Rule 13 Certification Of The Development And Implementation Of A Program To Reduce Pollutant Run-Off
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Rule 13 Certification Of The Development And Implementation Of A Program To Reduce Pollutant Run-Off Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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RULE 13 –
For questions regarding this form, contact:
Certification of the Development and Implementation of a
Program to Reduce Pollutant Run-Off from Municipal
Operations for the Municipal Operations Pollution
Prevention and Good Housekeeping MCM
State Form 51281 (R3 / 4-08)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
IDEM – Rule 13 Coordinator
100 North Senate Avenue, Rm 1255
Indianapolis, IN 46204-2251
(317) 234-1601 or
(800) 451-6027, ext. 41601 (within Indiana)
http://www.in.gov/idem (Search for Stormwater)
This form must be used to comply with section 17(b) of 327 IAC 1513.
The program required under this MCM must be implemented within
three hundred sixty-five (365) days of the Notice of Intent (NOI)
letter submittal date.
Submit this completed form when the program has been developed
Return this completed and signed form, and any required addenda
by mail to the IDEM Rule 13 Coordinator at the address listed in the
box on the upper-right.
CERTIFICATION AND SIGNATURE
The State of Indiana requires ________________________________________________________(MS4 Operator) to
develop and implement a program to ensure that existing municipal, State or Federal operations are performed in ways
that do not cause or contribute to contamination of storm water discharges. Written documentation of preventative
maintenance, control measures, pesticide use minimization, proper waste disposal, waste reduction, and municipal
employee training must be incorporated into this program. This program must be implemented within three hundred sixtyfive (365) days of the Notice of Intent (NOI) letter submittal date.
► The following statement, required by the State of Indiana, and the accompanying signature serve as the required
certification that the program has been developed and implemented per the requirements of 327 IAC 15-13 and
authorized under NPDES permit number INR040_________.
"I certify, under penalty of law, that this program and all required materials were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the
information, the above statement 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."
(typed or printed)
The "authorized signature" required above must be either that of the MS4 operator, or, if another entity is responsible for this MCM, the
The "title" must either be "MS4 operator", or, if a responsible individual signs, the title of that individual and associated MS4 entity
represented (for example, mayor of the City of Indianapolis).
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