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 Entit ies ( 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 Componen t 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 compo n ents under “P ublic E ducation and Outreach on Stormwater I mpacts” will have one entry in the ta ble 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**  **Numbe r**  **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 wi ll in clude 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 eac h 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**  **Numb er**  **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 Resul ts : 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 sto rmwater 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, administ rative fines, civil penalties, criminal a ctions). 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 thi s 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 (“Uniq ue Number for Each Municipality Covered Under MS4 Permit”).

SUBMIT REPORT