SCHEDULE A Site Drainage Self-Assessment and Application

(to discharge to the Storm Drainage System) Revision: January 2020

General Information – Please read before you complete this form Thank you for completing a Site Drainage Self-Assessment and Application. Use this Application to obtain approval to discharge water from your site into The City of Calgary Storm Drainage System. As there is little or no treatment of storm drainage before it enters the environment, The City of Calgary operates this drainage approval program to ensure the quality and quantity of water discharged from your site is acceptable.

• Before completing this form, obtain a Service Request (SR) number by contacting Calgary 311. Advise 311 youare applying for a Drainage Permit – they will ask you some basic questions, set up your service request in ourwork queue and e-mail you this application form.

• Carefully read the questions on the form. Your answers on the Self-Assessment section of the form willdetermine if your application is a Drainage Notification or Drainage Permit.

SCHEDULE A: Site Drainage Self-Assessment and Application A. 311 Service Request (provide a SR#)SR#: B. Contact Information for the Owner of the SiteCompany: Primary Contact Name: Telephone: Fax:

Address: Emergency Phone Number:

C. Contact Information for Person Responsible (if different from the owner of the Site)Company: Primary Contact Name: Telephone: Fax:

Address: Emergency Phone Number:

D. Site InformationMunicipal Address: Multiple site locations

Project Name:

Planned / Estimated Start Date for Drainage Activity: Format: yyyy-mm-dd

Planned/Estimated End Date for Drainage Activity: Format: yyyy-mm-dd

Type of Drainage Activity (select one or more): Remove water from trench/excavation Hydrant flushing / flow testing for fire prevention Commercial snow melting machine Hydrostatic test water disposal Ponded surface water disposal Stormwater detention/retention pond Other (describe):

Description of water (select one or more): Surface water (from rain / snowmelt) Groundwater seepage Surface water mixed with groundwater Potable (drinking) water: Must be de-chlorinated Process water Other (describe):

How will water be discharged to the Storm Drainage System (select one or more)? Pump(s) Gravity Other (describe):

What is the proposed discharge location to the Storm Drainage System (select one or more): Storm catch basin (at curb/gutter) Storm manhole Storm pond Overland storm drainage channel Roadway (to road gutter and storm catch basin) Other (describe):

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E. Self-Assessment Questions (Tip: Water Quality Results Table is at www.calgary.ca/esc under 'Permits')When completing this section, carefully read and answer the questions. You may need to find additional site / subjectmatter expertise (consultant, project manager) if you are unsure.Ensure you provide the additional information required for any questions you answer yes to (Special Conditions). Anincomplete Self-Assessment may result in applications being rejected or delayed.

*Special Conditions (Requires Drainage Permit)1. Are you discharging a total

volume greater than 1250 m3

within this calendar year?Estimated total volume: _______m3

No Yes → Attach the following supplemental information: Laboratory Water Quality Results Table and original laboratory results as required by the issuing inspector. → Provide required information in column one

2. Is a treatment system required?(check ‘no’ if treatment is onlyfor sediment or turbidity control)

No Yes → Attach the following supplemental information: A treatment system schematic and operating and monitoring procedure.

3. Will you need to discharge atmultiple locations under thesame Drainage Activity?

No Yes → Attach the following supplemental information: Description of Drainage Activity and discharge locations (e.g. de-chlorinated water from fire hydrant testing discharged to the nearest storm catch basin).

4. Do any of the following apply?• The site is contaminated, or is

within a 100 m radius of acontaminated site;

• There is an obvious chemical orhydrocarbon odour associatedwith the water to be pumped

• There is a sheen, foam or;discoloration associated with thewater to be pumped.

No Yes → Attach the following supplemental information: Laboratory Water Quality Results Table and original laboratory results as required by the issuing inspector.

Attach a location map showing discharge location (for single location applications) by clicking and selecting "Add Image" from the options. Ensure the location is easily identifiable from the map provided (e.g. include cross streets).

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5. Will you need to discharge intoan Environmental Reserve (ER)? Ifyes, provide location of ER:

No Yes → Provide required information in column one Note: The issuing inspector will discuss with The City’s Parks Business Unit and may request additional details.

6. Do either of the following apply?• The discharge rate will exceed 20

L/s (316 Gal/min)If yes, provide proposed discharge rate and units, and reason(s):

• Discharge will need to continueduring or within one hour ofRunoff Events

If yes, provide reason(s):

No Yes → Provide required information in column one Note: Ensure you provide sufficient information on proposed discharge rate and rationale. Attach supplemental information if necessary. The issuing inspector will request an internal review of Storm Drainage System capacity. Note that this process can take 2 – 3 weeks.Runoff Event means runoff caused by precipitation, snowmelt oroverland drainage entering the Storm Drainage System (DrainageCode of Practice, Part 1 – Definitions). There may be insufficientcapacity in the Storm Drainage System to discharge during a RunoffEvent, so ensure you provide detailed rationale. Attachsupplemental information if necessary.

7. Do any of the following apply?• The Drainage Activity will occur

over a period exceeding 30 daysIf yes, provide estimated length of Drainage Activity in months: _________ months• The site will be left unattended

during the Drainage ActivityIf yes, provide reason(s):

No Yes → Provide required information in column one Note: The maximum term for a Drainage Notification is 30 days. You will need to obtain a Drainage Permit for a Drainage Activity exceeding 30 days; For a Drainage Activity that will be left unattended (e.g. Activity running overnight), the issuing inspector may request that you provide additional supplemental information such as a monitoring plan and contingency plan

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F. Site Photos (photos must be in colour and clearly identifiable - they may be sent in a separate attachement)

Source of Discharge Pump(s) and Hose(s) - if applicable

G. Acknowledgement (this form must be completed by an Owner or Person Responsible in its entirety to be considered valid)

Confirm if your Application is a Drainage Notification or for a Drainage Permit. Provide all required supplemental application information with a Drainage Permit Application.

Drainage Notification: If you answered NO to ALL seven (7) questions on the Drainage Self-Assessment and Application:

• You must submit this document as Written Notice to the Director. You must ensure you submit afully completed application for your Drainage Notification to be valid.

• You may commence the Drainage Activity once you have submitted a complete Site Drainage Self-Assessment and Application. Your Drainage Notification is valid for 30 days from the date it isreceived.

• You must comply with all conditions set out in Schedule B of Code of Practice for Drainage Activities.• You must complete Schedule C (Inspection Documentation Table).

Drainage Permit: If you answered YES to one or more of the seven (7) questions on the Drainage Self- Assessment and Application:

• One or more Special Conditions exist for this Drainage Activity. You must not commence theDrainage Activity until your application is reviewed and a Drainage Permit has been issued.

• You must submit this document, and will require a Drainage Permit prior to commencing theDrainage Activity and throughout the duration of the activity.

• Supplemental information must be included with this application, and will be required in full priorto your Drainage Permit application being reviewed.

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Discharge Hose(s) Placement - if applicable Discharge Location - Downstream

• Further information or ongoing information such as water quality analytical results may berequired (water quality sampling, analysis and review may take up to 3 weeks).

• You must comply with all conditions set out in Schedule B of Code of Practice for DrainageActivities and any conditions specified in your written Drainage Permit.

• You may commence the Drainage Activity once you receive a Drainage Permit. Your DrainagePermit, if approved, is only valid for the dates specified.

Submission Checklist (check all boxes that apply to your Application): Drainage Notification

Drainage Permit Application (written approval required) Supplemental information attached (Drainage Permit applications missing any supplemental information will be deemed incomplete) When required, Laboratory Water Quality Results Table and original lab reports are attached with Application (Laboratory Water Quality Results Table available at www.calgary.ca/esc under ‘Permits’) When required, provide a schematic of the treatment system and operating and monitoring procedure For a Drainage Activity with multiple discharge locations, provide a detailed description of the Drainage Activity and discharge locations

Complete Application: Ensure that you have completed all sections of the application and checkboxes for all questions in the Self-Assessment are correctly checked.

Code of Practice: Ensure you are familiar with the Code of Practice for Drainage Activities and are following all Conditions (Schedule B) monitoring and record keeping (Schedule C).

Please read carefully, then print your name, sign and date the document: The owner or Person Responsible authorized by the owner hereby warrants that all information provided to The City of Calgary in this application is true and accurate, agrees to all conditions set out by the Code of Practice for Drainage Activities, and agrees to abide by The City of Calgary Drainage Bylaw, 37M2005, the Code of Practice and any Drainage Permit or Notification issued thereunder.

_______________________________________ ______________________________________ ______________________________ Name Signature Date (YYYY-MM-DD)

Submission of results: Any submission, application, notification or other communication given by delivery, courier or mail shall be deemed to have been received on the date it is received by the City Inspector or The City of Calgary. Any submission, application, notification or other communication to a City Inspector or The City of Calgary under this Code of Practice must be in writing, complete and in the approved form to be effective, and is effective when provided electronically through The City of Calgary’s 3-1-1 System or when provided by delivery in person or by courier, mail, email, or fax transmission. By delivery: Monitoring and Compliance, lower floor, Manchester - Building U, 677 - 25th Ave SE Mail: P.O. Box 2100, Station M, #413 Calgary, AB T2P 2M5 Email: ESC@calgary.ca Fax: 403-268-4557

The personal information on this form is being collected under the authority of The City of Calgary Drainage Bylaw Section 4(3)(e) and amendments thereto. It will be used for Drainage Notification and Drainage Permit review and inspection processes and may be communicated to relevant City Business Units. The name of the applicant and nature of the Drainage Notification or Drainage Permit will be available to the public. Please send inquiries by mail to the FOIP Program Administrator, Water Resources #413, PO Box 2100, Station M, Calgary, Alberta, T2P 2M5 or contact us by phone at 311.

ISC: Protected

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