6100-29 MSGP Industrial Discharge Monitoring Report Form

P roposed 2020 MSGP Appendix M – Discharge Monitoring Report (DMR) Form

NOTE: EPA proposes the text in this Appendix as part of the Proposed 2020 MSGP.

Proposed Appendix M - Discharge Monitoring Report (DMR) Form

Part 7.1 requires you to use the electronic DMR system to prepare and submit your Discharge Monitoring Report (DMR) form. However, if you are given approval by the EPA Regional Office to use a paper DMR form, and you elect to use it, you must complete and submit the following form.

NPDES FORM 6100-29

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460

MSGP INDUSTRIAL DISCHARGE MONITORING REPORT (DMR) FORM

OMB No. 2040-NEW

1. Approval to Use Paper DMR Form

   1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*? YES NO

If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:

Waiver granted: The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as under-served for broadband Internet access in the most recent report from the Federal Communications Commission.

The owner/operator has issues regarding available computer access or computer capability.

Name of EPA staff person that granted the waiver:

Date approval obtained: / /

* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper DMR form. If you have not obtained a waiver, you must file this form electronically using the NetDMR at http://www.epa.gov/netdmr/

2. Permit Information

1. NPDES ID:

2. Reason(s) for Submission (Check all that apply): Submitting monitoring data (Fill in all Sections).

Reporting no discharge for all outfalls for this monitoring period (Fill in Sections A, B, C, D, E.1, and G).

Reporting that your site status has changed to inactive and unstaffed and there are no industrial materials or activities exposed to stormwater (Fill in Sections A, B, C, D, and F.4 (include date of status change in comment field).

Reporting that your site status has changed to active and/or there are industrial materials or activities exposed to stormwater (Fill in all Sections and include date of status change in comment field in Section F.4).

3. Facility Operator Information

   1. Operator Information

Operator Name:

Mailing Address: Street:

City: State: ZIP Code: -

Phone: - - Ext. E-mail:

2. DMR Preparer (Complete if DMR was prepared by someone other than the certifier):

First Name, Middle Initial, Last Name:

Organization:

Phone: - - Ext.

E-mail:

D. Facility Information

1. Facility Name:

2. Facility Address:

Street/Location:

City:

State:

ZIP Code:

-

County or Similar Government Subdivision:

E. Discharge Information

1. Identify monitoring period:

Check here if proposing alternative monitoring periods due to irregular stormwater runoff. Identify alternative monitoring schedule and indicate for which alternative monitoring period you are reporting monitoring data:

Quarter 1 (January 1 – March 31)

Quarter 1:

From

/

To

/

Quarter 2 (April 1 – June 30)

Quarter 2:

From

/

To

/

Quarter 3 (July 1 – September 30)

Quarter 3:

From

/

To

/

Quarter 4 (October 1 – December 31)

Quarter 4:

From

/

To

/

2. Are you required to monitor for cadmium, copper, chromium, lead, nickel, silver, or zinc in freshwater? Yes (Skip to 3) No (Skip to 4)

3. What is the hardness level of the receiving water?

(mg/L)

4. Does your facility discharge into any saltwater receiving waters? Yes No

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460 MSGP INDUSTRIAL DISCHARGE MONITORING REPORT (DMR)

OMB No. 2040-NEW

F. Monitoring Information

Note: Make additional copies of this form as necessary.

1. Nature of Discharge: Rainfall (Complete line items 2.a., 2.b., & 2.c.) Snowmelt

2.a. Duration of the rainfall event (hours):

2.b. Rainfall amount (inches):

2.c. Time since previous measurable storm event (days):

3.a. Outfall ID (list the same 3- digit outfalls identified on the NOI form

3.b. Check if Any Outfalls are Substantially Identical to Other Outfalls Listed

3.c. Check if No Discharge

3.d. Monitoring Type UBM, SSBM, ELG, S/T, I, O*

3.e. Parameter

3.f. Quality or Concentration

3.g. Units

3.h. Results Description

3.i. Collection Date

3.j. Exceedance due to natural background pollutant levels

3.k. Exceedance due to run-on

3.l Exceedance was a single aberration per Part 5.2.2.1.c.i. AIM Tier 2

3.m Exceedance but discharge does not result in any exceedance of water quality standards per Part 5.2.3.3.b AIM Tier 3

Substantially identical to outfall:

Substantially identical to outfall:

Substantially identical to outfall:

Substantially identical to outfall:

* UBM - Universal benchmark monitoring; SSBM - Sector-specific benchmark monitoring; (ELG) - Annual effluent limitations guidelines monitoring; (S/T) - State- or tribal-specific monitoring; (I) - Impaired waters monitoring; (O) -Other monitoring as required by EPA

4. Comment and/or Explanation of Any Violations (Reference all attachments here)

Instructions for Completing EPA Form 6100-29 Discharge Monitoring Report (DMR) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit Proposed NPDES Form Date (01/20) Expiration Date (##/##) OMB No. 2040-NEW

Who Must Submit A Discharge Monitoring Report to EPA? Facilities covered under the Multi-Sector General Permit (MSGP or permit) that are required to monitor pursuant to Parts 4.2 and 8 of the permit must submit Discharge Monitoring Reports (DMRs) consistent with the reporting requirements specified in Part 7.1 of the permit. Completing the Form Obtain and read a copy of the 2015 MSGP, viewable at https://www.epa.gov/npdes/stormwater-discharges-industrial-activities To complete this form, type or print, using uppercase letters, in the appropriate areas only. Please place each character between the marks. Abbreviate if necessary to stay within the number of characters allowed for each item. Use only one space for breaks between words, but not for punctuation marks unless they are needed to clarify your response. Please submit original document with signature in ink - do not send a photocopied signature. Photocopy your DMR form for your records before you send the completed original form to the appropriate address. Section A. Approval to Use Paper DMR Form You must indicate whether you have been granted a waiver from electronic reporting from the EPA Regional Office. Note that you are not authorized to use this paper DMR form unless the EPA Regional Office has approved its use. Where you have obtained approval to use this form, indicate the waiver that you have been granted, the name of the EPA staff person who granted the waiver, and the date that approval was provided. See https://www.epa.gov/npdes/contact-us-stormwater for a list of EPA Regional Office contacts. Section B. Permit Information Provide the NPDES ID (i.e., NOI tracking number) assigned to the facility for which this DMR is being submitted. Indicate your reason(s) for submitting this DMR by checking all boxes that apply. The reasons for submission are defined as follows: Submitting monitoring data: For each storm sampled, submit one DMR form with data for all outfalls sampled. Select this reason even if you only have monitoring data for some of your outfalls (i.e., some outfalls did not discharge). If you select this reason you are required to complete all Sections of the form. Reporting no discharge for all outfalls for this monitoring period: Indicates that there were no discharges from all outfalls during this monitoring period. If you select this reason you are only required to complete Sections A, B, C, D, E.1, and G. Reporting that your site status has changed to inactive and unstaffed and there are no industrial materials or activities exposed to stormwater: Indicates that your facility is currently inactive and unstaffed and there are no industrial materials or activities exposed to stormwater (See Part 4.2.1.3 of the permit for more information). If you select this reason you are only required to complete Sections A, B, C, D, and F.4 (include date of status change in comment field). Reporting that your site status has changed from inactive to active and/or there are industrial materials or activities exposed to stormwater: Indicates that your facility is currently active (See Part 4.2.1.3 of the permit for more information). If you select this reason you are required to complete all Sections of the form and include date of status change in the comment field in Section F.4.

Section C. Facility Operator Information. Provide the legal name of the person, firm, public organization, or any other entity that operates the facility for which this DMR is being submitted. An operator of a facility is the legal entity that controls the operation of the facility. Refer to Appendix A of the permit for the definition of “operator”. Provide the operator’s mailing address, phone number, and e-mail. The operator information in this Section should match the operator information provided on your NOI form. Provide the name, organization, phone number, an email address for the person who prepared this DMR form. Section D. Facility Information Enter the official or legal name and complete street address, including city, state, ZIP code, and county or similar government subdivision of the facility. If the facility lacks a street address, indicate the general location of the facility (e.g., Intersection of State Highways 61 and 34). Complete facility information must be provided for permit coverage to be granted. The facility information in this Section should match the facility information provided on your NOI form. Section E. Discharge Information. Indicate the appropriate monitoring period (Quarter 1, 2, 3, or 4) covered by the DMR. “Alternative” monitoring periods can apply to facilities located in arid and semi-arid climates, or in areas subject to snow or prolonged freezing. To use alternative monitoring periods, you must provide a revised monitoring schedule here. If using alternative monitoring periods, identify the first day of the monitoring period through the last day of the monitoring period for each of the four periods. The dates should be displayed as month (Mo) / day (Day). See Parts 4.1.6 and 4.1.7 of the permit for more information. If you are submitting benchmark monitoring data, identify if your facility is required to collect benchmark samples for one or more hardness-dependent metals (i.e., cadmium, copper, lead, nickel, silver, and zinc). If you select “yes” to this question provide the hardness level of the receiving water (in mg/L)). If you select “no” to this question, you must identify if your facility discharges into any saltwater receiving waters.

Instructions for Completing EPA Form 6100-29 Discharge Monitoring Report (DMR) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit Proposed NPDES Form Date (01/20) Expiration Date (##/##) OMB No. 2040-NEW

Monitoring Information For the reported monitoring event indicate whether the discharge was from a rainfall or snowmelt event. If you select “rainfall” then indicate the duration (in hours) of the rainfall event, rainfall total (in inches) for that rainfall event, and time (in days) since the previous measurable storm event in line items 2.a-c. For both rainfall and snowmelt monitoring, you must identify the date of collection for the monitoring event in column 3.i. of the table. If the discharge occurs during a period of both rainfall and snowmelt, check both the rainfall and snowmelt boxes and report the appropriate rainfall information in item 2.a-c. To report multiple monitoring events in the same reporting period, copy this form and enter each monitoring event separately with data for all outfalls sampled. Identify all the outfalls from your facility that discharge stormwater. Each outfall must be assigned a unique 3-digit number (e.g., 001, 002, 003), and should match the outfalls identified on your NOI form. If any outfalls are substantially identical, check the box in 3.b and identify the outfall that the outfall in 3.a is substantially identical to. In 3.d – k, you only need to provide benchmark monitoring data for one of the outfalls. For any outfall for which there was no discharge during the monitoring period, check the box in 3. In 3.d, identify the type of monitoring using the specified codes, in parentheses, below: (QBM) – Quarterly benchmark monitoring (ELG) – Annual effluent limitations guidelines monitoring; (S/T) – State- or Tribal-specific monitoring; (I) – Impaired waters monitoring; or (O) – Other monitoring as required by EPA. In 3.e, enter each “parameter” (or “pollutant”) monitored. For QBM and ELG monitoring, use the same parameter name as in Part 8 of the permit. In 3.f., enter a sample measurement value for each parameter analyzed and required to be reported. Enter “ND” (i.e., not detected) for any sample results below the method detection limit or “BQL” (i.e., below quantitation limit) for sample results above the detection limit but below the quantitation limit. In 3.g., enter the units for sample measurement values (i.e., “mg/L” for milligrams per liter) for each parameter analyzed and required to be reported. For monitoring results reported as ND or BQL this space will be left blank and the units will be reported in Column 3.f. 3.h. must be completed for any monitoring results reported as ND or BQL in the “Quality or Concentration” column. For ND, report the laboratory detection level and units in this column. For BQL, report the laboratory quantitation limit and units in this column. In 3.i. identify the sampling date for each parameter monitoring result reported on this form. 3.j. Exceedance due to natural background pollutant levels: Check box if following the first 4 quarters of benchmark monitoring (or sooner if the exceedance is triggered by less than 4 quarters of data) you have determined that the exceedance of the

benchmark is attributable solely to the presence of that pollutant in the natural background for that discharge point and any substantially identical discharge points, or for impaired waters monitoring, the presence of the pollutant is caused solely by natural background, provided that all of the conditions in Part 5.2.4.1 are met. 3.k Exceedance due to run-on: Check box if you can demonstrate and obtain EPA agreement that run-on from a neighboring source (e.g., a source external to your facility) is the cause of the exceedance, provided that the conditions in Part 5.2.4.2 are met. 3.l. Exceedance was a single aberration per Part 5.2.2.1.c.i. AIM Tier 2: Check box if one single sampling event is over 8 times the benchmark threshold and you have immediately documented per Part 5.3 that the single event was an aberration and met all other conditions in Part 5.2.2.1.c.i. 3.m. Exceedance but discharge does not result in any exceedance of water quality standards per Part 5.2.3.3.b AIM Tier 3: Check box if you can demonstrate through an analysis that an exceedance triggering AIM requirements does not result in any exceedance of applicable water quality standards, provided that all the conditions in Part 5.2.3.3.b are met. Where violations of the permit requirements are reported, include a brief explanation to describe the cause and corrective actions taken, and reference each violation by date. Also, this section should include any additional comments such as are required when changing site status from inactive and unstaffed to active or vice versa. Attach additional pages if you need more space. Attach additional copies of Section F as necessary to address all outfalls and parameters. Section G. Certification Information DMRs must be signed by a person described below, or by a duly authorized representative of that person. For a corporation: By a responsible corporate officer. For the purpose of this Section, a responsible corporate officer means: (i) a president, secretary, treasurer, or 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 (ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. For a partnership or sole proprietorship: By a general partner or the proprietor, respectively; or For a municipality, state, federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this Part, a principal executive officer of a federal agency includes (i) the chief executive officer of the agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrator of EPA). Include the name and title of the person signing the form and the date of signing.

Instructions for Completing EPA Form 6100-29 Discharge Monitoring Report (DMR) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit Proposed NPDES Form Date (01/20) Expiration Date (##/##) OMB No. 2040-NEW

A person is a duly authorized representative only if: The authorization is made in writing by a person described above; The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, position of equivalent responsibility, or an individual or position having overall responsibility for environmental matters for the company, (A duly authorized representative may thus be either a named individual or any individual occupying a named position.) and The written authorization is submitted to the Director. An unsigned or undated DMR form be considered incomplete. Paperwork Reduction Act Notice Public reporting burden for this form is estimated to average 4.19 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding the burden estimate, any other aspect of the collection of information, or suggestions for improving this form, including any suggestions which may increase or reduce this burden to: Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number of this form on any correspondence. Do not send the completed DMR form to this address. Submitting Your Form If you have been granted a waiver from your Regional Office to submit a paper DMR form, you must send your DMR form by mail to one of the following addresses: Region 1 MSGP Discharge Monitoring Reports (OES4-SMR) EPA New England, Region 1 5 Post Office Square - Suite 100 Boston, MA 02109-3912 Region 2 MSGP Discharge Monitoring Reports 290 Broadway DECA/CAPBS/DMT 21st Floor New York, NY, 10007-1866 Region 3 Nancy Ford U.S. EPA Region 3 1650 Arch Street Mail Code #3WP60 Philadelphia, PA 19103

Region 5 U.S. Environmental Protection Agency Region 5 77 West Jackson Boulevard (WN-16J) Chicago, Illinois 60604 Attn: Brian Bell - Storm Water Coordinator Region 6 U.S. EPA, Region 6 MSGP DMRs Water Enforcement Branch (6EN-WC) 1445 Ross Avenue Dallas, TX 75202 Region 7 Neal Gilbert U.S. Environmental Protection Agency, Region 7 Enforcement Coordination Office 11201 Renner Blvd Lenexa, KS 66219 Region 8 U.S. EPA, Region 8 (ENF-PJ) Attention: DMR Coordinator 1595 Wynkoop Street Denver, CO 80202-1129 Region 9 Sandra Chew U.S. EPA Region 9 Information Management Section, ENF-4-1 75 Hawthorne Street San Francisco, CA 94105 Region 10 U.S. EPA Region 10 Attn: NPDES Data Manager, OCE-101 1200 Sixth Avenue, Suite 900 Seattle, WA 98101 Visit this website for instructions on how to submit electronically: https://www.epa.gov/npdes/stormwater-discharges-industrial-activities

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