligence” contained in the
Management of Fill policy, provide or attach the following:
Copies of
ALL
lab analytical testing performed as part of environmental due diligence (see Management of
Fill policy, #258-2182-773).
Name of the Laboratory that conducted the analysis:
Laboratory Accreditation Number:

2500-FM-BWM0008
Rev. 8/2010
- 2 -
C. IF the proposed material to be used as clean fill was subject to environmental due diligence
procedures as defined in the Management of Fill policy other than those listed in A and B, describe
those procedures.
I, the undersigned, certify under penalty of law (18 Pa. C.S.A. §4904) that the information provided in
Sections 1 and 2 of this form is true and correct to the best of my knowledge, information and belief.
Signature:
Section 3: Person Receiving or Placing Clean Fill
Name and address of person completing this form:
Name (Print):
Date:
Mailing Address:
City:
State:
Zip Code:
Telephone Number:
E-mail Address:
Fill material that has been determined to be clean fill will be placed on the following property solely for
property improvement or construction purposes:
Property Address:
City:
State:
Zip Code:
Current Owner of Property:
Telephone Number:
E-mail Address:
The quantity of clean fill to be placed on the property is:
<3,000 cubic yards
3,000 cubic yards to 20,000 cubic yards
>20,000 cubic yards
I, the undersigned, certify under penalty of law (18 Pa. C.S.A. §4904) that the information provided is true and
correct to the best of my knowledge, information and belief.
Signature:
* * * * *
Prior to placement of the clean fill, the owner of the property receiving fill material shall
provide a copy of this completed form and attachments to the DEP Regional Office serving
the county in which the receiving site is located. If a property receives fill from multiple
sources, a separate Form FP-001 is required for each source.

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