5500-PM-OG0005
Checklist
Rev. 2/2011
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERSHED MANAGEMENT
BUREAU OF OIL AND GAS MANAGEMENT
NOTICE OF INTENT (NOI) ADMINISTRATIVE COMPLETENESS CHECKLIST
EROSION AND SEDIMENT CONTROL GENERAL PERMIT FOR EARTH DISTURBANCE
ASSOCIATED WITH OIL AND GAS EXPLORATION, PRODUCTION, PROCESSING, OR
TREATMENT OPERATIONS OR TRANSMISSION FACILITIES
(ESCGP-1)
Please check the following list to make sure that you have included all the required information. Place a check mark in the column provided
for all items completed and/or provided. Failure to provide all of the requested information will delay the processing of the application, may
preclude the use of the expedited review, and may result in the application being placed ON HOLD with NO ACTION, or being considered
withdrawn and the application file closed.
THIS CHECKLIST MUST BE COMPLETED AND ENCLOSED WITH YOUR GENERAL PERMIT NOI
CHECKLIST FOR EROSION AND SEDIMENT CONTROL GENERAL PERMIT NOI
Minor revisions are not
required to be submitted
NEW NOI
RENEWAL
SUBSEQUENT PHASE
Major Revision
Minor Revision to the regional office for
review.
If a Renewal, Subsequent Phase or Revision, identify ESCGP-1 Permit Authorization #
Applicant
Check 
if
Official
Included Use Only
APPLICANT
PROJECT and PHASE NAME
1.
2.
Fully completed, properly signed and notarized Notice of Intent form (1 original and 2 copies).
(Not required for subsequent phases)
Complete Erosion and Sediment Control (E&S) Plans. (3 copies)
NOTE: Identify Location as Drawings (D), Narrative (N). (Identify Not Applicable as “N/A”.)
a. Topographic features
Location:
Page:
b. Soils information
Location:
Page:
c. Proposed alteration
Location:
Page:
d. Amount of runoff
Location:
Page:
Location of water which may receive runoff and receiving
e. water classification, pursuant to Chapter 93 and the Location:
“statewide existing use listing”.
Page:
f.
Supporting calculations
Location:
Page:
g.
BMPs used before, during, and after earth disturbance,
Location:
including special protection BMPs.
Page:
h. Maintenance program
Location:
Page:
i.
Plan drawings and narratives
Location:
Page:
j.
Sequence of BMP installation and removal
Location:
Page:
Location:
Page:
Permit filing fee of $500 plus $100/Acre of earth
disturbance payable to the appropriate Clean Water Fund. Location:
(Not required for subsequent phases)
Page:
Location map: USGS of scale 1:24,000 indicating project
location and boundaries. (3 copies) (Not required for
subsequent phases)
Page:
k. Recycling and disposal methods
3.
4.
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Location:
5500-PM-OG0005
Checklist
Rev. 2/2011
Applicant
Check 
if
Official
Included Use Only
CHECKLIST FOR ESCGP-1
5.
Act 14 Municipal Notifications to the local municipality and
county governments that specify that the application is for a
Erosion and Sediment Control General Permit for Earth
Disturbance Associated with Oil and Gas Activities.
(3 copies) A "sample" notification letter is provided as
Appendix A of the instructions. (Not required for subsequent
phases)
Location:
Page:
6.
Proof of receipt of municipal notifications; copies of certified
mail receipts or acknowledgment letters from the local
municipality and county government.
(3 copies) (Not
required for subsequent phases)
Location:
Page:
7.
The PNHP Review receipt for the project area. Include
impact clearance letters if proof of agency coordination is
required. (3 copies) (Not required for subsequent phases if
review receipt or impact clearance letters are still valid)
Location:
Page:
8.
Complete Post Construction Stormwater Management (PCSM)/Site Restoration Plan. (3 copies)
NOTE: Identify Location(s) by Drawing (D), Narrative (N) and page number(s).
Plans must address the following: (Identify Not Applicable as “N/A”.)
a. Written Narrative
Location:
Page:
9.
b. Location of BMPs showing final contours
Location:
Page:
c. Plan drawings of permanent stabilization
Location:
Page:
d. Plan drawings of BMPs
Location:
Page:
e. Operation and maintenance procedure
Location:
Page:
f. Supporting calculations or measurements
Location:
Page:
g. Design frequency storm rainfall amount
Location:
Page:
h. Area of impervious surface
Location:
Page:
i. Curve Number or Runoff Coefficient
Location:
Page:
j. Runoff from the design frequency storm
Location:
Page:
k. Volume of water infiltrated through BMPs
Location:
Page:
l. Peak discharge rate from the design frequency storm
Location:
Page:
Expedited Review
Is the expedited review being requested?
Yes
No
If yes all of the following items must be completed:
a. E&S and PCSM/Restoration Plan drawings and narrative sealed by licensed professional
b. Licensed professional prepared, sealed, and certified application/NOI
c. Licensed professional listed location and date of DEP training attended in application/NOI
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5500-PM-OG0005
Checklist
Rev. 2/2011
Applicant
Check 
if
Official
Included Use Only
CHECKLIST FOR ESCGP-1
10.
Phased Projects Is the activity being conducted as a phased project?
Yes
No
If yes all of the following must be completed:
11.
a.
Initial Phase - Is the master plan included?
Yes
No
b.
Subsequent Phase – Is the subsequent phase identified
on the master plan?
Yes
No
Yes
No
Certification for Subsequent Phase Expedited Reviews
Is the activity being conducted as a phased project and
is an expedited review being requested?
If yes all of the following must be completed:
I do hereby certify to the best of my knowledge, information, and belief, that the Erosion and Sediment Control and
PCSM/Site Restoration Plan 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.
Signature
Professional
Seal
Company
Address
Phone
Most Recent DEP Training Attended Location
Date
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 Plan 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 Erosion and Sediment Control and
PCSM/Site Restoration Plan and Post Construction 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.
12. Permit Renewals Is a permit renewal being requested?
If yes all of the following must be completed:
Yes
No
a. Administratively complete, signed, and notarized Notice of Intent Form, including Items 1-8.
(1 signed original and 2 copies of the NOI/application)
b. Permit filing fee of $500 plus $100/Acre of earth disturbance payable to the appropriate Clean
Water Fund.
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