RULE 13 STORM WATER QUALITY MANAGEMENT PLAN (SWQMP) PART B: BASELINE CHARACTERIZATION AND REPORT CERTIFICATION CHECKLIST State Form 51275 (R3 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used for compliance with a general NPDES permit pursuant to 327 IAC 15-13. 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) Submit this completed form with a complete “SWQMP – Part B: Baseline Characterization and Report” in accordance with 327 IAC 15-13-7. 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: SWQMP CHECKLIST ► Please check the appropriate box when the requirements for each numbered item have been met, or check “NA” if an item is not applicable. For some of the numbered items, the requirements must be met and “not applicable” is not provided as an option. X NA ITEM 1. Plan submitted within one hundred eighty (180) days of the NOI letter submittal or the expiration date of the previous 5-year permit term 2. Baseline characterization includes: a) An investigation of land usage within the MS4 area b) The identification and assessment of structural and nonstructural storm water BMP locations c) The identification of known sensitive water areas d) e) A review of known existing and available monitoring data of the MS4 area receiving waters The identification of areas having a reasonable potential for, or actually causing, storm water quality problems Other (please specify): f) 3. Characterization report includes: a) f) Conclusions, such as key observations or monitoring points in the MS4 conveyances, derived from the land usage investigation Characterization results of BMP locations and, as appropriate, the structural condition of the BMP, related to the BMP’s potential or actual effectiveness in improving storm water quality The characterization includes recommendations for placement and implementation of additional BMPs Identification of areas, such as public beaches or surface drinking water sources, that potentially or actually require added water quality protection considerations Any correlative conclusions that can be drawn from a review of existing monitoring data that assists the MS4 Operator in identifying potential or actual storm water quality problem areas The identification of areas or sources potentially or actually causing storm water quality problems g) Other (please specify): b) c) d) e) 4. SWQMP - Part B: Baseline Characterization and Report has been signed by a Qualified Professional and the MS4 Operator Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com PART B: CERTIFICATION AND SIGNATURE ► The Qualified Professional and the MS4 Operator (referenced in Part A, Item #4 of this form) must sign the following certification statement and provide the pertinent NPDES permit number: “By signing this checklist, I hereby certify under penalty of law that this protocol 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 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com