vpdes general permit registration statement industrial activity storm water discharges var05 please type or print all information 1 owner name __________________________________________________________________________________________________ mailing address __________________________________________________________________________________________ city ___________________________________ state _________ zip _____________ phone _______________________ 2 facility ________________________________________________________________________________________________ contact ______________________________________________ 3 ownership status federal q public private check one only 4 of the receiving s ____________________________________________________________________________ 5 if discharge is through a municipal separate sewer system ms4 operator ____________________________________________________________________________________________ 6 numbers for permits assigned to _________________________________________________ 7 does this runoff from coal storage piles yes no 8 has pollution prevention plan been developed in accordance with requirements associated 9 attach topographic map other which indicates location body and surface bodies within mile radius
