RULE 13 STORM WATER QUALITY MANAGEMENT PLAN (SWQMP) PART A: INITIAL APPLICATION CERTIFICATION SUBMITTAL AND CHECKLIST State Form 51277 (R3 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 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) NOTE: This form must be used for compliance with a general NPDES permit pursuant to 327 IAC 15-13. This completed form must be submitted with a complete NOI letter. Return this form, and any required addenda by mail to the IDEM Rule 13 Coordinator at the address listed in the box on the upper-right. PART A: STORM WATER QUALITY MANAGEMENT PLAN CHECKLIST ► Please check the appropriate box when the requirements for each numbered item have been met. X NA ITEM 1. 2. On page 2 of this form (TABLE 1: RESPONSIBLE ENTITY), provide a listing of entities that are covered under the attached NOI letter submittal. Duplicate the table if more entries are necessary and attach to this form. On page 3 of this form (TABLE 2: SCHEDULE OF ACTIVITIES), provide an itemized schedule of activities related to SWQMP implementation, with a corresponding milestone date. Duplicate the table if more entries are necessary and attach to this form. 3. At a minimum, the schedule complies with the compliance schedule found in 327 IAC 15-13-11. 4. On page 4 of this form (TABLE 3: PROPOSED BUDGET), provide an actual or estimated, proposed, itemized budget for the storm water program. Duplicate the table if more entity entries are necessary and attach to this form. 5. For NOI letter submittals covering multiple entities, the budget allocation is separated by each entity covered under this NOI letter submittal. 6. The budget identifies funding sources. 7. The “SWQMP – Part A: Initial Application” was submitted within 90 days of Rule 13’s effective date or within 180 days of becoming aware of changed entity designation conditions. 8. The “SWQMP – Part A: Initial Application” has been certified by a Qualified Professional and the MS4 Operator. PART B: CERTIFICATION AND SIGNATURE ► The Qualified Professional and MS4 Operator (referenced in PART A, Item #8 of this form) must sign the following certification statement and provide the pertinent NPDES permit number: “By signing this form, I hereby certify under penalty of law that this document was 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." Name of Qualified Professional: _________ NPDES Permit #: INR040 __ __________ (typed or printed) Signature of Qualified Professional: Date: _________ (mm/dd/year) Name of MS4 Operator: _________ (typed or printed) Signature of MS4 Operator: Date: _________ (mm/dd/year) Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com TABLE 1: RESPONSIBLE ENTITY Represented Entity Name Entity Representative Name Entity Representative Title Mailing Address Phone Number: Facsimile Number E-mail Address (if applicable) (if applicable) Street address: _________ 1. _________ _________ _________ City Town Village _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ Of: _________ Zip: _________ Street address: County: _________ _________ 2. _________ _________ _________ City Town Village Of: _________ Zip: _________ Street address: 3. _________ _________ _________ City Town County: _________ Village Of: _________ Zip: _________ Street address: County: _________ _________ 4. _________ _________ _________ City Town Village Of: _________ Zip: _________ Street address: County: _________ _________ 5. _________ _________ _________ City Town Village Of: _________ Zip: _________ Street address: County: _________ _________ 6. _________ _________ _________ City Town Village Of: _________ Zip: _________ Street address: 7. _________ _________ _________ City Town County: _________ Village Of: Zip: _________ County: _________ Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com TABLE 2: SCHEDULE OF ACTIVITIES Activity Name Milestone Date 1. _________ _________ 2. _________ _________ 3. _________ _________ 4. _________ _________ 5. _________ _________ 6. _________ _________ 7. _________ _________ 8. _________ _________ 9. _________ _________ 10. _________ _________ Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com TABLE 3: PROPOSED BUDGET ENTITY: _________ Control Measure/Item Proposed Budget 1. Public Education and Outreach _________ 2. Public Participation/Involvement _________ 3. Illicit Discharge Detection and Elimination _________ 4. Construction Site Run-Off Control _________ 5. Postconstruction Run-Off Control _________ 6. Municipal Operations Pollution Prevention and Good Housekeeping _________ 7. On-Going Water Quality Characterization _________ 8. Other _________ 9. Funding Source(s) _________ Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com