6100-059 Endangered Species Protection - Criterion C3 Eligib

NPDES FORM 6100-059				UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460 Endangered Species Protection - Criterion C3 Eligibility Form	OMB No. 2040-0300 Exp. Date: MM/DD/YYY
Instructions: In order to be eligible for coverage under Criterion C3, you must complete the Endangered Species Protection section of the Notice of Intent in the NPDES eReporting Tool (NeT-MSGP). Per Part 7.1, you must submit your NOI electronically via NeT-MSGP, unless the EPA Regional Office grants you a waiver from electronic reporting, in which case you may use this paper Criterion C3 form. If using the paper form, you must complete the following form and you must submit it to EPA following the instructions in Section VII a minimum of 30 days prior to filing your NOI for permit coverage. After you submit your form, you may be contacted by EPA with additional measures (e.g., additional stormwater controls or modifications to your discharge- related activities) that you must implement in order to ensure your eligibility under Criterion C3. If after completing this worksheet you cannot make a determination that your discharges and discharge-related activities are not likely to adversely affect ESA listed threatened or endangered species or designated critical habitat, you must submit this completed worksheet to EPA, and you may not file your NOI for permit coverage until you receive a determination from EPA that your discharges and/or discharge-related activities are not likely to adversely affect ESA-protected species and critical habitat. Note: Much of the information needed for this form can be obtained from your draft SWPPP which will be needed when you file your NOI.
Section I. Operator, Facility, and Site Location Information
1) Operator Information
	a) Operator Name: ________________________________________________________________ b) Point of Contact First Name: _______________________________________________ Last Name: _______________________________________________ Phone Number: _________ - _________ - _________________ E-mail: ________________________________________________________________
2) Facility Information
	a) Facility Name: ________________________________________________________________ b) Check which of the following applies:
		I am seeking coverage under the MSGP as a new discharger or as a new source
		I am seeking coverage under the MSGP as an existing discharger and my facility has modifications to its discharge characteristics (e.g., changes in discharge flow or area drained, different pollutants) and/or discharge-related activities (e.g., stormwater controls)
			Indicate the number of years the facility has been in operation: _______ years Provide your NPDES ID (i.e., permit tracking number) from your previous MSGP coverage: _________________________
		I am seeking coverage under the MSGP as an existing discharger and there are no modifications to my facility.
			Indicate the number of years the facility has been in operation: _______ years Provide your NPDES ID (i.e., permit tracking number) from your previous MSGP coverage: _________________________
	c) Facility Address Address 1: ________________________________________________________________ Address 2: ________________________________________________________________ City: _______________________________ State: ________________ Zip Code: ________________
	d) Identify the primary industrial sector to be covered under the 2021 MSGP: SIC Code ________________ or Primary Activity Code ________________ Sector ________________ and Subsector ________________
	e) Identify the sectors of any co-located activities to be covered under the 2021 MSGP: Sector ________________ and Subsector ________________ Sector ________________ and Subsector ________________ Sector ________________ and Subsector ________________ Sector ________________ and Subsector ________________ Sector ________________ and Subsector ________________ Sector ________________ and Subsector ________________
	f) Estimated area of industrial activity exposed to stormwater: ___________ acres

g) Provide a general description of the industrial activities that are taking place at this facility:

3) Receiving Waters Information

List all the stormwater outfalls from your facility.				For each outfall, provide the following receiving water information:
Discharge Point ID	Design Capacity (if known)	Latitude (decimal degrees)	Longitude (decimal degrees)	Name of the receiving water that receives stormwater from the discharge point and/or from the MS4 that the discharge point discharges to	Type of Waterbody (e.g., lake, pond, river/stream/creek, estuarine/marine water)
		_ _ _ . _ _ _ _	_ _ _ . _ _ _ _
		_ _ _ . _ _ _ _	_ _ _ . _ _ _ _
		_ _ _ . _ _ _ _	_ _ _ . _ _ _ _
		_ _ _ . _ _ _ _	_ _ _ . _ _ _ _
		_ _ _ . _ _ _ _	_ _ _ . _ _ _ _

Section II. Action Area

As required in Step 2 of Section E.4 of Appendix E, you must include a map and a written description of the action area of your facility in Attachment 1 of this appendix.

Section III. Listed Species and Critical Habitat

As required in Step 3 of Section E.4 of Appendix E, attach a copy of the species and critical habitat list(s) from the Service(s) to Attachment 2 of this appendix and use the list(s) to complete the rest of this worksheet. For FWS species, include the full printout from your IPaC query/Official Species List in Attachment 2. You can include the map from your IPaC query in Attachment 1.

Note: For the purposes of this permit, “terrestrial species” would not include animal or plant species that 1) spends any portion of its life cycle in a waterbody or wetland, or 2) if an animal, depends on prey or habitat that occurs in a waterbody or wetland. For example, shorebirds, wading birds, amphibians, and certain reptiles would not be considered terrestrial species under this definition. Please also be aware that some terrestrial animals (e.g., certain insects, amphibians) may have an aquatic egg or larval/juvenile phase.

Review your species list in Attachment 2, choose one of the following three statements, and follow the corresponding instructions:



The species list includes only terrestrial species and/or their designated critical habitat. No aquatic or aquatic- dependent species or their critical habitat are present in the action area. You may skip to Section IV of this form. You are not required to fill out Section V.



The species list includes only aquatic and/or aquatic-dependent species and/or their designated critical habitat. No terrestrial species or their critical habitat are present in the action area. You may skip to Section V of this form and are not required to fill out Section IV.



The species list includes both terrestrial and aquatic or aquatic-dependent species and/or their designated critical habitat. You must fill out both Sections IV and V of this form.

Section IV. Evaluation of Discharge-Related Activities Effects

Note: You are only required to fill out this section if your facility’s action area contains terrestrial species and/or their designated critical habitat. If your action area only contains aquatic and/or aquatic-dependent species and/or their designated critical habitat, you can skip directly to Section V.

Most of the potential effects related to coverage under the MSGP are assumed to occur to aquatic and/or aquatic-dependent species. However, in some cases, potential effects to terrestrial species and/or their critical habitat should be considered as well from any discharge-related activities that occur during coverage under the MSGP. Examples of discharge-related activities that could have potential effects on listed terrestrial species or their critical habitat include the storage of materials and land disturbances associated with stormwater management-related activities (e.g., the installation or placement of stormwater control measures).

A. Select the applicable statement(s) below and follow the corresponding instructions:



There are no discharge-related activities that are planned to occur during my coverage under the 2021 MSGP. You can conclude that your discharge-related activities will have no likely adverse effects, and:

• If there are any aquatic or aquatic-dependent species and/or their critical habitat in your action area, you must skip to Section V, Evaluation of Discharge Effects, below.

• If there are no aquatic or aquatic-dependent species, you may skip to Section VI and verify that your activities will have no likely adverse effects. You must submit this form to EPA as specified in Section VII of this form. You may select criterion C on your NOI form and may submit your NOI for permit coverage 30 days after you have submitted this Criterion C Eligibility Form. You must also provide a description of the basis for the criterion you selected on your NOI form, including the species and critical habitat list(s) in your action area, as well as any other documentation supporting your eligibility. You must also include this completed Criterion C Eligibility Form in your SWPPP.



There are discharge-related activities planned as part of the proposal. Describe your discharge- related activities in the following box and continue to (b) below.

B. In order to ensure any discharge-related activities will have no likely adverse effects on ESA- listed threatened and endangered species and/or their designated critical habitat, you must certify that all the following are true:



Discharge-related activities will occur:

• on previously cleared/developed areas of the site where maintenance and operation of the facility are currently occurring or where existing conditions of the area(s) in which the discharge-related activities will occur precludes its use by listed species (e.g., work on existing impervious surfaces, work occurring inside buildings, area is not used by species), and

• if discharge-related activities will include the establishment of structures (including, but not limited to, infiltration ponds and other controls) or any related disturbances, these structures and/or disturbances will be sited in areas that will not result in isolation or degradation of nesting, breeding, or foraging habitat or other habitat functions for listed animal species (or their designated critical habitat), and will avoid the destruction of native vegetation (including listed plant species).



If vegetation removal (e.g., brush clearing) or other similar activities will occur, no terrestrial listed species that use these areas for habitat would be expected to be present during vegetation removal and these activities will not occur within critical habitat.

If all the above are true, you can conclude that your discharge-related activities will have no likely adverse effects, and:

- If there are any aquatic or aquatic-dependent species and/or critical habitat in your action area, you must skip to Section V, Evaluation of Discharge Effects, below.

- If there are no aquatic or aquatic-dependent species, you may skip to Section VI and verify that your activities will have no likely adverse effects. You must submit this form to EPA as specified in Section VII of this form. You may select criterion C on your NOI and may submit your NOI for permit coverage 30 days after you have submitted this completed form. You must also provide a description of the basis for the criterion you selected on your NOI form, including the species and critical habitat list(s), and any other documentation supporting your eligibility. You must also include this completed Criterion C Eligibility Form in your SWPPP.

- If any of the above are not true, you cannot conclude that your discharge-related activities will have no likely adverse effects. You must complete the rest of this form (if applicable) and must submit the form to EPA for assistance in determining your eligibility for coverage.

Section V. Evaluation of Discharge Effects
	Note: You are only required to fill out this section if your facility’s action area includes aquatic and/or aquatic-dependent species and/or their critical habitat. In this section, you will evaluate the likelihood of adverse effects from your facility’s discharges. The scope of effects to consider will vary with each facility and species/critical habitat characteristics. The following are examples of discharge affects you should consider: • Hydrological Effects. Stormwater discharges may adversely affect receiving waters by causing changes in water quality parameters such as turbidity, temperature, salinity, or pH. Stormwater discharges may adversely affect the immediate vicinity of the discharge point through streambank erosion and scour. These effects will vary with the amount of stormwater discharged and the volume and condition of the receiving water. Where a stormwater discharge constitutes a minute portion of the total volume of the receiving water, adverse hydrological effects are less likely. • Toxicity of Pollutants. Pollutants in stormwater may have toxic effects on listed species and may adversely affect critical habitat. Exceedances of benchmarks, effluent limitation guidelines, or state or tribal water quality requirements may be indicative of potential adverse effects on listed species or critical habitat. However, some listed species may be adversely affected at pollutant concentrations below benchmarks, effluent limitation guidelines, and state or tribal water quality standards due to exposures to multiple stressors at the same time. In addition, stormwater pollutants identified in Part 6.2.3.2 of your SWPPP, but not monitored as benchmarks or effluent limitation guidelines, may also adversely affect listed species and critical habitat. As these effects are difficult to analyze for listed species, their prey, habitat, and designated critical habitat, this form helps you to analyze your discharges to make a determination of whether your discharges will likely have adverse effects and whether there are any additional controls you can implement to ensure no likely adverse effects.
		A. Evaluation of Pollutants and Controls to Avoid Adverse Effects. In this section, you must document all of your pollutant sources and pollutants expected to be discharged in stormwater (see Part 8). You must also document the controls you will implement to avoid adverse effects on listed aquatic and aquatic-dependent species and critical habitat. You must include specific details about the expected effectiveness of the controls in avoiding adverse effects to the listed aquatic-and aquatic-dependent species and critical habitat. Attach additional pages if needed.
		Potential Pollutant Source			Potential Pollutants		Controls to Avoid Adverse Effects on Listed Aquatic and Aquatic-Dependent Species and Critical Habitat. Include information supporting why the control(s) will ensure no adverse effects, including any data you have about the effectiveness of the control(s) in reducing pollutant concentrations. You may also attach photos of your controls to this form.
		e.g., vehicle and equipment fueling			e.g., • Oil & grease • Diesel • Gasoline • TSS • Antifreeze		e.g., • Fueling operators (including the transfer of fuel from tank trucks) will be conducted on an impervious or contained pad or under cover • Drip pans will be used where leaks or spills of fuel can occur and where making and breaking hose connections • Spill kit will be kept on-site in close proximity to potential spill areas • Any spills will be cleaned-up immediately using dry clean-up methods • Stormwater runoff will be diverted around fueling areas using diversion dikes and curbing
		Potential Pollutant Source			Potential Pollutants		Controls to Avoid Adverse Effects on Listed Aquatic and Aquatic-Dependent Species and Critical Habitat.
		Potential Pollutant Source			Potential Pollutants		Controls to Avoid Adverse Effects on Listed Aquatic and Aquatic-Dependent Species and Critical Habitat.
			Check if you are not able to make a preliminary determination that any of your pollutants will be controlled to a level necessary to avoid adverse effects on aquatic and/or aquatic-dependent listed species and their designated critical habitat. You must check in Section VI that you are unable to make a determination of no likely adverse effects and must complete the rest of the form. You must submit your completed form to EPA for assistance in determining your eligibility for coverage.
	B. Analysis of Effects Based on Past Monitoring Data. Select which of the following applies to your facility:
			I have no previous monitoring data for my facility because there are no applicable monitoring requirements for my facility’s sector(s).
			I have no previous monitoring data for my facility because I am a new discharger or a new source, but I am subject to monitoring under the 2021 MSGP. You must provide information to support a conclusion that your facility’s discharges are not expected to result in benchmark or numeric effluent limit exceedances that will adversely affect listed species or their critical habitat:
			My facility has not had any exceedances under the 2015 MSGP of any required benchmark(s) or numeric effluent limits. I comply with the applicable monitoring requirements and have not had any exceedances
			My facility has had exceedances of one or more benchmark(s) or numeric effluent limits under the 2015 MSGP, but I have addressed them during my coverage under the 2015 MSGP, or in my evaluation of controls to avoid adverse effects in (A) above. Describe all actions (including specific controls) that you will implement to ensure that the pollutants in your discharge(s) will not result in likely adverse effects from future exceedances.
			Check if your facility has had exceedances of one or more benchmarks or numeric effluent limits under the 2015 MSGP and you have not been able to address them to avoid adverse effects from future exceedances, or if you are a new discharger or a new source but you are not sure if you can avoid adverse effects from possible exceedances. You must check in Section VI that you are unable to make a determination of no likely adverse effects. You must submit your completed form to EPA for assistance in determining your eligibility for coverage. You may not file your NOI for permit coverage until you are able to make a determination that your discharges will avoid adverse effects on listed species and designated critical habitat.
Section VI. Verification of Preliminary Effects Determination
	Based on Steps I – V of this form, you must verify your preliminary determination of effects on listed species and designated critical habitat from your discharges and/or discharge-related activities:
			Following the applicable Steps in I – V above, I have provided information supporting a preliminary determination that my discharges and/or discharge-related activities are not likely to adversely affect listed species and designated critical habitats.
			Following the applicable Steps in I – V above, I am not able to provide information supporting a preliminary determination that my discharges and/or discharge-related activities are not likely to adversely affect listed species and designated critical habitats.
	Certification Information
	I 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 gathered and evaluated 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.
	First Name, Middle initial, Last Name
	Title
	Signature:			_________________________________________________________________________________		Date:
	E-mail:

Section VII. Criterion C Eligibility Form Submission Instructions
	Only if the applicable EPA Regional Office has granted you a waiver from electronic reporting, you must submit this completed form to EPA at [email protected], including any attachments and any additional information that demonstrates how you will avoid or eliminate adverse effects to listed threatened and endangered species or designated critical habitat (e.g., specific controls you will implement to avoid or eliminate adverse effects). Any missing or incomplete information may result in a delay of your coverage under the permit. If you have made a preliminary determination that your discharges and/or discharge-related activities are not likely to adversely affect listed species and critical habitat, this form must be submitted a minimum of 30 days prior to submitting your NOI for permit coverage under criterion C. Please note that during either the 30-day Criterion C Eligibility Form review period prior to your NOI submission, or within 30 days after your NOI submission and before you have been authorized for permit coverage, EPA may advise you that additional information is needed, or that there are additional measures you must implement to avoid likely adverse effects. If you are unable to make a preliminary determination that your discharges and/or discharge- related activities are not likely to adversely affect listed species and critical habitat, this worksheet must be submitted to EPA, but you may not file your NOI for permit coverage until you have received a determination from EPA that your discharges and/or discharge-related activities are not likely to adversely affect listed species and critical habitat.
	Attachment 1 Include a map and a written description of the action area of your facility, as required in Step 2 of Section E.4 of Appendix E. You may choose to include the map that is generated from the FWS’ on-line mapping tool IPaC (the Information, Planning, and Consultation System) located at http://ecos.fws.gov/ipac/. The written description of your action area that accompanies your action area map must explain your rationale for the extent of the action area drawn on your map. For example, your action area written description may look something like this: The action area for the (name of your facility)’s stormwater discharges extends downstream from the outfall(s) in (name of receiving waterbody) (# of meters/feet/kilometers/miles). The downstream limit of the action area reflects the approximate distance at which the discharge waters and any pollutants would be expected to cause potential adverse effects to listed species and/or critical habitat because (insert rationale). The action area does/does not extend to the (name of receiving waterbody)’s confluence with (name of confluence waterbody) because (insert rationale). Note that your action area written description will be highly site-specific, depending on the expected effects of your facility’s discharges and discharge-related activities, receiving waterbody characteristics, etc.
	Attachment 2 List or attach the list(s) of species and critical habitat in your action area on this sheet, as required in Step 3 of Section E.4 of Appendix E. You must include a list for applicable listed NMFS and USFWS species and critical habitat. If there are listed species and/or critical habitat for only one Service, you must include a statement confirming there are no listed species and/or critical habitat for the other Service. For USFWS species, include the USFWS Official Species List full printout from your IPaC query (including the consultation code and event code at the top of the FWS printout). Note: If your Official Species List from the USFWS indicated no species or critical habitat were present in your action area, include the consultation code and event code that can be found at the top of your Official Species List in your NOI basis statement. If an Official Species List was not available on IPaC, list the contact date, the ecological services field office and the name of the Service staff with whom you corresponded to identify the existence of any USFWS species or critical habitat present in your action area.
	Paperwork Reduction Act Notice This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2040-0300). Responses to this collection of information are mandatory (40 CFR 122.26). 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. The public reporting and recordkeeping burden for this collection of information is estimated to range from 2.5 to 3 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

NPDES Form 6100-29 Page E-8 of 8