1

Municipal Separate Storm Sewer Program Report 

EPA Regulations – 122.34(g)(3) and 122.42(c) 

Example Data Entry Form

[Note: Users will also be able to batch this data into this form via a spreadsheet or CSV file.]

NPDES Number <system generated>

Start Date of Reporting Period (YYYY-MM-DD)

End Date of Reporting Period (YYYY-MM-DD) 

NPDES Data Group Number 6

<system generated>

MS4 Reliance on Other Government Entities (Status Flag):

MS4 Reliance on Other Government Entities (Status Flag): This is a code indicating that the permittee relies on another unique 

governmental entity to satisfy any of the permit requirements.
2

Listing of MS4 Permit Components

This table will list the MS4 activities that are included in the MS4 individual NPDES permit (Phase I MS4s) or general NPDES permit 

(Phase II MS4s). The groupings of these MS4 permit components will include:

1. public education and outreach on stormwater impacts; 

2. public involvement/participation; 

3. illicit discharge detection and elimination; 

4. construction site stormwater runoff; 

5. post-construction stormwater management in new development and redevelopment; and 

6. pollution prevention/good housekeeping for municipal operations.

The MS4 Permit Component Number will allow users to separately list all of the MS4 permit components and group them in the 

above categories. For example, a MS4 permittee with two components under “Public Education and Outreach on Stormwater 

Impacts” will have one entry in the table with 1-1 as the MS4 Permit Component Number and 1-2 as the other MS4 Permit 

Component Number. Each entry in the table below will also list the municipalities (by their unique number) that are covered by the 

permit component.

MS4 Permit 

Component 

Number

Municipality 

Covered by this 

Permit 

Component

(unique number)

MS4 Permit 

Component

Descriptions

MS4 Reliance on 

Other Government 

Entities (unique 

number)

Changes to MS4 

Permit 

Components

Changes to MS4 

Measurable 

Goals

Identified 

Measureable 

Goal

(Phase II MS4s 

only)

* ** **

* ** **

* ** **

*Note: This number will be system generated with information from the individual NPDES permit (Phase I MS4s) or general NPDES 

permit (Phase II MS4s).

**Note: The MS4 permittee will be able to select a number from a set of unique municipalities that are covered by this NPDES 

permit. 
3

MS4 Permit Components Descriptions: This code/description will identify for each unique municipality all of the permitted

components that are included in the MS4 permit. For Phase II MS4s, these components will be pre-populated from the BMPs each 

Phase II MS4 permittee indicated it will implement in its NOI or permit application. The groupings of these MS4 components will 

include public education and outreach on stormwater impacts; public involvement/participation; illicit discharge detection and 

elimination; construction site stormwater runoff; post-construction stormwater management in new development and 

redevelopment; and pollution prevention/good housekeeping for municipal operations.

Changes to MS4 Permit Components: This code/description will describe for each unique municipality any changes made to MS4 

permit components (e.g., BMPs) during the reporting period.

Changes to MS4 Measurable Goals: This code/description will identify any changes the permittee made to the measurable goals for 

each unique municipality that were made since the last annual report was submitted.

Identified Measurable Goal for Each MS4 Permit Component: Identified measurable goal for each MS4 permit component for each 

unique municipality for each MS4 permit component. This data element only applies to Phase II MS4s.
4

Status Report and Updates to MS4 Permit Components

MS4 Permit 

Component 

Number

Status and 

Assessment of 

Compliance with 

MS4 Permit 

Components

Progress Toward 

Achieving 

Identified MS4 

Measurable Goals

Summary of MS4 Data and 

Monitoring Results

Summary of Planned MS4 

Activities

*

*

*

*Note: This number will be system generated with information from the preceding table.

Status and Assessment of Compliance with MS4 Permit Components: Status and assessment of the permittee’s compliance with its 

MS4 permit for each unique municipality.

Progress Toward Achieving Identified MS4 Measurable Goals: This is an indication of the progress made to date on achieving the 

identified measurable goals for each unique municipality for each MS4 permit component.

Summary of MS4 Data and Monitoring Results: Provide text summary of information collected and analyzed, including monitoring 

data, if any, during the reporting period for each unique municipality for each MS4 permit component.

Summary of Planned MS4 Activities: Provide a text summary of the stormwater activities to be undertaken during the next reporting 

cycle for each unique municipality for each MS4 permit component.
5

Standard Signature Block and Certification 

Statement for CWA Reporting (in compliance 

with CFR Parts 3, 122.22, and 127).

Enforcement Actions

Unique Municipality Covered 

Under this Permit

MS4 Enforcement 

Action Type

MS4 Enforcement 

Action Number

MS4 Municipality Enforcement Agency

(by Unique Municipality Number)

* *

* *

* *

*Note: The MS4 permittee will be able to select a number from a set of unique municipalities that are covered by this NPDES permit.

MS4 Enforcement Action Type: For each unique municipality covered under the MS4 permit, identify the types of enforcement 

actions taken during the past reporting period (e.g., notice of violations, stop work orders, administration orders, administrative 

fines, civil penalties, criminal actions). The unique municipality covered under the MS4 permit will identify “No Authority” for this 

data element if the municipality does not have the authority to conduct enforcement actions.

MS4 Enforcement Action Number: For each unique municipality covered under the MS4 permit and for each MS4 Enforcement 

Action Type, identify the number of enforcement actions taken by responsible MS4 Municipal Enforcement Agency. The unique 

municipality covered under the MS4 permit will identify “No Authority” for this data element if the municipality does not have the 

authority to conduct enforcement actions.

MS4 Municipality Enforcement Agency: For each unique municipality that has the authority to conduct enforcement actions covered 

under the MS4 permit and for each MS4 Enforcement Action Type, identify the corresponding MS4 Municipal Enforcement Agency 

by its unique municipality number (“Unique Number for Each Municipality Covered Under MS4 Permit”).

SUBMIT 

REPORT