# Appendix D : Sample Form for Notice of Intent to Seek

Coverage under the MSGPNPDES

FORM

3510 -6 

### U NITED 

### S TATES 

### E NVIRONMENTAL 

### P ROTECTION 

### A GENCY



### W ASHINGTON



### , DC 20460

N OTICE OF 

### I NTENT 

### (NOI) FOR 

### S TORMWATER 

### D ISCHARGES 

### A SSOCIATED WITH



### I NDUSTRIAL 

### A CTIVITY UNDER THE 

### NPDES M ULTI



### - S ECTOR 

### G ENERAL 

### P ERMIT Form Approved.

OMB No. 2040

- 0004

Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to

the NPDES Stormwater Multi

- Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that

the operator identified in Sectio n C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To obtain

authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if you r NOI is incompl ete or inaccurate or if you were never

eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI.



### A. Approval to Use Paper NOI Form

1. Have you been granted a waiver from electronic reporting from the Regional Office*? YES NO

If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, an d the date of approval:

Waiver granted: The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that

is identified as under

- served for broadband Internet access in the most recent report from the Federal

Communications Commission

The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that

gra nted the waiver:

Date approval obtained: / /

* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you must

file this form electronically using the electronic Notice of Intent (eNOI) system at www.epa.gov/npdes/stormwater/msgpenoi



### B. Permit Information NPDES ID (EPA Use Only) :

1. Master Permit Number: (see Appendix C of the MSGP for the list of eligible master permit numbers)

2. Are you a new discharger as defined in Appendix A? YES NO (If yes, skip to Part C of this form).

3. If you are not a new discharger, have stormwater discharges from your facility been covered previously under an NPDES perm it? YES NO

If yes, provide the NPDES ID if you had coverage under EPA’s MSGP 2008 or the NPDES ID if you had coverage under an EPA

individual permit:



### C. Facility Operator Information

1. Operator Information:

Operator Name:

Mailing Address:

Street:

City: State: ZIP Code:

-

Phone:

- - Ext.

E- mail:

2. Operator Point of Contact Information:

First Name, Middle Initial,

Last Name:

Title:

3. NOI Preparer Information (Complete if NOI was prepared by someone other than the certifier):

First Name, Middle Initial,

Last Name:

Organization:Phone:

- - Ext.

E- mail:



### D. Facility Information

1. Facility Name:

2. Facility Address:

Street/Location:

City: State: ZIP Code:

-

County or Similar

Government Subdivision:

3. Latitude/Longitude for the facility:

Latitude: ___ ___. ___ ___ ___ ___° N (degrees decimal) Longitude: ___ ___ ___. ___ ___ ___ ___° W (degrees decimal)

Latitude/Longitude Data Source: USGS topographic map EPA Website GPS Other:

If you used a USGS topographic map, what was the scale?

__________________________________________________________________________________________

Horizontal Reference Datum: NAD 27 NAD 83 or WGS 84

4. Is your facility located on Indian Country lands? YES NO

If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable):

________________________________ ________________________________ ____________

5. Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A? YES NO

6. What is the ownership type of the facility? Federal Facility (U.S. Government) Privately Owned Facility City Government County Government

State Government Tribal Government Other:

_______________________________

7. Estimated area of industrial activity at your facility exposed to stormwater: (acres)

8. Sector

- Specific Information

Identify the 4

- digit Standard Industrial Classification (SIC) code or 2

- letter Activity Code that best represents the products produced or services rendered for

which your facility is primarily engaged, as defined in the MSGP, and the applicable sector and subsector of your primary industrial activity (See Appendix D):

Primary SIC Cod e: OR Primary Activity Code:

Sector: Subsector:

Identify the applicable sector(s) and subsector(s) of any co

- located industrial activity for which you are requesting permit coverage:

Sector: Subsector: Sector: Subsector: Sector: Subsector:

Sector: Subsector: Sector: Subsector: Sector: Subsector:

If you are a Sector S (Air Transportation) facility, do you anticipate using more than 100,000 gallons of glycol

- based deicing/anti

- icing chemicals and/or 100

tons or more of urea on an average annual basis? YES NO

If you are a Sector G (Metal Mining) facility, check the type of ore you mine at your site: Tungsten Ore Nickel Ore Al uminum Ore

Mercury Ore Iron Ore Platinum Ore Titanium Ore Vanadium Ore Molybdenum Uranium, Radium,

and/or Vanadium

Ore

9. Is your facility presently inactive and unstaffed?* YES NO* Note that if your facility becomes inactive and unstaffed during the permit term, you must submit an NOI modification to re flect the change.



### E. Discharge Information

1. By indicating “Yes” below, I confirm that I understand that the MSGP only authorizes the allowable stormwater discharges in Part 1.1.2 and the allowable non

stormwater discharges listed in Part 1.1.3

. Any discharges not expressly authorized under the MSGP are not covered by the MSGP or the permit shield provision

of the CWA Sect ion 402(k) and they cannot become authorized by disclosure to EPA and/or a state via this Notice of Intent to be covered by the permit or

by any other means (e.g., in the Stormwater Pollution Prevention Plan or during an inspection). If any discharges req uiring NPDES permit coverage other than

the allowable stormwater and non

- stormwater discharges listed in Parts 1.1.2 and 1.1. 3 will be discharged, they must be covered under another NPDES

permit. YES NO

2. Federal Effluent Limitation Guidelines

Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines? YES NO

If yes, which effluent limitation guidelines apply to your stormwater discharges?

40 CFR Part/Subpart Eligible Discharges Affected MSGP Sector New Source Date Check if Applicable

Part 411, Subpart C Runoff from material storage piles at cement manufacturing

facilities E 2/20/1974

Part 418 Subpart A Runoff from phosphate fertilizer manufacturing facilities that

comes into contact with any raw materials, finished product,

by

- products or waste products (SIC 2874) C 4/8/1974

Part 423 Coal pile runoff at steam electric generating facilities O 11/19/1982

10/8/1974 1

Part 429, Subpart I Discharges resulting from spray down or intentional wetting of

logs at wet deck storage areas A 1/26/1981

Part 436, Subpart B, C, or

D Mine dewatering discharges at crushed stone mines,

construction sand and gravel mines, or industrial sand mines J N/A

Part 443, Subpart A Runoff from asphalt emulsion facilities D 7/28/1975

Part 445, Subparts A & B Runoff from hazardous waste and non

- hazardous waste

landfills K, L 2/2/2000

Part 449 Existing and new primary airports with 1,000 or more annual

jet departures that discharge wastewater associated with

airfield pavement deicing that contains urea commingled

with stormwa ter S 6/15/2012

1 NSPS promulgated in 1974 were not removed via the 1982 regulation; therefore wastewaters generated by Part 423

- applicable sources that were New Sources

under the 1974 regulations are subject to the 1974 NSPS.

3. Receiving Waters Information: (Attach a separate list if necessary)

List all of the stormwater outfalls from your facility. Each outfall

must be identified by a unique 3

- digit ID (e.g., 001, 002). Also

provide the latitude and longitude in degrees decimal for

each outfall. For each outfall, provide the following receiving water information:

Provide the name of the

first water of the U.S. that

receives stormwater

directly from the outfall

and/or from the MS4 that

the outfall discharges to: Is the receiving

water

impaired? If yes, list the pollutants

that are causing the

impairment: Has a TMDL

been

completed for

this receiving

waterbody? Outfall ID Latitude Longitude Check if Any Outfalls

Are Substantially

Identical to Any

Out fall Listed Above

YES NO YES NO

Substantially

identical to

outfall:________ YES NO YES NO

Substantially

identical to

outfall:________ YES NO YES NO

Substantially

identical to

outfall:________ YES NO YES NO

Substantially

identical to

outfall:________ YES NO YES NOSubstantially

identical to

outfall:________ YES NO YES NO

Substantially

identical to

outfall:________ YES NO YES NO

4. Provide the following Information about your outfall latitude longitude:

Latitude/Longitude Data Source: USGS topographic map EPA Website GPS Other:

If you used a USGS topographic map, what was the scale?

__________________________________________________________________________________________

Horizontal Reference Datum: NAD 27 NAD 83 or WGS 84

5

. Does your facility discharge into a Muncipal Separate Storm Sewer System (MS4)? YES NO

If yes, provide the name of the MS4 operator:

6. Check if you discharge to any of the waters of the U.S. that are designated by the state or tribal authority under its antide gradation policy as a Tier 2 (or Tier

2.5) water (water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water) or as a Tier 3

water (Outstanding Natural Resource Water)? (See Appendix L).

Tier 2/2.5. Provide the name(s) of receiving water (s):

Tier 3 (Outstanding Natural Resource Waters*

* Note: You are ineligible for coverage if you are a new discharger to waters designated as Tier 3 (outstanding natural resourc e waters) for antidegr adation

purposes under 40 CFR 131.13(a)(3).

7. If you are subject to benchmark monitoring requirements for a hardness

- dependent metal, what is the hardness of your receiving water(s) (see Appendix J)?

_________________ (mg/L)

8. If you are subject to benchmark monitoring requirements for metals, does your facility discharge into any saltwater receiv ing waters? YES NO

9. Does your facility discharge to a F ederal CERCLA site as defined in Appendix A and listed in Appendix P? YES NO

If yes, did you notify your applicable EPA Regional Office in advance of filing your NOI, and did the EPA Office determine th at you are eligible for permit

coverage pursuant to Part 1.1.4.10*? YES NO

* Note: You are ineligible for coverage under this permit unless you notify your applicable EPA Regional Office in advance and the EPA offic e determines you

are eligible coverage under this permit. In determining your eligibility for coverage under this Part, the EPA Regional Office may evaluate whether you have

included appropriate controls and implementation procedures designed to ensure you r discharge will not lead to recontamination of aquatic media at the

CERCLA Site.



### F . Stormwater Pollution Prevention Pla n (SWPPP) Information

1. Has the SWPPP been prepared in advance of filing this NOI, as required? YES NO

2. SWPPP Contact Information:

First Name, Middle Initial,

Last Name:

Phone:

- - Ext.

E- mail:

2. SWPPP Availability:

Your current SWPPP or certain information from your SWPPP must be made available through one of the following two options. Se lect one of the options and

provide the required information*:

* Note: You are not required to post any confidential business inf ormation (CBI) or restricted information (as defined in Appendix A) (such information may be

redacted), but you must clearly identify those portions of the SWPPP that are being withheld from public access.

Option 1 : Maintain a current copy of your SWPPP on an Internet page (Universal Resource Locator or URL).

Provide the web address URL:

Option 2 : Provide the following information from your SWPPP:

A. Describe your onsite industrial activities exposed to stormwater (e.g., material storage; equipment fueling, maintenance, and cleaning, cutting steel beams),

and potential spill and leak areas:B. List the pollutant(s) or pollutant constituent(s) associated with each industrial activity exposed to stormwater that coul d be discharged in stormwater and/or

in any authorized non

- stormwater discharges listed in Part 1.1.3:

C. Describe the control measures you will employ to comply with the non

- numeric technology

- based effluent limits required in Part 2.1.2 and Part 8, and any

other measures taken to comply with the requirements in Part 2.2 Water Quality

- Based Effluent Limitations (see Part 5.2.4.1):

D. Provide a schedule for good housekeeping and maintenance (see Part 5.2.5.1) and a schedule for all inspections required in Part 4 (see Part 5.2.5.2):



### G . Endangered Species Protection

1. Using the instructions in Appendix E of the MSGP, under which endangered species criterion listed in Part 1.1.4.5 are you eligible for coverage under this

permit (only check 1 box)?

A B C D E

2. Provide a brief summary of the basis for the criterion selected in Appendix E (e.g., communication with U.S. Fish and Wildlif e Service or National Marine

Fisheries Service to determine no species in action area; implementation of controls approved by EPA a nd the Services):

_____________________________________________________________________________________________________________________________________________________

3. If you select criterion B, provide the NPDES ID from the other operator’s NOI authorized under this permit:

4. If you select criterion C, you must answer the following questions:

a. What federally

- listed species or federally

- designated critical habitat are located in your “action area”:

_________________________________________________________________________________________________________________________________________________

b. Using the Appendix E worksheet, check which of the following is applicable to your facility and answer any corresponding q uestions:

I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and agree to implement any controls that were

determined by EPA to be necessary to ensure that my discharges and/or discharge

- related activities will not have likely adverse affects on listed species

and critical habitat.Date your Criterion C

Eligibilty Form was sent to

EPA: / /

Describe any EPA

- approved controls and/or management practices you will implement to ensure your discharges will not have likely adverse affects on

listed species and critical habitat:

_______________________________________________________________________________________________________________________________________________

I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and have not been notified of any additional

controls necessary to ensure no likely adver se affects on listed species and critical habitat

Date your Criterion C

Eligibility Form was sent

to EPA: / /

* Note: After you submit your NOI and before your NOI is authorized, EPA may notify you if any additional controls are necessar y to ensure your discharges

have no likely adverse affects on listed species and critical habitat.

5. If you select criterion D or E, you must attach copies of any letters or other communications with the U.S. Fish and Wildlife Service or National Marin e Fisheries

Service.

H. Historic Preservation

1. If your facility is not located o n Indian country land, is your facility located on a property of religious or cultural significance to an Indian tribe? YES

NO

If yes, provide the name of the Indian tribe associated with the property:

_____

2. Using the instructions in Appendix F of the MSGP, under which historic properties preservation criterion listed in Part 1.1.4 .6 are you eligible for coverage under

this permit (only check 1 box)?

A B C D

I. Certification Information

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 pers on or persons who manage the

system, or those persons directly respon sible 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.

First Name, Middle

Initial, Last Name:

Title:

Signature: Date: / /

E- mail: