3810-FM-BPNPSM0514b 7/2015
Urban Stormwater BMP Project
Program Project Application
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
LOCAL STORMWATER BMP IMPLEMENTATION
PROGRAM PROJECT APPLICATION
APPLICANT / PERMITTEE INFORMATION
1.
Applicant Name:
2. Applicant DUNS No.:
3.
Applicant Address:
4. Entity Type:
5.
Applicant Contact:
6.
Applicant Email:
7. Applicant Phone:
8.
Permittee Name:
9. NPDES Permit No.:
10. Permittee Contact:
11. Permittee Email:
12. Permittee Phone:
GENERAL PROJECT INFORMATION
1. Project Name:
2. Project Description:
3. Project Coordinates:
(Attach Map)
Latitude
Degrees
Longitude
Minutes
4. County:
Seconds
5. UA?
6. Drains To:
MS4
Yes
Degrees
Minutes
Seconds
No
CSS
7. Receiving Waters:
8. Impaired?
Yes
No
If Yes, list cause(s):
9. TMDL?
Yes
No
If Yes, TMDL name:
PROJECT DETAILS
1. Is/are the proposed BMP(s) identified in a CBPRP, MS4 TMDL Plan or CSO Long Term Control Plan (LTCP) that has
been submitted to DEP?
Yes
No
Date of Actual or Proposed Submission:
2. If Yes to question 1, has the CBPRP, TMDL Plan or CSO LTCP been approved by DEP?
Yes
No
DEP Approval Date:
3. Is/are the proposed BMP(s) recognized by EPA’s Chesapeake Bay Model?
Yes
No
Comments:
4. Describe the specific water quality problem(s) that the BMP is intended to address.
5. Estimate the total pounds (lbs) per year of nutrient and sediment load reduction that will be achieved upon
implementation of the project. Provide or attach an explanation of how those estimates were determined.
Nitrogen Load Reduction
lbs/year:
Phosphorus Load Reduction
lbs/year:
Sediment Load Reduction
lbs/year:
Estimates were determined as follows (attach additional sheets as necessary):
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3810-FM-BPNPSM0514b 7/2015
Urban Stormwater BMP Project
Program Project Application
PROJECT MILESTONES
Milestone Description
Projected
Start Date
Projected
Completion Date
Comments
OTHER INFORMATION
1. If the applicant is not the permittee where the BMP will be located, attach a letter from the permittee indicating
support for the project.
2. Describe the applicant’s experience in managing state or federal grant or loan projects.
3. Identify project partners and their proposed involvement with the project.
4. The project is proposed to take place on:
Public Property
Private Property
If private property, attach written consent from the property owner(s).
5. Is the applicant an approved distressed municipality under Act 47, Financially Distressed Municipalities Act of 1987?
Such a municipality must be listed on the Department of Community and Economic Development website to be
eligible.
Yes
No
6. Specify operation and maintenance (O&M) activities for each BMP upon completion of the project, and the frequency
such O&M activities should occur to assure continued pollutant reductions throughout the life of the BMP.
7. Identify the responsible party for ongoing O&M following completion of the project and the mechanism to assure
O&M activities will occur.
8. Identify any environmental permits that are required to allow the construction to proceed and the agency(ies)
responsible for approval of those permits. Include permit application submissions in the Project Milestones section of
this application.
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3810-FM-BPNPSM0514b 7/2015
Urban Stormwater BMP Project
Program Project Application
PROJECT BUDGET
Category
Funds
Requested ($)
Description
Matching Funds
($)
Administration
Interest During Construction
Architectural/Engineering
Fees
Permits
Construction
TOTALS:
CERTIFICATION
I certify under penalty of law that this document and all attachments were prepared 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. I am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations. See 18 Pa. C.S. § 4904 (relating to unsworn falsification).
Name (Type or Print Legibly)
Official Title
Responsible Official Signature
Date
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