3510-6 Notice of Intent (NOI) Form

2021 MSGP Appendix G – Notice of Intent (NOI) Form

Appendix G - Notice of Intent (NOI) Form

Part 7.2 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your Notice of Intent (NOI). However, if the applicable EPA Regional office grants you a waiver to use a paper NOI form, and you elect to use it, you must complete and submit the following form.

Submission of this NOI constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to the NPDES Multi-Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that the operator identified in Section C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI.

Page G-1 of 11

NPDES FORM 3510-6

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460

NOTICE OF INTENT (NOI) FOR STORMWATER DISCHARGES ASSOCIATED WITH

INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT

OMB No. 2040-0300

Exp. Date:

MM/DD/YYYY

Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to the NPDES Stormwater Multi-Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that the operator identified in Section C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI.

1. Approval to Use Paper NOI 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 NOI form. If you have not obtained a waiver, you must file this form electronically using the NPDES eReporting Tool (NeT) at http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOI-System-for- EPAs-MultiSector-General-Permit.cfm

2. Permit Information NPDES ID (EPA Use Only):

1. Master Permit Number: (see Appendix C of the MSGP for the list of eligible master permit numbers)

2. Are you a new discharger or a new source as defined in Appendix A? YES NO (If yes, skip to Part C of this form).

3. If you are not a new discharger or a new source, have stormwater discharges from your facility been covered previously under an NPDES permit? YES NO

If yes, provide the NPDES ID if you had coverage under EPA’s 2015 MSGP or the NPDES ID if you had coverage under an

EPA individual permit:

4. Do you have a pending enforcement action related to industrial stormwater by EPA, a state, or a citizen (to include both notices of violation (NOVs) by
   EPA or a state and notices of intent to bring a citizen suit)? ¨ YES ¨ NO

1. Facility Operator Information

1. Operator Information: Operator Name:

Mailing Address: Street:

City: State: ZIP Code: -

County or Similar Government Subdivision:

Phone: - - Ext.

E-mail:

2. Operator Point of Contact Information: First Name, Middle Initial, Last Name:

Title:

3. 

   
   

   NOI Preparer Information (Complete if NOI 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:

3. Latitude/Longitude for the facility:

Latitude:

. _ ° N (decimal degrees)

Longitude:

. _ ° W (decimal degrees)

Latitude/Longitude Data Source:

Map

GPS

Other

If you used a USGS topographic map, what was the scale?

Horizontal Reference Datum:

NAD 27

NAD 83

WGS 84

4. Is your facility located on Indian Country lands? YES NO

If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable):

5. Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A? YES NO

6. What is the ownership type of the facility?

Federal Facility (U.S. Government)

Privately Owned Facility

Municipality

County Government

Corporation

State Government

Tribal Government

School District

District

Mixed Ownership (e.g.,

Public/Private)

Municipal or Water District

7. Estimated area of industrial activity at your facility exposed to stormwater: (to the nearest quarter acre)

8. Will you have stormwater discharges from paved surfaces that will be sealed or re-sealed with coal-tar sealcoat where industrial activities are located during coverage under this permit? YES NO

9. Sector-Specific Information

Identify the 4-digit Standard Industrial Classification (SIC) code or 2-letter Activity Code that best represents the products produced or services rendered for which your facility is primarily engaged, as defined in the MSGP, and the applicable sector and subsector of your primary industrial activity (See Appendix D):

Primary SIC Code

:

O

R

OR Primary Activity Code:

Sector:

Subsector:

Identify the applicable sector(s) and subsector(s), SIC codes, and activity codes of any co-located industrial activity for which you are requesting permit coverage:

Sector:

Subsector:

SIC Code

Activity Code:

Sector:

Subsector:

SIC Code

Activity Code:

Sector:

Subsector:

SIC Code

Activity Code:

Sector:

Subsector:

SIC Code

Activity Code:

If you are a Sector A (Timber Products) facility, do you manufacture, use, or store creosote or creosote-treated wood in areas that are exposed to precipitation? YES NO

If you are a Sector S (Air Transportation) facility, do you anticipate using more than 100,000 gallons of pure glycol in glycol-based deicing fluids and/or 100 tons or more of urea on an average annual basis? YES NO

If you are a Sector G (Metal Mining) facility, do you have discharges from waste rock and overburden piles? YES NO

_{Check the type of ore you mine at your facility:}

Tungsten Ore

Nickel Ore

Aluminum Ore

Mercury Ore

Iron Ore

Platinum Ore

Titanium Ore

Vanadium Ore

Molybdenum

Uranium, Radium, and/or Vanadium Ore

Ore not listed

9. Is your facility presently inactive and unstaffed and are there no industrial materials or activities exposed to stormwater?* YES NO

*The requirement for benchmark monitoring does not apply at a facility that is inactive and unstaffed, provided that there are no industrial materials or activities exposed to stormwater. Note that if your facility becomes inactive and unstaffed and/or industrial materials or activities become exposed to stormwater during the permit term, you must submit an NOI modification to reflect the change.

E. Discharge Information

1. By indicating “Yes” below, I confirm that I understand that the MSGP only authorizes the authorized stormwater discharges in Part 1.2.1 and the allowable non-stormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA section 402(k) by disclosure to EPA, state, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the authorized stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must be covered under another NPDES permit. YES

2. Federal Effluent Limitation Guidelines

Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines? YES NO

40 CFR Part/Subpart	Eligible Discharges	Affected MSGP Sector	New Source Date	Check if Applicable
Part 411, Subpart C	Runoff from material storage piles at cement manufacturing facilities	E	2/20/1974
Part 418 Subpart A	Runoff from phosphate fertilizer manufacturing facilities that comes into contact with any raw materials, finished product, by-products or waste products (SIC 2874)	C	4/8/1974
Part 423	Coal pile runoff at steam electric generating facilities	O	11/19/1982 10/8/19741
Part 429, Subpart I	Discharges resulting from spray down or intentional wetting of logs at wet deck storage areas	A	1/26/1981
Part 436, Subpart B, C, or D	Mine dewatering discharges at crushed stone mines, construction sand and gravel mines, or industrial sand mines	J	N/A
Part 443, Subpart A	Runoff from asphalt emulsion facilities	D	7/28/1975
Part 445, Subparts A & B	Runoff from hazardous waste and non-hazardous waste landfills	K, L	2/2/2000
Part 449	Runoff containing urea from airfield pavement deicing at existing and new primary airports with 1,000 or more annual non-propeller aircraft departures	S	6/15/2012

If yes, which effluent limitation guidelines apply to your stormwater discharges?

¹NSPS promulgated in 1974 were not removed via the 1982 regulation; therefore, wastewaters generated by Part 423-applicable
sources that were New Sources under the 1974 regulations are subject to the 1974 NSPS.

3. Receiving Waters Information: (Attach a separate list if necessary): (Attach a separate list if necessary)

ers generated by Part 42

3-applicable sources t

List all of the stormwater discharge points from your facility. Each discharge point must be identified by a unique 3-digit ID (e.g., 001, 002). Also provide the latitude and

longitude in degrees decimal for each discharge point.

For each outfall, provide the following receiving water information:

Provide the name of the first water of the U.S. that receives stormwater directly from the discharge point and/or from the MS4 that the outfall discharges to:

If the receiving water is impaired (on the CWA 303(d) list), list the pollutants that are causing the impairment:

If a TMDL has been completed for this receiving waterbody, providing the following information:

Is this receiving water saltwater or freshwater?

Is this receiving water designated by the state or tribal authority under its antidegradation policy as a Tier 2 (or Tier 2.5) water (water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water) or as a Tier 3 water (Outstanding National Resource Water)?

For freshwater discharges from operators in subsectors K1 and G2 only: is this receiving water still/standing (lentic) (e.g., lake or impoundment) or flowing (lotic) (e.g., river or stream)?

Discharge Point ID

TMDL ID:_____

Pollutants for which there is a TMDL:_____ _____________ _____________

 Freshwater

 Saltwater

 Tier 2/2.5

 Tier 3 (Outstanding National Resource Waters)*

 Still/standing

 Flowing

Latitude

Longitude

Discharge Point ID

TMDL ID:_____

Pollutants for which there is a TMDL:_____ _____________ _____________

 Freshwater

 Saltwater

 Tier 2/2.5

 Tier 3 (Outstanding National Resource Waters)*

 Still/standing

 Flowing

Latitude

Longitude

If substantially identical to other discharge point, list identical discharge point ID:

Discharge Point ID

TMDL ID:_____

Pollutants for which there is a TMDL:_____ _____________ _____________

 Freshwater

 Saltwater

 Tier 2/2.5

 Tier 3 (Outstanding National Resource Waters)*

 Still/standing

 Flowing

Latitude

Longitude

If substantially identical to other discharge point, list identical discharge point ID:

*Note: You are ineligible for coverage if you are a new discharger or new source to waters designated as Tier 3 (Outstanding National Resource Waters) for antidegradation purposes under 40 CFR 131.13(a)(3).

4. Provide the following Information about your discharge point latitude/longitude:
Latitude/Longitude Data Source:
If you used a USGS topographic map, what was the scale?
Horizontal Reference Datum: NAD 27 NAD 83 WGS 84
5. Does your facility discharge into a Municipal Separate Storm Sewer System (MS4)? YES NO
If yes, provide the name of the MS4 operator:
6. If you are subject to benchmark monitoring requirements for a hardness-dependent metal, what is the hardness of your receiving water(s) (see Appendix J)? _______________(mg/L)
7. For facilities in EPA Region 10: Does your facility discharge to a federal CERCLA site listed in Appendix P? YES NO 7.a. If yes, did you notify the EPA Regional Office in advance of filing your NOI, and did the EPA Regional Office determine that you are eligible for permit coverage pursuant to Part 1.1.7*? YES NO * Note: If you discharge to a federal CERCLA site listed in Appendix P, you are ineligible for coverage under this permit unless you notify the EPA Regional Office in advance and the EPA Regional Office determines you are eligible coverage under this permit. In determining your eligibility for coverage under this Part, the EPA Regional Office may evaluate whether you have included adequate controls and/or procedures to ensure that your discharges will not lead to recontamination of aquatic media at the CERCLA Site such that it will cause or contribute to an exceedance of a water quality standard.
8. For operators in New Mexico only: Do you anticipate the discharge of groundwater or spring water from your facility? YES* NO *If yes, below you are asked to provide information on flow and potential to encounter impacted ground or spring water such that there is a potential for contamination. If potential for contamination exists, you will be asked to provide test result data to EPA Region 6 and the NMED Surface Water Quality Bureau. If the test data exceed State Water Quality Standards, the ground or spring water cannot be discharged from the facility into surface waters under this permit. Discharge to surface waters must be conducted under a separate NPDES individual permit to ensure proper treatment and disposal. If disposal will be to the ground surface or in an unlined pond, you must submit a Notice of Intent to Discharge (NOI) to the NMED Ground Water Quality Bureau. For further assistance determining whether your facility may encounter impacted groundwater, the permittee may contact the NMED Ground Water Quality Bureau at (505) 827-2965. 8.a. If yes, what is the anticipated flow rate of the groundwater or spring water? ____________________ 8.b. Provide information on the potential to encounter impacted ground or spring water in the space provided below: 8.c. Using the Mapper tool located at https://gis.web.env.nm.gov/oem/ for reference, check if the following groundwater pollutant sources are located nearby the anticipated source of groundwater or spring water such that there is potential for contamination:
Project Location Relative to a Source of Potential Groundwater Contamination	Constituents likely to be required for testing	Check if applicable
Within 0.5 mile of an open Leaking Tank site	BTEX (Benzene, Toluene, Ethylbenzene, and Xylene) plus additional parameters depending on site conditions.
Within 0.5 mile of an open Voluntary Remediation site	All parameters listed in 20.6.4.900 NMAC, hardness and pH (or an alternate list approved by the NMED SWQB)
Within 0.5 mile of an open RCRA Corrective Action site	All parameters listed in 20.6.4.900 NMAC, hardness and pH (or an alternate list approved by the NMED SWQB)
Within 0.5 mile of an open Abatement site	All parameters listed in 20.6.4.900 NMAC, hardness and pH (or an alternate list approved by the NMED SWQB)
Within 0.5 mile of an open Brownfield site	All parameters listed in 20.6.4.900 NMAC, hardness and pH (or an alternate list approved by the NMED SWQB)
Within 1.0 mile of a Superfund site with associated groundwater contamination	All parameters listed in 20.6.4.900 NMAC, hardness and pH (or an alternate list approved by the NMED SWQB)
EPA approved-sufficiently sensitive methods must be used – approved methods are listed in 40 C.F.R. 136.3.
8.d. If any of the above are applicable, provide a summary of test data indicating the quality of the groundwater or spring water to be discharged:

F. Stormwater Pollution Prevention Plan (SWPPP) Information
1. Has the SWPPP been prepared in advance of filing this NOI, as required? YES NO
2. SWPPP Contact Information:
First Name, Middle Initial, Last Name:
Professional Title:
Phone:		-		-		Ext.
E-mail:
3. SWPPP Availability:
Your current SWPPP or certain information from your SWPPP must be made available through one of the following two options. Select one of the options and provide the required information*: * Note: You are not required to post any confidential business information (CBI) or restricted information (as defined in Appendix A) (such information may be redacted), but you must clearly identify those portions of the SWPPP that are being withheld from public access. Option 1: Maintain a current copy of your SWPPP on an Internet page (Universal Resource Locator or URL). Provide the web address URL:
Option 2: Provide the following information from your SWPPP:
Describe your onsite industrial activities exposed to stormwater (e.g., material storage; equipment fueling, maintenance, and cleaning; cutting steel beams), and potential spill and leak areas:
List the pollutant(s) or pollutant constituent(s) associated with each industrial activity exposed to stormwater that could be discharged in stormwater and any authorized non-stormwater discharges listed in Part 1.2.2:
Describe the control measures you will employ to comply with the non-numeric technology-based effluent limits required in Part 2.1.2 and Part 8, and any other measures taken to comply with the requirements in Part 2.2 Water Quality-Based Effluent Limitations (see Part 6.2.4):
Provide a schedule for good housekeeping and maintenance (see Part 6.2.5.1) and a schedule for all inspections required in Part 3 (see Part 6.2.5.2):
G. Endangered Species Protection
Using the instructions in Appendix E of the MSGP and the Criterion Selection Worksheet in Appendix E, Part E.4, under which criterion listed below are you eligible for coverage under this permit?* You must consider Endangered Species Act listed (ESA-listed) threatened or endangered species and/or designated critical habitat(s) under the jurisdiction of both the U.S. Fish and Wildlife Service (USFWS) and National Marine Fisheries Service (NMFS) and check only the 1 box that is the most conservative criterion that applies to your facility stormwater discharge. *Note: You must use the information from the USFWS IPaC and NMFS Species Directory (see MSGP Appendix E, Part E.4, Step 2 and 3) when determining the presence of ESA-listed species and critical habitat. Attaching aerial image(s) of the site to this NOI is helpful to EPA, USFWS, and NMFS in confirming eligibility under this criterion. Please Note: NMFS’ jurisdiction includes ESA-listed marine and estuarine species that spawn in inland rivers. After you submit your NOI and before your NOI is authorized, EPA may notify you if any additional controls are necessary to ensure your discharges have no likely adverse effects on ESA-listed species and critical habitat.

A. No ESA-listed species and/or critical habitat present in action area. No ESA-listed species and designated critical habitat(s) are likely to occur in your facility’s “action area” as defined in Appendix A. You must provide a description below of the basis for selecting this criterion and provide documentation supporting your eligibility determination in your SWPPP. [Basis statement content: A basis statement supporting the selection of this criterion should identify the USFWS and NMFS information sources used. State resources are not acceptable. Attaching aerial image(s) of the site to this NOI is helpful to EPA, USFWS, and NMFS in confirming eligibility under this criterion. Note that NMFS’ jurisdiction includes ESA-listed marine and estuarine species that spawn in inland rivers.]

B. Eligibility requirements met by another operator under the 2021 MSGP. Your industrial activity’s discharges and discharge-related activities were already addressed in another operator’s valid certification of eligibility for your “action area” under eligibility criteria A, C, D, or E of the 2021 MSGP and you have confirmed that no additional ESA-listed species and designated critical habitat not considered in that certification may be present or located in the “action area” (e.g., due to a new species listing or critical habitat designation). To certify your eligibility under this criterion, there must be no lapse of NPDES permit coverage in the other 2021 MSGP operator’s certification. By certifying eligibility under this criterion, you must comply with any conditions upon which the other operator’s certification was based. You must include in your NOI the NPDES ID assigned to the other 2021 MSGP operator’s authorization under this permit. If your certification is based on another 2021 MSGP operator’s certification under criterion C, you must provide EPA with the relevant supporting information required (i.e., permit tracking number, industrial activity SWPPP, a description of the basis for the criterion selected) in your NOI form. [Basis statement content: A basis statement supporting the selection of this criterion must identify the eligibility criterion of the other MSGP NOI, the authorization date, and confirmation that the authorization is effective.]

If you select criterion B, provide the NPDES ID from the other operator’s notification of authorization under this permit: ________________________

C(1). Facility eligible for Criterion C in the 2015 MSGP with NO CHANGE to listed species, critical habitat, or action area. Your facility was eligible for Criterion C in the 2015 MSGP and there has been no change in your facility’s action area and you have confirmed that there are no additional threatened or endangered species or designated critical habitat under the jurisdiction of the USFWS and/or NMFS in your action area since your certification under Criterion C in the 2015 MSGP. You must provide a description of the basis of this criterion selected on your NOI form and provide documentation supporting your eligibility determination in your SWPPP. [Basis statement content: A basis statement supporting the selection of this criterion must provide the USFWS and/or NMFS resources consulted that helped you determine that there are no additional species and/or critical habitat under the jurisdiction of the Services in your action area.]

C(2). Facility eligible for Criterion C in the 2015 MSGP with CHANGES to listed species, critical habitat, or action area. Your facility was eligible for Criterion C in the 2015 MSGP, but there have been changes in your facility’s action area, and/or there are additional threatened or endangered species and/or designated critical habitat under the jurisdiction of the USFWS and/or NMFS in your action area since your certification under Criterion C under the 2015 MSGP. You must provide a description of the basis of this criterion selected on your NOI form and provide documentation supporting your eligibility determination in your SWPPP. [Basis statement content: A basis statement supporting the selection of this criterion must identify the following:

1. A description of the changes in the facility’s action area (if applicable).

2. The USFWS and/or NMFS resources consulted that helped you determine that additional species and/or critical habitat have been listed/designated by either of the Services in your action area.

3. What ESA-listed species and/or designated critical habitat are located in your “action area”.

4. Distance in miles between your site and the ESA-listed species and/or designated critical habitat within the action area (in miles, state “on site” if the ESA-listed species and/or designated critical habitat is within the area to be disturbed.

5. A description of EPA approved measures you will implement or will continue to implement to ensure no likely adverse effects on ESA-listed species and/or critical habitat.]

C(3). ESA-listed species and/or designated critical habitat likely to occur, but discharges not likely to adversely affect them. ESA-listed threatened or endangered species or their designated critical habitat(s) under the jurisdiction of USFWS and/or NMFS are likely to occur in or near your facility’s “action area,” and you certify to EPA that your industrial activity’s discharges and discharge-related activities are not likely to adversely affect ESA-listed and/or critical habitat. To certify your eligibility under this criterion, you must complete the Criterion C Eligibility Form, which you must submit to EPA at least 30 days prior to filing your NOI for permit coverage. After evaluation of your Criterion C Eligibility Form, EPA may require additional measures that you must implement to avoid or eliminate likely adverse effects on ESA-listed species and/or critical habitat from discharges and discharge-related activities. You may submit your NOI for permit coverage 30 days after submitting to EPA your completed Criterion C Eligibility Form. You must also provide a description of the basis for the criterion you selected on your NOI form and provide documentation supporting your eligibility determination in your SWPPP.
[Basis statement content: A basis statement supporting the selection of this criterion must identify the following:

1. The USFWS and NMFS information resources and expertise (e.g., state or federal biologists) used to arrive at this conclusion. Any supporting documentation should explicitly state that both ESA-listed species and designated critical habitat under the jurisdiction of the USFWS and/or NMFS were considered in the evaluation.

2. What ESA-listed species and/or designated critical habitat are located in your “action area”.

3. Distance in miles between your site and the ESA-listed species and/or designated critical habitat within the action area (in miles, state “on site” if the ESA-listed species and/or designated critical habitat is within the area to be disturbed).

4. A description of EPA approved measures you will implement to ensure no likely adverse effects on ESA-listed species and/or critical habitat

5. A statement affirming that “I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and agree to implement any additional measures that were determined by EPA to be necessary to ensure that my discharges and/or discharge-related activities will not have likely adverse effects on listed species and critical habitat.”

6. Date you sent completed Criterion C Eligibility form to EPA.]

D. ESA Section 7 consultation has successfully concluded. Consultation between a Federal Agency and the U.S. Fish and Wildlife Service and/or the National Marine Fisheries Service under section 7 of the Endangered Species Act has concluded. The consultation must have addressed the effects of the facility’s discharges and discharge-related activities on ESA-listed species and/or designated critical habitat under the jurisdiction of USFWS and/or NMFS. To certify eligibility under this criterion, indicate the result of the consultation:

1. A biological opinion and/or conference opinion that concludes that the action in question (taking into account the effects of your facility’s discharges and discharge-related activities) is not likely to jeopardize the continued existence of ESA-listed species, or result in the destruction or adverse modification of designated critical habitat; or

Written concurrence from the applicable Service(s) with a finding that your facility’s discharges and discharge-related activities are not likely to adversely affect ESA-listed species or designated critical habitat. You must verify that the consultation does not warrant reinitiation under 50 CFR §402.16. If reinitiation of consultation is required, in order to be eligible under this criterion you must ensure consultation is reinitiated and the result of the consultation must be consistent with Criterion D (i), or (ii) above. If eligible under Criterion D, you must also provide supporting documentation for your determination in your NOI and SWPPP, including the Biological Opinion (or ECO tracking number) or concurrence letter. You must include copies of the correspondence between yourself and the USFWS and/or NMFS in your SWPPP and your NOI. [Basis statement content: A basis statement supporting the selection of this criterion should identify the federal action agency(ies) involved, the field office/regional office(s) providing that consultation, any tracking numbers of identifiers associated with that consultation (e.g., IPaC number, ECO number), and the date the consultation was completed.]
E. Issuance of section 10 permit. Potential take is authorized through the issuance of a permit under section 10 of the ESA by the USFWS and/or NMFS, and this authorization addresses the effects of the facility’s discharges and discharge-related activities on ESA-listed species and designated critical habitat. You must include copies of the correspondence between yourself and the participating agencies in your SWPPP and your NOI. [Basis statement content: A basis statement supporting the selection of this criterion should identify whether USFWS or NMFS or both agencies provided a section 10 permit, the field office/regional office(s) providing permit(s), any tracking numbers of identifiers associated with that consultation (e.g., IPaC number, ECO number), and the date the permit was granted.]
H. Historic Preservation
1. If your facility is not located on Indian country lands, is your facility located on a property of religious or cultural significance to an Indian tribe? YES NO
If yes, provide the name of the Indian tribe associated with the property:
2. Using the instructions in Appendix F of the MSGP, under which historic properties preservation criterion listed in Part 1.1.4.6 are you eligible for coverage under this permit (only check 1 box)? A B C D
I. 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, Last Name e I nitia l, L ast N am e:
Title:
Signature:	Date:			/			/
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Instructions for Completing EPA Form 3510-6 Notice of Intent (NOI) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit NPDES Form Date (01/21) Expiration Date (MM/YY) This Form Replaces Form 3510-6 (06/15) Form Approved OMB No. 2040-0300

Who Must File an NOI Form Under section 402(p) of the Clean Water Act (CWA) and regulations at 40 CFR Part 122, stormwater discharges associated with industrial activity are prohibited to waters of the United States unless authorized under a National Pollutant Discharge Elimination System (NPDES) permit. You can obtain coverage under the MSGP by submitting a completed Notice of Intent (NOI) if you are an operator of a facility: that is located in a jurisdiction where EPA is the permitting authority, listed in Appendix C of the MSGP, that discharges stormwater associated with industrial activities, identified in Appendix D of the MSGP, that meets the eligibility requirements in Part 1.1 of the permit, that has developed a stormwater pollution prevention plan (SWPPP) in accordance with Part 6 of the MSGP; and that installs and implements control measures in accordance with Part 2 and Part 8 to meet numeric and non-numeric effluent limits. Completing the Form Obtain and read a copy of the 2021 MSGP, viewable at http://water.epa.gov/polwaste/npdes/stormwater/EPA-Multi- Sector-General-Permit-MSGP.cfm. 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. Section A. Approval to Use Paper NOI 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 NOI 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 http://water.epa.gov/polwaste/npdes/stormwater/Stormwater- Contacts.cfm for a list of EPA Regional Office contacts. Section B. Permit Information Provide the master permit number of the permit under which you are applying for coverage (see Appendix C of the general permit for the list of eligible master permit numbers). You must indicate whether you are a new discharger or a new source (see Appendix A for the definitions). If you are not a new discharger or a new source, you must indicate whether stormwater discharges from your facility have been previously covered under another NPDES permit. If yes, you must provide the unique NPDES ID (i.e., permit tracking number) for the previous permit your facility was covered under. You must also indicate whether you have a pending enforcement action by EPA, a state, or a citizen, related to industrial stormwater. Section C. Facility Operator Information Provide the legal name of the person, firm, public organization, or any other entity that operates the facility described in this NOI. 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. Correspondence for the NOI will be sent to this address. Also provide the name and title for the operator point of contact (note that the point of contact name may be the same as the operator name). If the NOI was prepared by someone other than the certifier (for example, if the NOI was prepared by the facility SWPPP contact or a consultant for the certifier’s signature), include the full name, organization, phone number, and e-mail address of the NOI preparer. Section D. Facility Information Enter the official or legal name and complete 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. Provide the latitude and longitude of your facility in decimal degrees format. The latitude and longitude of your facility can be determined in several different ways, including through the use of global positioning system (GPS) receivers, U.S. Geological Survey (USGS) topographic or quadrangle maps. Refer to http://transition.fcc.gov/mb/audio/bickel/DDDMMSS- decimal.html/ for assistance in providing the proper latitude/longitude format. For consistency, EPA requests that measurements be taken from the approximate center of the facility. Specify which method you used to determine latitude and longitude. If a USGS topographic map is used, specify the scale of the map used. Enter the horizontal reference datum for your latitude and longitude. The horizontal reference datum used on USGS topographic maps is shown on the bottom left corner of USGS topographic maps; it is also available for GPS receivers. Indicate whether the facility is on Indian country lands, and if so, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable). Indicate whether you are seeking coverage under this permit as a “federal operator” as defined in Appendix A. Also check the ownership type for the facility (e.g., Federal Facility, Privately Owned Facility, Municipality, County Government, Corporation, State Government, Tribal Government, School District, District, Mixed Ownership [e.g., public/private], Municipal or Water District). Enter the estimated area of industrial activity at your facility exposed to stormwater to the nearest quarter acre. Indicate whether, during coverage under this permit, there will be stormwater discharges from paved surfaces that will be sealed or re-sealed with coal-tar where industrial activities are located. List the four-digit Standard Industrial Classification (SIC) code or two character activity code that best describes the primary industrial activities performed by your facility under which you are required to obtain permit coverage. Your primary industrial activity includes any activities performed on-site which are (1) identified by the facility’s primary SIC code and included in the descriptions of 40 CFR 122.26(b)(14)(ii), (iii), (vi), or (viii); or (2) included in the narrative descriptions of 40 CFR 122.26(b)(14)(i), (iv), (v), (vii), or (ix). See Appendix D of the MSGP for a complete list of SIC codes and activities codes covered under the MSGP. Also provide the applicable sector and subsector associated with the SIC code or activity code for your primary industrial activities. For a complete list of sector and subsector codes, see Appendix D of the MSGP. If your facility has co-located industrial activities that are not identified as your primary industrial activity, identify the sector, subsector, SIC, and activity codes that describe these other industrial activities.

Instructions for Completing EPA Form 3510-6 Notice of Intent (NOI) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit NPDES Form Date (06/15) Expiration Date (MM/YY) This Form Replaces Form 3510-6 (09/08) Form Approved OMB No. 2040-0004

For Sector A facilities (Timber Products), indicate whether you manufacture, use or store creosote or creosote treated wood in areas that are exposed to precipitation. For Sector S facilities (Air Transportation), indicate whether you anticipate that the entire airport facility will use more than 100,000 gallons of pure glycol in glycol-based deicing fluids and/or 100 tons or more of urea on an average annual basis. If so, additional effluent limits and monitoring conditions apply to your discharge (see Part 8.S of the permit). For Sector G facilities (Metal Mining), check the type of ore(s) mined at the facility. Indicate whether your facility is currently inactive and unstaffed. Note that if your facility becomes inactive and unstaffed and/or industrial materials or activities become exposed to stormwater during the permit term, you must submit an NOI modification to reflect the change. Section E. Discharge Information You must confirm that you understand that the MSGP only authorizes the allowable stormwater discharges listed in Part 1.2.1 and the allowable non-stormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized under the MSGP are not covered by the MSGP or the permit shield provision of the CWA Section 402(k) and they cannot become authorized or shielded by disclosure to EPA, state, or local authorities via the NOI to be covered by the permit or by any other means (e.g., in the SWPPP or during an inspection). If any discharges requiring NPDES permit coverage other than the allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must either be eliminated or covered under another NPDES permit. Depending on your industrial activities, your facility may be subject to federal effluent limitation guidelines which include additional effluent limits and monitoring requirements for your facility. Please review these requirements, described in Part 2.1.3 of the MSGP, and check any appropriate boxes on the NOI form. You must identify all the discharge points from your facility that discharge stormwater. Each outfall must be assigned a unique 3-digit ID (e.g., 001, 002, 003). You must also provide the latitude and longitude for each discharge point from your facility. Indicate whether any discharge points are substantially identical to a discharge point already listed, and identify the discharge point it is identical to. For each unique discharge point you list, you must specify the name of the first water of the U.S. that receives stormwater directly from the discharge point and/or from the MS4 that the discharge point discharges to. You must specify whether any receiving waters that you discharge to are listed as ”impaired” as defined in Appendix A, and the pollutants for which the water is impaired. You must also check identify any Total Maximum Daily Loads (TMDL) that have been completed for any of the waters of the U.S. that you discharge to. For each unique discharge point you must indicate whether the receiving water is saltwater or freshwater, and indicate whether discharges from the facility will enter into a water of the U.S that is designated as a Tier 2, Tier 2.5, or Tier 3 water. A list of Tier 2, 2.5, and 3 waters is provided as Appendix L. If the answer is “yes”, name all waters designated as Tier 2, Tier 2.5, or Tier 3 to which the facility will discharge. Note that you are ineligible for coverage if you are a new discharger or a new source to waters designated as Tier 3 (outstanding national resource waters) for antidegradation purposes under 40 CFR 131.13(a)(3).

If your facility is in subsector K1 or G2, you must also indicate, for each unique discharge point, if the receiving water is still/standing (lentic) (e.g., a lake or impoundment) or flowing (lotic) (e.g., a river or stream). You must also provide information about the discharge point latitude/longitude, including data source, the scale (if applicable), and the horizontal reference datum. See the instructions in Section D for more information about determining the latitude and longitude. Identify whether your facility discharges into a Municipal Separate Storm Sewer System (MS4). If yes, provide the name of the MS4 operator. If you are uncertain of the MS4 operator, contact your local government for that information. If you are subject to any benchmark monitoring requirements for metals (see the requirements applicable to your Sector(s) in Part 8 of the permit), indicate the hardness for your receiving water(s). See Appendix J of the permit for information about determining waterbody hardness. If you are subject to benchmark monitoring requirements for hardness- dependent metals you must also answer whether your facility discharges into any saltwater receiving waters. If our facility is located in EPA Region 10, indicate whether your facility will discharge to a federal CERCLA site listed in Appendix P. Note that if your facility will discharge into a federal CERCLA site listed in Appendix P, you are not eligible for coverage under this permit unless you notify the EPA Regional Office in advance and the EPA Regional Office authorizes overage under this permit after you have included adequate controls and/or procedures designed to ensure that discharges will not lead to recontamination of aquatic media at the CERCLA site such that your discharge will cause or contribute to an exceedance of a water quality standard. Operators in New Mexico, indicate whether you anticipate the discharge of groundwater or spring water from your facility. If yes, you must provide information on flow and potential to encounter impacted ground or spring water such that there is a potential for contamination. You must also use the mapper tool located at https://gis.web.env.nm.gov/oem/ to determine if the groundwater sources listed are located near the anticipated source of groundwater or spring water such that there is potential for contamination. If potential for contamination exists, you must provide a summary of test data indicating the quality of the groundwater or spring water to be discharged. Section F. Stormwater Pollution Prevention Plan (SWPPP) Information All facilities eligible for coverage under this permit are required to prepare a SWPPP in advance of filing the NOI, in accordance with Part 6. Indicate whether the SWPPP has been prepared in advance of filing the NOI. Indicate the contact information (name, phone, and e-mail) for the person who developed the SWPPP for this facility. You identify how your SWPPP information will be made available, consistent with Part 5.4 and 7.3 of the permit. If you are making your SWPPP publicly available on a web site, check Option 1 and provide the appropriate Internet URL address. If you are not providing a URL, check Option 2 and provide the selected SWPPP information on this NOI form. You may copy and paste this information directly from your SWPPP.

Instructions for Completing EPA Form 3510-6 Notice of Intent (NOI) for Stormwater Discharges Associated with Industrial Activity Under the NPDES Multi-Sector General Permit NPDES Form Date (06/15) Expiration Date (MM/YY) This Form Replaces Form 3510-6 (09/08) Form Approved OMB No. 2040-0004

Section G. Endangered Species Protection Using the instructions in Appendix E, indicate the Part 1.1.4.5 criterion (i.e., A, B, C, D, or E) you are eligible under with regard to the protection of federally listed endangered and threatened species and designated critical habitat. A description of the basis for the criterion selected must also be provided. If criterion B is selected, provide the NPDES ID (i.e., permit tracking number) for the other operator who has certified their eligibility under this permit. The NPDES ID was assigned when the operator received coverage under this permit. If criterion C is selected, you must specify the federally-listed species or designated critical habitat that are located in the “action area” of the facility. You must also indicate under which scenario you determined you were eligible to submit your NOI under criterion C using Appendix E, and answer any corresponding questions. If criterion D or E is selected, attach copies of any communications between you and the U.S. Fish and Wildlife Service and National Marine Fisheries Service to this NOI. Section H. Historic Preservation If the project is not located in Indian country lands, indicate whether the project is located on a property of religious or cultural significance to an Indian tribe, and if so, provide the name of the Indian tribe associated with the property. Use the instructions in Appendix F to complete the questions on the NOI form regarding historic preservation. Section I. Certification Certification statement and signature (see Section B.11 of Appendix B of the MSGP for more information). Enter certifier’s printed name, title and email address. Sign and date the form. (CAUTION: An unsigned or undated NOI form will prevent the granting of permit coverage.) Federal statutes provide for severe penalties for submitting false information on this application form. Federal regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which 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. An unsigned or undated NOI form will not be considered eligible for permit coverage. Modifying Your NOI If you have been granted a waiver from your Regional Office from electronic reporting, and if after submitting your NOI you need to correct or update any fields on this NOI form, you may do so by indicating changes on this same form. 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 be 4.1 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. Submitting Your Form If you have been granted a waiver from your Regional Office to submit a paper NOI form, you must send your NOI by mail to one of the following addresses: For Regular U.S. Mail Delivery: Stormwater Notice Processing Center Mail Code 4203M, ATTN: 2021 MSGP Reports U.S. EPA 1200 Pennsylvania Avenue, NW Washington, DC 20460 For Overnight/Express Mail Delivery: Stormwater Notice Processing Center William Jefferson Clinton East Building - Room 7420 ATTN: 2021 MSGP Reports U.S. EPA 1201 Constitution Avenue, NW Washington, DC 20004 Visit this website for instructions on how to submit electronically: http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOI- System-for-EPAs-MultiSector-General-Permit.cfm