RULE 6 NOTICE OF INTENT (NOI) LETTER State Form 51286 (R7 / 11-10) Approved by State Board of Accounts, 2010 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: Mail this form to: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT CASHIER’S OFFICE – MAIL CODE 50-10C 100 North Senate Avenue Indianapolis, IN 46204-2251 Web Access: www.idem.IN.gov/4901.htm This form must be used to apply for a general NPDES permit pursuant to 327 IAC 15-6. Please type or print in ink. For questions regarding this form, required addenda, and permit requirements contact the IDEM Rule 6 Coordinator at telephone number (317) 233-0202 or (800) 451-6027, ext. 30202 (within Indiana) EXCLUSIONS APPLICATION TYPE (check one) Permit coverage under 327 IAC 15-6 applies to all entities that: 1. 2. 3. 4. 5. are not required to obtain an individual NPDES permit under 327 IAC 15-2-9(b); meet the general permit rule applicability requirements under 327 IAC 15-2-3; have not received an approved “No Exposure” exclusion for storm water permitting; have a discharge composed entirely of storm water and allowed non-storm water contributions; and operate, maintain, or otherwise have responsibility for an industrial facility meeting the applicability requirements of 327 IAC 15-6-2. Initial NOI letter Renewal NOI letter Amended NOI letter Was there a change of ownership since the last NOI letter? Yes No PART A: GENERAL INFORMATION FOR FACILITY 1. Name of facility 2. Standard Industrial Classification (SIC) Code for the facility (4 digits) 3. Address of facility location City: 4. ZIP code: County: Longitude and Latitude of the approximate center of the facility to the nearest fifteen (15) seconds Decimal Longitude: Decimal Latitude: LONGITUDE Degrees LATITUDE Minutes ° Seconds ’ Degrees ” 5. Telephone number of On-site Facility Contact 8. Facsimile numbr of On-site Facility Contact (if applicable) 9. ” Title of On-site Facility Contact 7. Seconds ’ Name of On-site Facility Contact 6. Minutes ° E-mail address of On-site Facility Contact (if applicable) 10. Has the facility been issued a past or present NPDES permit? (if yes, provide permit numbers) Permit Number(s): IN- IN- IN- Yes No IN- 11. Brief narrative description of the industrial processes performed at the facility (attach additional sheets if necessary) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter PART B: GENERAL INFORMATION FOR RESPONSIBLE INDIVIDUAL 12. Name of Responsible Individual 13. Title of Responsible Individual 14. Mailing address of Responsible Individual City State ZIP code 15. Telephone number of Responsible Individual 16. Facsimile number of Responsible Individual (if applicable) 17. E-mail address of Responsible Individual (if applicable) PART C: GENERAL INFORMATION FOR BILLING CONTACT 18. Name of Billing Contact 19. Title of Billing Contact 20. Mailing address of Billing Contact City State ZIP code 21. Telephone number of Billing Contact 22. Facsimile number of Billing Contact (if applicable) 23. E-mail address of Billing Contact (if applicable) PART D: (CORPORATIONS ONLY) GENERAL INFORMATION FOR REGISTERED AGENT 24. Name of Registered Agent 25. Title of Registered Agent 26. Mailing address of Registered Agent City State ZIP code 27. Telephone number of Registered Agent 28. Facsimile number of Registered Agent (if applicable) 29. E-mail address of Registered Agent (if applicable) PART E: GENERAL INFORMATION FOR STORM WATER DISCHARGE(S) FROM FACILITY 30. Identification of the number and location of each outfall where storm water exposed to industrial activity discharges to a water of the state, including a narrative description of the industrial activity associated with the drainage area of each identified outfall 31. Identification of any outfalls, listed above in item 30, that are substantially similar (Include reason as to why outfalls are deemed similar) 32. Identification of the outfall(s) to be monitored as representative of all such discharges 33. Identification of receiving water(s) for the storm water discharge outfall(s) identified above in item 30 34. Does the facility discharge storm water into a municipal separate storm sewer system (MS4)? (If yes, provide the name of the MS4) Yes No Name of the MS4 entity Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter PART F: MATERIALS TO BE SUBMITTED WITH THIS NOI LETTER ► In addition to the information in Parts A, B, C, and D facility representative must provide the following (check when completed) 1) Proof of publication in a newspaper of largest circulation in the affected area. The proof of publication Must include "(Facility name, address, address of the location of the discharging facility, and the stream(s) receiving the discharge(s)) is submitting an NOI letter to notify the Indiana Department of Environmental Management of our intent to comply with the requirements under 327 IAC 15-6 to discharge storm water exposed to industrial activities." Notices without the proper information will not be sufficient, and IDEM will require that a new notice be place in the newspaper. The actual proof of publication from the newspaper should be submitted. If the proof of publication is not available, a legible photocopy of the article, along with the name of the newspaper and the date(s) that the article was run is also acceptable. Example: "Xert Industries (with corporate offices at 10 Willow Lane, Indianapolis, Indiana 46206) is submitting an NOI letter for our facility (located at 5 South Wet Street, Indianapolis, Indiana 46206) to notify the Indiana Department of Environmental Management of our intent to comply with the requirements under 327 IAC 15-6 to discharge storm water exposed to industrial activities. Run-off from the facility will discharge to the White River. Questions or comments should be directed to Walter Water at the above mentioned Xert Industries corporate address." PART G: FEES, CERTIFICATION, AND SIGNATURE • Upon submission of this NOI letter, the responsible individual or registered agent 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) facility location 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 responsible individual or registered agent and approved by IDEM within three (3) days of submittal to IDEM or prior to the NOI letter processing by IDEM, whichever is earlier. • There is also an annual fee of one hundred dollars ($100), for which you will be billed. • Pursuant to 327 IAC 15, the NOI letter is NOT: Transferable from one (1) facility location to another (a new NOI letter is required for each facility location); Transferable from one (1) facility name to another at the same location (a new NOI letter is required for a name change to the facility location). • • Pursuant to 327 IAC 15, the annual fee requirement is terminated: When a written request for the “no exposure” exclusion from the facility is approved by IDEM; When a period of five (5) years passes, from the date of the NOI letter submittal. (Within ninety (90) days from the five (5) year permit term ending, a new, reapplication NOI letter must be submitted.). • 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 will result in a delay in processing and issuance of your Notice of Sufficiency. • Unless not applicable, all information requested in this NOI letter is MANDATORY for the administration and processing of your permit pursuant to 327 IAC 15-6. All data received will be regarded as a public record. ► The persons listed in "Part B: Responsible Individual" 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 Name of Responsible Individual Signature of Responsible Individual Date (mm/dd/year) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter APPENDIX A: SUPPLEMENTARY INSTRUCTIONS Part A, Item #2: Enter the 4-digit Standard Industrial Classification (SIC) code which identifies the facility’s activity. SIC codes can be obtained from the Standard Industrial Classification Manual, 1987, by accessing the Occupational Safety and Health Administration (OSHA) web site at http://www.osha.gov/oshstats/sicser.html, or by contacting the Indiana Department of Workforce Development at 1-317-232-7458. Part A, Item #4: Enter the longitude and latitude of the approximate center of the facility in degrees/minutes/seconds. Longitude and latitude can be obtained from United States Geological Survey (USGS) quadrangle or topographic maps, by calling 1-888-275-8747, or by accessing a locational web site at http://www.geocode.com and conducting a search based on the facility street address. Longitude and latitude of the approximate center of the facility must be converted to degrees, minutes, and seconds for proper entry on the NOI letter. To convert decimal longitude and latitude to degrees/minutes/seconds, follow the steps in the following example: Example: Convert decimal latitude 45.1234567 to degrees, minutes, and seconds a) b) c) d) e) The numbers to the left of the decimal point are the degrees: 45. To obtain minutes, multiply the first four numbers to the right of the decimal point by 0.006: 1234 x 0.006 = 7.404. The numbers to the left of the decimal point in the result obtained in (b) are the minutes: 7. To obtain seconds, multiply the remaining three numbers to the right of the decimal from the result obtained in (b) by 0.06: 404 x 0.06 = 24.24. Since the numbers to the right of the decimal point are not used, the result is 24 seconds. The conversion for 45.1234567 = 45 degrees, 7 minutes, and 24 seconds. Part A, Item #11: Enter a brief narrative description of the industrial processes that occur at the facility. This description should include: a) b) c) raw materials; processes (including general chemical additives) utilized to created intermediary or final products; and products created. To provide an adequate narrative description, please create a similar text format to the following example: Example: Lead-acid battery reclamation The facility utilizes a battery breaker and secondary lead smelter to create lead ingots. The lead ingots are sold for use in battery production. The broken battery casings, other solid components, and waste acid are disposed of as wastestreams. Part B: For purposes of this rule, “responsible individual” means: (A) For a corporation, (1) a president, secretary, treasurer, any vice president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision making functions for the corporation; or (2) the manager of one or more manufacturing, production, or operating facilities employing more than two hundred fifty (250) persons or having gross annual sales or expenditures exceeding twenty-five million dollars ($25,000,000), if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. (B) For a partnership or sole proprietorship, a general partner or the proprietor, respectively. (1) a general partner or the proprietor, respectively. Part C: An annual fee of one hundred dollars ($100) will be billed to the facility. Enter billing contact information to ensure the bill is mailed to the appropriate individual or department. Part D: For purposes of this rule, “registered agent” means an individual who: (A) is the corporation’s agent for service of process, notice, or demand required or permitted by law to be served on the corporation; and (B) is registered along with a business office with the Indiana Secretary of State’s Office. Part E, Item #30: Enter a narrative description of the number of outfalls, including a given name, location, and a detailed description of industrial activity related to each. Outfall is defined in 327 IAC 15-6 as a point source discharge from a point source. Point source outfalls include any of the following, but are not limited to, from which pollutants are or may be discharged: Pipe, ditch, channel, tunnel, conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, landfill leachate system, vessel, or other floating craft. Drainage is defined in 327 IAC 15-6 as the flow patterns of storm water run-off. Part E, Item #31: Clearly state which (if any) outfalls are substantially similar. Include a clear and descriptive statement on why these outfalls are substantially similar. When a facility has more than one outfall which have substantially similar storm water discharges based on consideration of industrial activity, significant materials, and management, one outfall may be selected to represent the group of similar outfalls provided that this strategy has been clearly stated. All outfalls should be included on the drainage base map and documented within the Storm Water Pollution Prevention Plan (SWPPP). Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter Part E, Item #32: Enter the given name of each outfall which will be monitored annually to meet your permit requirements. If the outfall is listed in Item #24, and not listed as being substantially similar in Item #25, then it qualifies as an outfall to be monitored. Each discharge outfall identified or representative discharge outfall, composed entirely of storm water and allowable nonstorm water run-off, shall be monitored. Part E, Item #33: Identify the receiving water body name. The receiving water name is the water body, stream, creek, tributary, etc. in which the outfall(s) listed in Item #30 are draining into or are receiving storm water run-off. Part E, Item #34: Municipal Separate Storm Sewer System (MS4) entities are cities, towns, counties, colleges, universities, correctional facilities, homeowner's associations, conservancy districts, military bases, and hospitals that have responsibility for maintaining or operating a storm water conveyance or system of conveyances. Example: The City of Indianapolis acts as the principal MS4 entity for storm water run-off control within Marion County (excluding the Cities of Beech Grove, Lawrence, Southport and Speedway). Several additional MS4 entities are regulated under 327 IAC 15-13 (Rule 13). An MS4 entity listing for those entities regulated under Rule 13 and additional information about the requirements placed on these entities are available from the Rule 13 web page at www.idem.IN.gov/5437.htm. Part F: Notices without the proper information will not be sufficient, and IDEM will require that a new notice be placed in the newspaper. The actual proof of publication from the newspaper should be submitted. If the proof of publication is not available, a legible photocopy of the article, along with the name of the newspaper and the date(s) that the article was run is also acceptable. Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com