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. FORM FP-001 - CERTIFICATION OF CLEAN FILL
      8. * * * * *

3800-PM-BCW0405a
12/2017
COMMONWEALTH OF PENNSYLVANIA
Instructions
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
- 1 -
PERMIT SUMMARY SHEET
FOR GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMITS FOR STORMWATER
DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
Please read this Summary Sheet prepared by the
Department of Environmental Protection (DEP) 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 (see
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 ensure that stormwater
management is integrated into the project design process.
Act 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 floodplain and
wetland areas, and prior land use.
Information on other potential permit requirements can be
found at
www.dep.pa.gov
(select Tools – PACT Tool).
Additional DEP 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
greater than or equal to 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
greater than or equal to one (1) acre of earth disturbance.
This permit does not apply to agricultural plowing and tilling,
animal heavy use areas, timber harvesting activities, 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 will be met. Construction activities
which are not eligible for coverage under the General
Permit as referenced in 25
Pa. Code
Chapter 92a, 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 an 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 instructions.
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.elibrary.dep.state.pa.us
and select Permit and
Authorization
Packages
Department-Wide
General
Information – General Information Form (GIF).
What Is a Surface Water?
Surface waters are defined at 25 Pa. Code § 92a.2 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 at 25 Pa. Code §
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?
A PCSM Plan Stormwater Analysis under 25 Pa. Code §
102.8(g) includes the following regulatory standards:
Do not increase the post-development total runoff
volume for all storms equal to or less than the two
year/24-hour event
Existing (pre-development) non-forested pervious areas
must be considered meadow in good condition or its
equivalent

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Instructions
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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 is 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 High Quality (HQ)
waters due to an existing or designated use as a Class A wild
trout stream and Exceptional Value (EV) waters. Increasing
impervious areas can lead to significant degradation of
surface waters by increasing water temperatures. 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
BMPs that address temperature, such as reductions in the
impervious footprint of the project, capturing and treating the
“first flush” and preservation or 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. The DEP guidance, “Guidelines for the Development
and Implementation of Environmental Emergency Response
Plans” (400-2200-001) is recommended for developing PPC
Plans and can be found at
www.elibrary.dep.state.pa.us
(select Technical Guidance Final Documents – Field
Operations).
Notice of Termination
Upon permanent stabilization of the earth disturbance activity
under § 102.22, and upon completion of proper installation of
PCSM BMPs, the person who obtains permit coverage 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). The Notice of Termination (NOT) is available at
www.elibrary.dep.state.pa.us
(select
Permit
and
Authorization Packages – Clean Water – Chapter 102 –
Notice of Termination).
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” (363-2134-013). A copy of this
policy is available online at
www.elibrary.dep.state.pa.us
(select Technical Guidance Final Documents – Watershed
Management) 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 at 25 Pa. Code § 92a.54(a)(5), if you have
provided data confirming that there is a potential for toxic or
hazardous pollutants to be discharged from the 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 determined 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 off-site 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 the
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 DEP’s policy,
“Management of Fill”
(258-2182-773). A copy of this policy is
available online at
www.elibrary.dep.state.pa.us
(select
Technical Guidance Final Documents – Waste Management
– 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

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Instructions
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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 may still qualify as clean fill if 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 DEP’s “Management of Fill” policy.
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 DEP or authorized conservation district. Failure
to produce the form upon request may result in the revoking,
suspension or termination of 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 DEP’s
“Management of Fill” policy.
Fill material that does not qualify as clean fill is regulated fill.
Regulated fill is waste and must be managed in accordance
with DEP’s residual or municipal waste regulations in 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 HQ and
EV waters or watersheds, and 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 § 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 applicant’s pre to
post comparative analysis must demonstrate no net change
in stormwater runoff will occur 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).

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Instructions
- 4 -
INSTRUCTIONS
FOR A GENERAL (PAG-02) OR INDIVIDUAL NPDES PERMIT FOR
STORMWATER DISCHARGES ASSOCIATED WITH CONSTRUCTION ACTIVITIES
GENERAL INFORMATION
DEP requires that you use the most up-to-date Notice of
Intent (NOI) or 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 must file an administratively complete
and acceptable NOI or application no later than 60 days prior
to the proposed commencement of earth disturbance
activities for PAG-02 General Permit coverage, 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 DEP, conservation district
or to third party litigation.
Permit Application Filing Fees
.
The administrative filing fee for PAG-02 coverage 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 DEP 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, DEP requires that both the owner
and operator apply for coverage under a permit as co-
permittees (see § 102.5(h)). 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 DEP regulations at 25 Pa. Code
Chapter 102, Erosion and Sediment Control.
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” (DEP 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 or will
be located in a HQ or EV watershed pursuant to Chapter 93,
the required E&S Plan must address the antidegradation
requirements at §102.4(b)(6).
NOTE:
All technical guidance, application forms and
instructions related to the E&S, NPDES, and PCSM
Programs
can
be
found
at
www.dep.pa.gov/
constructionstormwater
.
BMPs not included in DEP’s
guidance will require documentation to support the
effectiveness of the BMP.
PCSM Plans
.
A PCSM Plan identifying 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 surface waters.
Technical references for both E&S and PCSM BMPs can be
found at
www.dep.pa.gov/constructionstormwater
.
BMPs
not
included
in
DEP’s
guidance
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 DEP or the authorized county
conservation district completes its review of the NOI/permit
application. DEP may consider and under certain conditions
rely upon comprehensive planning and zoning ordinances in
the 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 DEP may issue or
deny an NPDES Permit. The written notice (letter) must also
include either a completed 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:
(1) A copy of correspondence (Appendix B and C) notifying
the municipality and county government of your intention
to discharge under this permit; and

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(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.
In addition, applicants are encouraged to submit copies of
local zoning approvals with their permit 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.
PNDI receipts from each jurisdictional agency, signed as
appropriate, must 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 DEP in the
“Policy for Pennsylvania Natural
Diversity Inventory (PNDI) Coordination During Permit
Review and Evaluation” (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.
o
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 completed
prior to submitting the permit application package,
the application will be subject to the concurrent
review process as outlined below.
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.
It is important to note, however, that the concurrent review
option carries certain risks and consequences to the
applicant, including:
o
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).
o
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.

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Instructions
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INFORMATION
REQUIRED
TO
BE
CONSIDERED
COMPLETE PERMIT APPLICATION
The reviewing entity will give the applicant written notification
of permit approval or denial. If DEP or the 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 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 DEP in identifying the organization
and prevents duplicate data entry.
Email Address.
Primary email 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.
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.

3800-PM-BCW0405a 12/2017
Instructions
- 7 -
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.
USGS Quad Map Name
. Locate the project boundaries
on a photocopy of the USGS topo map area. The map must
include the name of the appropriate 1:24,000 scale USGS
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) 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
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 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.
5.
Stormwater Discharges.
Receiving Water/Watershed Name and Chapter 93
Receiving Water Classification.
Receiving water designated use information can be obtained
from Chapter 93 at
www.pacode.com
.
Existing use
information
is
available
at
www.dep.pa.gov
(select
Businesses – Water – Bureau of Clean Water – Water Quality
Standards – Statewide Existing Use Classifications).
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
Stormwater BMP Manual (363-0300-002), as amended
and updated, or other alternative BMPs 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 PAG-02
General 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

3800-PM-BCW0405a 12/2017
Instructions
- 8 -
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,
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 a location 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, standalone 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 DEP 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, 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 Stormwater 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. BMPs not included
in DEP’s guidance 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 E&S 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.
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.

3800-PM-BCW0405a 12/2017
Instructions
- 9 -
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 DEP 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 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

3800-PM-BCW0405a 12/2017
Instructions
- 10 -
professional land surveyors, professional geologist or
landscape architects may seal applications, plans and
specifications for nonstructural and the following structural
stormwater BMPs 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.
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.
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. 6/2017
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.
Fill containing a concentration of total PCBs greater than 2 ppm may be subject to regulation under the Toxic
Substances Control Act (TSCA), 15 U.S.C. Section 2601
et seq.,
and 40 C.F.R. Part 761, which is administered and
implemented by the USEPA. For all such material, contact the PCB Coordinator for EPA Region 3 by email at
R3_PCB_Coor@epa.gov
to determine the allowable PCB level for your site and situation prior to transporting the
material off the site of origin or accepting the material for use.
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).

2500-FM-BWM0008
Rev. 6/2017
- 2 -
Name of the Laboratory that conducted the analysis:
Laboratory Accreditation Number:
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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