For questions regarding this form, contact: RULE 13 ANNUAL REPORT State Form 51278 (R4 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: In order to comply with 327 IAC 15-13-18, annual reports must be submitted to the Indiana Department of Environmental Management. Failure to submit this form will be considered noncompliance with your permit. For the first five (5)-year permit term, this completed form must be submitted by 1 year from the SWQMP – Part C submittal date and, thereafter, 1 year from the previous report (i.e., in years two (2) through five (5) of permit coverage). In the second and subsequent five (5)-year permit terms, this completed form must be submitted in years two (2) and four (4) of permit coverage, by 1 and 3 years from the SWQMP – Part C resubmittal date. Please type or print in ink. IDEM – Rule 13 Coordinator 100 North Senate Avenue, Rm 1255 MC 65-42 Indianapolis, IN 46204-2251 Phone: (317) 234-1601 or (800) 451-6027, ext. 41601 (within Indiana) Web Access: http://www.in.gov/idem (Search for Stormwater) Please answer all questions thoroughly and return the form by the due date. Return this form and any required addenda to the IDEM Rule 13 Coordinator at the address listed in the box on the upperright. REPORTING YEAR (Check one) 2005 2006 2007 2008 2009 2010 2011 2012 2013 PART A: GENERAL INFORMATION – MS4 OPERATOR 1. Report Completed By: (MS4 Operator — i.e., name of permit holder) 2. 3. Permit Number: INR 0 4 0 Mailing Address Street Address: City Town Of: Zip: County: PART B: GENERAL INFORMATION – CONTACT PERSON 4. Contact Person Name (please print): 5. Contact Person Title: 6. Phone Number: 7. Facsimile Number (if applicable): 8. E-mail Address (if applicable): Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com PART C: CONTROL MEASURE ACTIVITIES 9. For the following items, please provide a summary of control measure activities related to Rule 13 performed during the previous year. List any updated measurable goals from the SWQMP, compliance activities, BMPs installed or initiated, updated programmatic indicator data, and updated or developed regulatory mechanisms with effective dates. a. Public Education and Outreach: b. Public Involvement and Participation: c. Illicit Discharge Detection and Elimination: d. Construction Site Storm Water Run-off Control: e. Post-construction Storm Water Management in New Development and Redevelopment: f. Pollution Prevention and Good Housekeeping for Municipal Operations: g. Other controls: 10. List all receiving water(s) and corresponding outfall(s) not submitted in the original NOI letter (form): 11. Provide any data regarding the following programmatic indicators, since the previous annual report (Attach separate sheets as necessary, and indicate, as appropriate, the rationale behind not using a listed indicator): i. Number or percentage of citizens that have an awareness of storm water quality issues ii. Number and description of meetings, training sessions, and events conducted to involve citizens iii. Number or percentage of citizens that participate in storm water quality improvement projects iv. Number and location of storm drains marked or cast v. Estimated linear feet or percentage of MS4 conveyances mapped vi. Number and location of MS4 area outfalls mapped vii. Number and location of MS4 area outfalls screened for illicit discharges viii. Number and location of illicit discharges detected ix. Number and location of illicit discharges eliminated x. Number of, and amount of material collected from, HHW collections xi. Number and location of citizen drop-off centers for automotive fluids xii. Number or percentage of citizens that participate in HHW collections xiii. Number of construction sites permitted for storm water quality xiv. Number of construction sites inspected xv. Number and type of enforcement actions taken against construction site operators xvi. Number of public informational requests received related to construction sites xvii. Number, type, and location of structural BMPs installed xviii. Number, type, and location of structural BMPs inspected xix. Number, type, and location of structural BMPs maintained, or improved xx. Type and location of nonstructural BMPs utilized xxi. Estimated acreage or square footage of open space preserved and mapped xxii. Estimated acreage or square footage of mapped pervious and impervious surfaces xxiii. Number and location of retail gasoline outlets or municipal, state, federal, or institutional refueling areas with installed BMPs Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com xxiv. Number and location of entity facilities that have containment for accidental releases xxv. Estimated acreage or square footage and location where pesticides, herbicides and fertilizers are applied by the entity xxvi. Estimated linear feet or percentage and location of unvegetated swales and ditches that have an adequately sized vegetated filter strip xxvii. Estimated linear feet or percentage and location of MS4s cleaned or repaired xxviii. Estimated linear feet or percentage and location of roadside shoulders and ditches stabilized xxix. Number and location of storm water outfall areas remediated from scouring conditions xxx. Number and location of de-icing salt and sand storage areas covered or otherwise improved to minimize storm water exposure xxxi. Estimated amount, in tons, of salt and sand used for snow and ice control xxxii. Estimated amount of material collected from catch basin, trash rack, or other structural BMP cleaning xxxiii. Estimated amount of material collected from street sweeping xxxiv. Number or percentage and location of canine parks sited at least 150 feet away from a surface water body xxxv. Other PART D: MISCELLANEOUS INFORMATION 12. On-Going Water Quality Characterization Activities a. Monitoring Data (submit summary of appropriate results): b. Other: 13. Discuss any problems encountered during this period (include any BMP changes in response to problems encountered). 14. Identify any new funding source(s) for implementing this permit. ` 15. Identify any non-routine (i.e. do not include routine maintenance or cleaning) budgetary transactions related to your permit. List all storm water improvement projects started during this reporting period. 16. Provide a summary of complaints received and the follow-up actions taken in reference to storm water quality issues. 17. Implementation status: a. Are the six minimum control measures being implemented within the compliance schedule and SWQMP timetables? Yes No* * If no, explain: b. Do you foresee any problems which may affect full implementation of all the measures? Yes No* * If yes, explain: c. Are the six minimum control measures meeting percent reduction goals specified in the SWQMP? Yes No* * If no, explain: PART E: CERTIFICATION AND SIGNATURE The individual completing this report, listed in "PART A: GENERAL INFORMATION – MS4 OPERATOR" must sign the following certification statement: “By signing this Rule 13 annual report, I hereby 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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible 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.” Type or Print Name: Signature: _______________________________________________________________________________________ ____________ (mm/dd/year) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com