1. NOTICE OF INTENT (NOI) FOR COVERAGE
      2. PRODUCTION, PROCESSING, OR TREATMENT OPERATIONS OR TRANSMISSION FACILITIES

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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICE OF WATER MANAGEMENT
OFFICE OF OIL AND GAS MANAGEMENT
OFFICIAL USE ONLY
ID #
Date Received
NOTICE OF INTENT (NOI) FOR COVERAGE
UNDER THE EROSION AND SEDIMENT CONTROL GENERAL PERMIT (ESCGP-2)
FOR EARTH DISTURBANCE ASSOCIATED WITH OIL AND GAS EXPLORATION,
PRODUCTION, PROCESSING, OR TREATMENT OPERATIONS OR TRANSMISSION FACILITIES
READ THE INSTRUCTIONS PROVIDED IN THIS PERMIT APPLICATION PACKAGE BEFORE COMPLETING THIS FORM.
PLEASE PRINT OR TYPE INFORMATION IN BLACK OR BLUE INK.
SECTION A. APPLICANT INFORMATION
APPLICATION TYPE
NEW
RENEWAL
MAJOR MODIFICATIONS
EXPEDITED
PHASED
Applicant's Last Name (If applicable)
First Name
MI
Phone
FAX
Organization Name or Registered Fictitious Name
Phone
FAX
Mailing Address
City
State
ZIP + 4
Email Address
Co-Applicant's Last Name (If applicable)
First Name
MI
Phone
FAX
Organization Name or Registered Fictitious Name
Phone
FAX
Mailing Address
City
State
ZIP + 4
Email Address
SECTION B. SITE INFORMATION
Site Name
Site Location
Site Location – City
State
ZIP+4
Detailed Written Directions to Site
County
Municipality
City
Boro Twp.

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SECTION C. PROJECT INFORMATION
1. Total Project Area/Project Site (Ac):
Total Disturbed Area (Ac):
2. Project Name
3. Project Type (Check all that apply)
Oil/Gas Well
Transmission Facility
Gathering Facility
Processing Facility
Treatment Facility
Centralized Fresh Water Impoundment
Centralized Wastewater Impoundment
Water Pipeline
Ground/Surface Water Withdrawal Site
Other
If Oil/Gas well, is the well conventional or unconventional?
Conventional
Unconventional
Project Description
4. Please provide the latitude and longitude coordinates for the center of the project. The coordinates should be in
degrees, minutes seconds (DD MM SS.SS) and North American Datum 1983. For linear projects provide the
project’s termini.
Latitude
degrees
minutes
seconds Longitude
degrees
minutes
seconds
Latitude
degrees
minutes
seconds Longitude
degrees
minutes
seconds
Horizontal Collection Method:
GPS
Interpolated from U.S.G.S. Topographic Map
DEP’s eMAP
5. U.S.G.S. 7.5 min. Quad Map Name
(Include a copy of the project area on the 7.5 min quad map)
6. Will the project be conducted as a phased permit project?
Yes
No
If Yes, Include Master Site Plan Estimated Timetable for Phased Projects.
Additional sheet(s) attached.
Phase No.
or Name
Description
Total Area
Disturbed
Area
Start Date
End Date
7. List existing and previous land use for a minimum of the previous 5 years.
8. Other Pollutants: Will the stormwater discharge contain pollutional substances other than sediment?
Yes
No
If yes, explain and provide any available quantitative data.
9. Will fuels, chemicals, solvents, other hazardous waste or materials be used or stored on site during earth disturbance
activities?
Yes
No
(If yes, a PPC Plan must be maintained on site during earth disturbance.)
10. Does the project have the potential to discharge to siltation-impaired waters?
Yes
No
(If yes, show how the project will not result in a net change in volume, rate or water quality.
See section G below.)

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11. Has the project site been investigated to identify naturally occurring geologic formations or soil types that may cause
pollution when disturbed?
Yes
No
Have naturally occurring geologic formations or soil types that may cause pollution when disturbed been identified?
Yes
No
(If yes, BMPs to avoid or minimize the potential pollution must be utilized.)
12. Has the project site been analyzed to determine potential thermal impacts to surface waters of the Commonwealth?
Yes
No
Have potential thermal impacts to surface water of the Commonwealth from earth disturbance activity been
identified?
Yes
No
(If yes, BMPs to avoid, minimize or mitigated the thermal pollution must be utilized.)
13. Have the E&S Plan and PCSM/SR Plan been planned, designed and implemented to be consistent?
Yes
No
14. Have existing and/or proposed Riparian Forest Buffers been identified?
Yes
N/A
(If not, they must be shown on the plans.)
15. Is a riparian buffer waiver being requested?
Yes
No
If yes, the applicant requesting a waiver must submit a written request that demonstrates that reasonable alternatives
will meet the requirements of 25 Pa. Code § 102.14 and to demonstrate that any existing riparian buffer will remain
undisturbed to the extent practicable.
16. Have antidegradation implementation requirements for special protection waters been addressed?
Yes
No
(If no, antidegradation requirements must be included in the plan.)
N/A
17. Has the seasonal high groundwater level been identified at all excavation locations for pits and impoundments other
than those which will contain top-hole water, fresh water and uncontaminated drill cuttings?
Yes
No
N/A
(If no, be advised that a 20-inch separation between the seasonal high
groundwater and the bottom of all pits and impoundments containing pollutional substances is required.)
18. Receiving Water/Watershed Name
Chapter 93, Designated Use and Existing Use
Stream Classification
High Quality
Exceptional Value
Other
Siltation-impaired
Secondary Receiving Water
Name of Municipal or Private Separate Storm Sewer Operator
19. Is an Expedited Review being requested?
Yes
No
If yes, be advised that the Expedited Review is not available for all projects.
Refer to the “Expedited Review
Process” Item 8, Page 17 of the ESCGP-2 Instructions to determine if your project is eligible.
SECTION D. EROSION AND SEDIMENT CONTROL PLAN BMPS
See the attached Instructions on how to complete this section.
Erosion and Sediment Control Plan BMPs should be designed to minimize accelerated erosion and sedimentation
through limiting the extent and duration of earth disturbance, protection of existing drainage and vegetation, limiting soil
compaction and controlling the generation of increased runoff. The Department recommends the use of the Erosion and
Sediment Control BMP Manual to achieve this goal. The E&S Plan must meet the requirements of Pa. Code § 102.4(b)
and submitted with the NOI.

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1. E & S Plan
The E & S Plan must satisfy at least one of subparagraph A or B below.
Provide a brief summary of proposed BMPs and their performance to manage E & S for the project. If E & S BMPs
and their application do not follow the guidelines referenced in the Pa. Erosion and Sediment Pollution Control
Program Manual, provide documentation to demonstrate performance equivalent to, or better than, the BMPs in the
Manual.
A.
E & S plan is designed using BMPs in the Pennsylvania Erosion & Sedimentation Pollution Control Manual
(ESPC) (Technical Guidance #3632134-008/March 2012)
OR
B.
E & S plan is designed using an alternative BMP or design standard
2. Riparian Buffer Information
A. Will you be protecting, converting or establishing a riparian buffer or a riparian forest buffer as a part of this
project?
Protect
Yes
No Convert
Yes
No Establish
Yes
No
B. Will you be protecting, converting or establishing a voluntary riparian forest buffer as part of this project?
Yes
No
C. Are you proposing to conduct oil and gas activities for which site reclamation or restoration is required as part of
the Chapter 78 permit authorization in a high quality or exceptional value watershed that is currently attaining its
designated use and within 150 ft of a perennial or intermittent river, stream or creek or lake, pond or reservoir?
Yes
No If yes, provide a demonstration that any existing riparian buffer is undisturbed to the extent
practicable.
D. If the regulations require a riparian buffer or riparian forest buffer and you are not providing one, list the waiver
provisions in the Chapter 102 regulations, Section 102.14(d)(2)(i)-(vi), that you are requesting and provide
additional documentation to demonstrate reasonable alternatives for compliance with 102.14 requirements and to
demonstrate that any existing reparian buffer will remain undisturbed to the extent practicable.
Note: If the proposed activity protects, converts or establishes a riparian or riparian forest buffer a Buffer Management
Plan is required in the PCSM Plan.

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3. Thermal Impacts Analysis
Please explain how thermal impacts associated with this project were avoided, minimized, or mitigated.
SECTION E. SITE RESTORATION (SR) PLAN BMPS
See the attached Instructions on how to complete this section.
If this section is not applicable to your project, please indicate by checking this box: N/A
For earth disturbance projects involving oil and gas activities authorized by Chapter 78 (well pads) or pipelines and other
similar utility infrastructure provide the information outlined below. If your project includes both oil and gas activities
authorized by Chapter 78 (well pads) or pipelines and other similar utility infrastructure and other activities requiring Post
Construction Stormwater Management, provide the information outlined in this Section as well as Section F.
Site Restoration BMPs should be designed to use natural measures to eliminate pollution, infiltrate runoff, not require
extensive construction/maintenance activity, promote pollutant reduction, and preserve the integrity of stream channels.
The Department recommends the use of PA Stormwater BMP manual to achieve this goal. The SR Plan must meet the
requirements of Pa Code § 102.8(n) and be submitted with the NOI.
1. Site Restoration Plan Information –
The Site Restoration 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 protect the physical, biological and chemical qualities of the receiving surface water.
Design standards applied to develop the Site Restoration Plan. Check those that apply.
Act 167 Plan – The attached SR Plan is consistent with an applicable approved Act 167 Plan.
Complete the following for all approved Act 167 Stormwater Management Plans. (Use additional sheets if necessary)
Act 167 Plan Name
Date Adopted
Consistency Letter Included
Verification Report Included
NOTE
: A consistency letter is not required if a verification report is provided. Please see NOI Instructions.
The Site
Restoration Plan must satisfy either sub paragraph A, B,
or
C below. Check those that apply.

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A.
Act 167 Plan approvals on or after January 2005 - The attached PCSM Plan, in its entirety, is consistent
with all requirements pertaining to rate, volume, and water quality from an Act 167 Stormwater
Management Plan approved by DEP on or after January 2005. Letter A must be checked if a current, DEP
approved Act 167 plan exists.
B.
The PCSM meets the standard design criteria from the PA Stormwater BMP Manual. For projects involving
oil and gas activities authorized by a permit issued under Chapter 78 (well pads) or pipelines and other
similar utility infrastructure, post construction stormwater management requirements are met for all areas
that are restored to preconstruction conditions or to a condition of meadow in good condition or better.
C.
Alternative Design Standard – The attached PCSM Plan was developed using approaches other than
102.8(g)(2). Demonstrate/explain in the space provided below how this standard will be either more
protective than what is required in 102.8(g)(2) or will maintain and protect existing water quality and existing
and designated uses.
2. Riparian Buffer Information
A. Will you be protecting, converting or establishing a riparian buffer or a riparian forest buffer as part of this activity?
Protect
Yes
No Convert
Yes
No Establish
Yes
No
B. Will you be protecting, converting or establishing a voluntary riparian forest buffer as part of this activity?
Yes
No
C. Are you proposing to conduct oil and gas activities for which site reclamation or restoration is required under a
permit issued under the auhtority of the 2012 Oil and Gas Act and Chapter 78 in a high quality or exceptional
value watershed that is currently attaining its designated use and within 150 ft of a perennial or intermittent river,
stream or creek or lake, pond or reservoir?
Yes
No
If yes, provide a demonstration that any existing riparian buffer is undisturbed to the extent
practicable.
D. If the regulations require a riparian buffer or riparian forest buffer and you are
not
providing one, list below the
waiver provisions in the Chapter 102 regulations, Section 102.14(d)(i)-(vi), that you are requesting and provide
additional documentation to demonstrate reasonable alternatives for compliance with 102.14 requirements and to
demonstrate that any existing reparian buffer will remain undisturbed to the extent practicable.
Note: If the proposed activity protects, converts or establishes a riparian or riparian forest buffer a Buffer Management
Plan is required in the PCSM Plan.
3. SUMMARY TABLE FOR SUPPORTING CALCULATION AND MEASUREMENT DATA
See Attachment D in the Instructions on how to Complete This Section
This section does not need to be completed for areas of projects involving oil and gas activities authorized by Chapter
78 (well pads) or pipelines and other similar utility infrastructure which will be restored to meadow in good condition or
better or existing conditions.
Watershed Name:
Design storm frequency
Rainfall amount
inches
Pre-construction
Post Construction
Net Change
Impervious area (acres)
Volume of stormwater runoff (acre-
feet) without planned stormwater
BMPs
Volume of stormwater runoff (acre-
feet) with planned stormwater BMPs

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Stormwater discharge rate for the
design frequency storm
Pre-construction
Post Construction
Net Change
1) 2-Year/24-Hour
2) 10-Year/24-Hour
3) 50-year/24-Hour
4) 100-year/24-Hour
4. SUMMARY DESCRIPTION OF SITE RESTORATION BMPs
In the lists below, check the BMPs identified in the Post Construction Stormwater Management Plan. The primary
function(s) of the BMP listed in the functions column (infiltration/recharge; detention/retention; water quality). Additional
functions may be added if applicable to that BMP. List the stormwater volume and area of runoff to be treated by each
BMP type when calculations are required. If any BMP in the Site Restoration Plan is not listed below, describe it in the
space provided after "Other".
BMP
Function(s)
Volume of stormwater
treated
Acres treated
Site Restoration
Infiltration/Recharge
Detention/WQ
Treatment
Restore Site to Meadow in
Good Condition or Better, or
Existing Conditions
Bio-infiltration areas
Infiltration/Recharge
Infiltration Trench
Infiltration Bed
Infiltrated Basin
Natural Area Conservation
Infiltration/Recharge
Streamside Buffer Zone
Wetland Buffer Zone
Sensitive Area Buffer Zone
Pre-Construction Drainage
Pattern Intact
Stormwater Retention
Detention/Retention
Constructed Wetlands
Wet Ponds
Retention Basin
Sediment and Pollutant
Removal
Water Quality
Treatment
Vegetated Filter Strips
Detention Basins
Access Road Design
Infiltration/Recharge
Road Crowning
Ditches
Turnouts
Culverts
Roadside Vegetated Filter
Strips

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Stormwater Energy Dissipaters
Infiltration/Recharge
Level Spreaders
Riprap Aprons
Upslope Diversions
5. Off-site Discharge Analysis.
Does the activity propose any off-site discharges to areas other than surface waters?
Yes
No
If yes, it is the applicant’s responsibility to ensure that they have legal authority for any off-site discharge.
The Applicant must provide a demonstration in both the E&S and Site Restoration Plans that the discharge will not
cause erosion, damage, or a nuisance to off-site properties.
6. Thermal Impact Analysis.
Explain how thermal impacts associated with this project were avoided, minimized, or mitigated.
SECTION F. POST CONSTRUCTION STORMWATER MANAGEMENT (PCSM) PLAN BMPS
See the attached Instructions on how to complete this section.
If this section is not applicable to your project, please indicate by checking this box: N/A
For earth disturbance projects requiring post construction stormwater management, provide the information outlined
below. If your project includes both oil and gas activities authorized under a well permit issued under the 2012 Oil and
Gas Act and Chapter 78 (well pads) or pipelines and other similar utility infrastructure and other activities requiring Post
Construction Stormwater Management, provide the information outlined in this Section as well as Section E.
Post Construction Stormwater Management BMPs should be designed to use natural measures to eliminate pollution,
infiltrate runoff, not require extensive construction/maintenance activity, promote pollutant reduction, and preserve the
integrity of stream channels. The Department recommends the use of PA Stormwater BMP manual to achieve this goal.
If PCSM BMPS and their application do not follow the guidelines referenced in the PA Stormwater BMP Manual, provide
documentation to demonstrate performance equivalent to, or better than, the BMPs in the Manual.

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1. Post Construction Stormwater Management Plan Information –
The Post Construction Stormwater Management
Plan must meet the requirements in 25 Pa. Code §102.8 and 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 protect the physical, biological and chemical qualities of the receiving surface water.
Design standards applied to develop the Post Construction Stormwater Management Plan. Check those that apply.
Act 167 Plan – The attached PCSM Plan is consistent with an applicable approved Act 167 Plan.
Complete the following for all approved Act 167 Stormwater Management Plans. (Use additional sheets if necessary)
Act 167 Plan Name
Date Adopted
Consistency Letter Included
Verification Report Included
NOTE: A consistency letter is not required if a verification report is provided. Please see NOI Instructions.
The PCSM Plan must satisfy either subparagraph A, B,
or
C below. Check those that apply. If a current, DEP
approved Act 167 Plan exists, letter A must be checked.
A.
Act 167 Plan approvals on or after January 2005 - The attached PCSM Plan, in its entirety, is consistent
with all requirements pertaining to rate, volume, and water quality from an Act 167 Stormwater Management
Plan approved by DEP on or after January 2005.
B.
The PCSM meets the standard design criteria from 102.8(g)(2) and (3) the PA Stormwater BMP Manual.
[Note: PCSM plans have to meet both the volume and rate requirements in the regulations, which are
provided in these 2 sections].
C.
Alternative Design Standard – The attached PCSM Plan was developed using alternative approaches as
provided in 102.8(g)(2)(iv) and 102.(g)(3)(iii). Demonstrate/explain in the space provided below how this
standard will be either more protective than what is required in 102.8(g)(2) and 102.8(g)(3) or will maintain
and protect existing water quality and existing and designated uses.
2. Riparian Buffer Information
A. Will you be protecting, converting or establishing a riparian buffer or a riparian forest buffer as part of this activity?
Protect
Yes
No
Convert
Yes
No
Establish
Yes
No
B. Will you be protecting, converting or establishing a voluntary riparian forest buffer as part of this activity?
Yes
No
C. Are you proposing to conduct oil and gas activities for which site reclamation or restoration is is required under a
well permit issued under the authority of the 2012 Oil and Gas Act and Chapter 78 and in a high quality or
exceptional value watershed that is currently attaining its designated use and within 150 ft of a perennial or
intermittent river, stream or creek or lake, pond or reservoir?
Yes
No If yes, provide a demonstration that any existing riparian buffer is undisturbed to the extent
practicable.
D. If the regulations require a riparian buffer or riparian forest buffer and you are not providing one, list below the
waiver provisions in the Chapter 102 regulations, Section 102.14(d)(i)-(vi), that you are requesting and provide
additional documentation to demonstrate reasonable alternatives for compliance with 102.14 requirements and to
demonstrate that any existing reparian buffer will remain undisturbed to the extent practicable.
Note: If the proposed activity protects, converts or establishes a riparian or riparian forest buffer a Buffer Management
Plan is required in the PCSM Plan.

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3. SUMMARY TABLE FOR SUPPORTING CALCULATION AND MEASUREMENT DATA
See Attachment D in the Instructions on how to Complete This Section
Watershed Name:
Design storm frequency
Rainfall amount
inches
Pre-construction
Post Construction
Net Change
Impervious area (acres)
Volume of stormwater runoff (acre-
feet) without planned stormwater
BMPs
Volume of stormwater runoff (acre-
feet) with planned stormwater BMPs
Stormwater discharge rate for the
design frequency storm
1) 2-Year/24-Hour
2) 10-Year/24-Hour
3) 50-year/24-Hour
4) 100-year/24-Hour
4. SUMMARY DESCRIPTION OF POST CONSTRUCTION STORMWATER BMPs
In the lists below, check the BMPs identified in the Post Construction Stormwater Management Plan. The primary
function(s) of the BMP listed in the functions column (infiltration/recharge; detention/retention; water quality). Additional
functions may be added if applicable to that BMP. List the stormwater volume and area of runoff to be treated by each
BMP type when calculations are required. If any BMP in the Site Restoration Plan is not listed below, describe it in the
space provided after “Other”.
BMP
Function(s)
Volume of stormwater
treated
Acres treated
Bio-infiltration areas
Infiltration/Recharge
Infiltration Trench
Infiltration Bed
Infiltrated Basin
Natural Area Conservation
Infiltration/Recharge
Streamside Buffer Zone
Wetland Buffer Zone
Sensitive Area Buffer Zone
Pre-Construction Drainage
Pattern Intact
Stormwater Retention
Detention/Retention
Constructed Wetlands
Wet Ponds
Retention Basin
Sediment and Pollutant Removal
Water Quality
Treatment
Vegetated Filter Strips
Compost Filter Sock
Detention Basins

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Access Road Design
Infiltration/Recharge
Road Crowning
Ditches
Turnouts
Culverts
Roadside Vegetated Filter
Strips
Stormwater Energy Dissipaters
Infiltration/Recharge
Level Spreaders
Riprap Aprons
Upslope Diversions
5. Off-site Discharge Analysis.
Does the activity propose any off-site discharges to areas other than surface waters?
Yes
No
If yes, it is the applicant’s responsibility to ensure that they have legal authority for any off-site discharge.
The Applicant must provide a demonstration in both the E&S and PCSM Plans that the discharge will not cause
erosion, damage, or nuisance to off-site properties.
6. Thermal Impact Analysis.
Explain how thermal impacts associated with this project were avoided, minimized, or mitigated.
7. Critical PCSM Plan stages.
Identify and list critical stages of implementation of the PCSM Plan for which a licensed professional or designee shall
be present on site.

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SECTION G. ANTIDEGRADATION ANALYSIS
This section must be completed where earth disturbance activities will be conducted in special protection or
siltation-impaired watersheds.
Part 1 NONDISCHARGE ALTERNATIVES EVALUATION
The applicant must consider and describe any and all nondischarge alternatives for the entire project area which are
environmentally sound and will
:
Minimize accelerated erosion and sedimentation during the earth disturbance activity
Achieve no net change from pre-development to post-development volume, rate and concentration of pollutants in
water quality
E & S Plan
Official
Use
Only
PCSM/Site Restoration Plan
Official
Use
Only
Check off the environmentally sound
nondischarge Best Management Practices
(BMPs) listed below to be used prior to,
during, and after earth disturbance activities
that have been incorporated into your E & S
Plan based on your site analysis. For non-
discharge BMPs not checked, provide an
explanation of why they were not utilized.
Also for BMPs checked, provide an
explanation of why they were utilized.
(Provide your analysis and attach additional
sheets if necessary)
Check off the environmentally sound
nondischarge Best Management Practices
(BMPs) listed below to be used after
construction that have been incorporated into
your PCSM/SR Plan based on your site
analysis.
For non-discharge BMPs not
checked, provide an explanation of why they
were not utilized. Also for BMPs checked,
provide an explanation of why they were
utilized. (Provide your analysis and attach
additional sheets if necessary)
Nondischarge BMPs
Alternative Siting
Alternative location
Alternative configuration
Alternative location of discharge
Limited Disturbed Area
Limiting
Extent
&
Duration
of
Disturbance (Phasing, Sequencing)
Riparian Buffers (150 ft. min.)
Riparian Forest Buffer (150 ft. min.)
Other
Nondischarge BMPs
Alternative Siting
Alternative location
Alternative configuration
Alternative location of discharge
Low Impact Development (LID / BSD)
Riparian Buffers (150 ft. min.)
Riparian Forest Buffer (150 ft. min.)
Infiltration
Water Reuse
Other
Will the non-discharge alternative BMPs eliminate the net change in rate, volume and quality during and after
construction?
Yes
No
If yes, antidegradation analysis is complete.
If no, proceed to Part 2.

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PART 2 ANTIDEGRADATION BEST AVAILABLE COMBINATION OF TECHNOLOGIES (ABACT)
If the net change in stormwater discharge from or after construction is not fully managed by nondischarge BMPs, the
applicant must utilize ABACT BMPs to manage the difference. The Applicant must specify whether the discharge will
occur during construction, post-construction or both, and identify the technologies that will be used to ensure that the
discharge will be a non-degrading discharge. ABACT BMPs include but are not limited to:
E & S Plan
Official
Use
Only
PCSM/Site Restoration Plan
Official
Use
Only
Treatment BMPs:
Sediment basin with skimmer
Sediment basin ratio of 4:1 or greater
(flow length to basin width)
Sediment basin with 4-7 day detention
Flocculants
Compost Filter Socks
Compost Filter Sock Sediment Basin
RCE w/ Wash Rack
Land disposal:
Vegetated filters
Riparian buffers <150ft.
Riparian Forest Buffer <150ft.
Immediate stabilization
Pollution prevention:
PPC Plans
Street sweeping
Channels, collectors and diversions
lined with permanent vegetation, rock,
geotextile
or
other
non-erosive
materials
Stormwater reuse technologies:
Sediment basin water for dust control
Sediment basin water for irrigation
Other
Treatment BMPs:
Infiltration Practices
Wet ponds
Created wetland treatment systems
Vegetated swales
Manufactured devices
Bio-retention/infiltration
Green Roofs
Land disposal:
Vegetated filters
Riparian Buffers <150ft.
Riparian Forest Buffer <150ft.
Disconnection of roof drainage
Bio-retention/bio-infiltration
Pollution prevention:
Street sweeping
Nutrient, pesticide, herbicide or other
chemical
application
plan
alternatives
PPC Plans
Non-structural Practices
Restoration BMPs
Stormwater reuse technologies:
Divert rainwater into impoundment
Underground storage
Spray/Drip Irrigation
Other

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SECTION H. COMPLIANCE REVIEW
Is the applicant in violation of any existing permit, regulation, order, or schedule of compliance issued by the Department
within the last 5 years?
Yes
No
If yes, provide the permit number or facility name, a brief description of the violation, the compliance schedule (including
dates and steps to achieve compliance) and the current compliance status. (Attach additional information on a separate
sheets, when necessary)

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SECTION I. CERTIFICATION BY PERSON PREPARING APPLICATION
I do hereby certify to the best of my knowledge, information, and belief, that the Erosion and Sediment Control and
PCSM/Site Restoration Plans are true and correct, represent actual field conditions, and are in accordance with the 25 Pa.
Code Chapters 78 and 102 of the Department’s rules and regulations. I am aware that there are significant penalties for
submitting false information, including the possibility of fine and imprisonment.
Print Name
Signature
Professional Seal
Company
Address
Phone
Most Recent DEP Training Attended
Location
Date
e-Mail Address
EXPEDITED REVIEW PROCESS
In addition to the certification required above applicants using the expedited permit review process must attach an E&S
and PCSM/Site Restoration Plans developed and sealed by a licensed professional engineer, surveyor or professional
geologist. The plans shall contain the following certification:
I do hereby certify to the best of my knowledge, information, and belief, that the E & S Control and SR/PCSM BMPs are
true and correct, represent actual field conditions and are in accordance with the 25 Pa. Code Chapters 78 and 102 of the
Department’s rules and regulations. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment
.
SECTION J. APPLICANT CERTIFICATION
Applicant Certification. I certify under penalty of law that this document and all attachments were prepared by me or under
my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those
persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. The responsible official’s signature also verifies that the activity is eligible to
participate in the permit, and that the applicant agrees to abide by the terms and conditions of the permit. I am aware that
there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
Print Name and Title of Applicant
Print Name and Title of Co-Applicant (if applicable)
Signature of Applicant
Signature of Co-Applicant
Date Application Signed
Date Application Signed
Notarization
Sworn to and subscribed to before me this
Commonwealth of Pennsylvania
day of
, 20
County of
My Commission expires
Notary Public
AFFIX SEAL

8000-PM-OOGM0005 Rev. 1/2014
Notice of Intent
- 16 -
SECTION K. CONTACT FOR ADDITIONAL INFORMATION
Contact’s Last Name
First Name
MI
Phone
FAX
Mailing Address
City
State
ZIP + 4
e-Mail Address

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