RULE 13 NOTICE OF INTENT (NOI) LETTER For questions regarding this form, contact: 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) State Form 51270 (R4 / 4-08) Form Approved by State Board of Accounts, 2003 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used to apply for a general NPDES permit pursuant to 327 IAC 15-13. Please type or print in ink. This completed form must be submitted with the Rule 13 Storm Water Quality Management Plan (SWQMP) – Part A: Initial Application Certification Submittal and Checklist, and proof of publication. Return this form, required addenda, and payment by mail to the IDEM Rule 13 Coordinator at the address listed in the box on the upper-right. APPLICABILITY APPLICATION TYPE (check one) Permit coverage under 327 IAC 15-13 applies to all entities that: 1. are not required to obtain an individual NPDES permit under 327 IAC 152-9(b); 2. meet the general permit rule applicability requirements under 327 IAC 152-3; 3. do not have coverage under an individual MS4 permit; and 4. operate, maintain, or otherwise have responsibility for an MS4 conveyance within a designated MS4 area. Initial NOI letter Renewal NOI letter PART A:GENERAL INFORMATION FOR MS4 OPERATOR 1. Operator Name: 2. Operator Title: 3. 4. Represented Entity1: Mailing Address Address: City Town Of: Zip: 5. Phone Number: 6. Facsimile Number (if applicable): 7. E-mail Address (if applicable): 8. County: Is the primary contact person for the MS4 area the same as the operator listed in Part A? PART B: GENERAL INFORMATION FOR PRIMARY CONTACT PERSON FOR THE MS4 AREA Yes* 9. No** * If yes, omit items #9-15 below and skip to Part C. ** If no, fill out items #9-15 below. Contact Person Name: 10. Contact Person Title: 11. Represented Entity1: 12. Mailing Address Address: City Town Of: Zip: County: 13. Phone Number: 14. Facsimile Number (if applicable): 15. E-mail Address (if applicable): 1 The “Represented Entity” is the name of the facility and/or organization that you are representing for purposes of this application. This can be a business, municipality, university, etc. PF Reason = NOI13 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY MS4 Notice of Intent (NOI) Letter PART C: GENERAL INFORMATION FOR MS4 ENTITIES 16. Receiving Water: List all separate storm water outfall receiving waters for all entities seeking coverage under this NOI submittal and corresponding outfall designations. Attach separate sheets as necessary. If all receiving waters and outfalls are not known at the time of the NOI letter submittal, state known ones and provide the information in the corresponding annual report. Entity Receiving Water Outfall(s) a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. 17. Do any outfalls discharge to another MS4 conveyance? (These conveyances may either be regulated or non-regulated under Rule 13. ) If yes, provide the name of the responsible individual for the storm sewer and provide the name of the initial receiving water. Yes* No** * If yes, fill in items #18-22 below. ** If no, omit items #18-22, and advance to item #23 below. 18. Responsible Individual Name: 19. Responsible Individual Title: 20. Responsible MS4 Entity 21. Phone Number: (e.g. municipality): 22. Initial Receiving Water(s): 23. Has a TMDL study been completed on any of the receiving water(s)? (To determine if a TMDL study has been completed, you may contact IDEM's TMDL program area by phone at 1-317-308-3173.) If yes, note which outfall(s) is subject to effluent limitations and identify the impairment parameter(s) in the table provided below. (attach separate sheets as necessary) Yes* No** * If yes, fill in items a.-m. below. ** If no, omit items a.-m. and advance to Part D. Receiving Water a. b. Outfall(s) Parameter(s) c. d. e. f. g. h. i. j. k. l. m. PF Reason = NOI13 Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY MS4 Notice of Intent (NOI) Letter PART D: MATERIALS TO BE SUBMITTED WITH THIS NOI LETTER ► In addition to the information in Parts A ,B, and C, an MS4 operator must provide the following. (Check when completed, or check “NA” if an item is not applicable. For the first of the numbered items below, the requirement must be met and “not applicable” is not provided as an option.): X NA ITEM 1) ---- A copy of the Storm Water Quality Management Plan – Part A: Initial Application Certification Submittal and Checklist. 2) ---- Proof of publication in a newspaper of largest circulation in the affected area . 3) 1 Certification that appropriate legally-binding agreements or contracts between MS4 entities have been obtained (see APPENDIX A). PART E: APPLICATION FEE • Upon submission of this NOI letter, the MS4 Operator shall pay a fee in the amount of fifty dollars ($50). Make all checks and money orders payable to “IDEM”. • Pursuant to 327 IAC 15, the fee is NOT: Transferable from one (1) MS4 operator to another; Transferable from one (1) person to another; Transferable to any other type of permit issued by IDEM; or Refundable. Unless requested by the MS4 operator and approved by IDEM within three (3) days of submittal to IDEM or prior to the NOI letter processing by IDEM, whichever is earlier. PART F: CERTIFICATION AND SIGNATURE • Allow a minimum of four (4) weeks for processing the NOI letter information and receipt of your Notice of Sufficiency. • Make sure you have completed all appropriate sections of this NOI letter and have included all required addenda. Sign and date the NOI letter and return it to the address shown on page one (1) of this NOI letter. Incomplete or incorrect NOI letters may result in a delay in processing and issuance of your Notice of Sufficiency. • All information requested in this NOI letter is MANDATORY for the administration and processing of your permit pursuant to 327 IAC 15-13. All data received will be regarded as a public record subject to disclosure in accordance with IC 5-14-3 and 327 IAC 12.1. ► The Operator listed in "Part A: GENERAL INFORMATION FOR MS4 OPERATOR" must sign the following certification statement: “By signing this NOI letter, 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 Operator Name: Signature of Operator: Date: (mm/dd/year) 1 The notice must be published one (1) time in at least one (1) newspaper of general circulation in each of the counties comprising the MS4 area represented by the entities seeking coverage under this NOI letter submittal. The publication of notice must, at a minimum, include the language specified in 327 IAC 15-136(a)(4). PF Reason = NOI13 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY MS4 Notice of Intent (NOI) Letter APPENDIX A: LEGALLY-BINDING AGREEMENT/CONTRACT CERTIFICATION FOR IMPLEMENTATION OF A SWQMP On _____________ (date), 1. 3. 5. 7. 9. 11. 2. 4. 6. 8. 10. 12. (List entity names above) Entered into an agreement or contract to satisfy the implementation requirements in Parts B and C of the Storm Water Quality Management Plan (SWQMP). As stated in the agreement or contract, entities agree to the following responsibilities Please check the boxes corresponding with responsibilities, or portions thereof, of each entity (entity numbers correspond to entity name numbers listed above) entering into this agreement in the table below: RESPONSIBILITY ENTITY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 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. Postconstruction Storm Water Management in New Development and Redevelopment f. Pollution Prevention and Good Housekeeping for Municipal Operations g. Baseline Characterization and On-Going Monitoring Plan h. Other: Specify: If any entity(s) is agreeing to accomplish only a portion of an aforementioned responsibility in the table, please elaborate below on the exact responsibility portion (e.g. entity 1 is responsible for storm drain marking in the MS4 area, entity 2 is responsible for conducting behavioral phone surveys for item (a) in the table). Attach separate sheets as needed. The following statement and the accompanying signatures serve as the required certification that an agreement or contract has been developed and agreed upon per the requirements of 327 IAC 15-13. “By signing this certification, I hereby certify under penalty of law that this document and all attachments are, to the best of my knowledge, 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.” Entity Authorized Signature 1. 3. 5. 7. 9. 11. PF Reason = NOI13 Date Entity Authorized Signature Date 2. 4. 6. 8. 10. 12. Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com