6100-28 Annual Report Form

2021 MSGP Appendix I – Annual Report Form

Appendix I - Annual Report Form

Part 7.2 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your Annual Report. However, if you are given a waiver by the EPA Regional Office to use a paper annual report form, and you elect to use it, you must complete and submit the following form.

NPDES FORM 6100-28

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460

ANNUAL REPORT FOR STORMWATER DISCHARGES ASSOCIATED WITH

INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT

OMB No. 2040-0300

Exp. Date: MM/DD/YYYY

1. Approval to Use Paper Annual Report 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 annual report form. If you have not obtained a waiver, you must file this form electronically using the NPDES eReporting Tool (NeT) at https://www.epa.gov/npdes/stormwater-discharges-industrial-activities

2. Permit Information

1. NPDES ID:

3. Facility Information

1. Facility Name:

2. Facility Phone: - - Ext.

3. Facility Mailing Address:

Street:

City: State: ZIP Code: -

County or Similar Government Subdivision:

4. Point of Contact:

First Name, Middle Initial, Last Name:

4. General Findings

1. Provide a summary of your past year’s routine facility inspection documentation, including dates (see Part 3.1.6 of the permit). In addition, if you are an operator of an airport facility (Sector S) that is subject to the airport effluent limitations guidelines, and are complying with the MSGP Part 8.S.8.1 effluent limitation through the use of non-urea-containing deicers, provide a statement certifying that you do not use pavement deicers containing urea (e.g., “Urea was not used at [name of airport] for pavement deicing in the past year and will also not be used in 2021.” (Note: Operators of airport facilities that are complying with Part 8.S.8.1 by meeting the numeric effluent limitation for ammonia do not need to include this statement.)

2. Provide a summary of your past year’s quarterly visual assessment documentation, including dates (see Part 3.2.3 of the permit).
3. Provide a summary of your past year’s corrective action and/or advanced implementation measures (AIM) documentation (See Part 5.1.3 of the permit). (Note: If corrective action is not yet completed at the time of submission of this annual report, you must describe the status of any outstanding corrective action(s).) Note that you must modify your SWPPP based on the corrective actions and deadlines required under Part 5. Also describe any incidents of noncompliance in the past year or currently ongoing, or if none, provide a statement that you are in compliance with the permit.
E. 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:

Instructions for Completing EPA Form 6100-28 Annual Report 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 6100-28 (06/15) OMB No. 2040-0300

Who Must File an Annual Report Operators must submit an Annual Report to EPA electronically, per Part 7.4, by January 30th for each year of permit coverage containing information generated from the past calendar year. Completing the Form 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 Annual Report 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 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 your facility. Section C. Facility Information Enter the official or legal name, phone number, and complete street address, including city, state, ZIP code, and county or similar government subdivision, for the facility that is covered by the NPDES ID identified in Section B. If the facility lacks a street address, indicate the general location of the facility (e.g., Intersection of State Highways 61 and 34). Also provide a point of contact name for the facility. Section D. General Findings To complete this section you must provide the following information in your annual report: A summary of your past year’s routine facility inspection documentation, including inspection dates, required by Part 3.1.6 of the permit. A summary of your past year’s quarterly visual assessment documentation, including visual assessment dates, required by Part 3.2.3 of the permit. Information copied or summarized from the corrective action and/or advanced implementation measures (AIM) documentation required per Part 5.1.3 (if applicable). If corrective action and/or advanced implementation measures are not yet completed at the time of submission of this Annual Report, you must describe the status of any outstanding corrective action(s)/advanced implementation measures. You must also describe any incidents of noncompliance in the past year or currently ongoing, or if none, provide a statement that you are in compliance with the permit.

Section E. Certification Information The Annual Report 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. 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 Annual Report form will be considered incomplete. 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 1 hour 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.

Instructions for Completing EPA Form 6100-28 Annual Report 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 6100-28 (06/15) OMB No. 2040-0300
Submitting Your Form If you have been granted a waiver from your Regional Office to submit a paper Annual Report form, you must send your Annual Report form by mail to one of the following addresses: For Regular U.S. Mail Delivery: Stormwater Notice Processing Center Mail Code 4203M, ATTN: 2020 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: 2020 MSGP Reports U.S. EPA 1201 Constitution Avenue, NW Washington, DC 20004 Visit this website for instructions on how to submit electronically: https://www.epa.gov/npdes/stormwater-discharges-industrial-activities

NPDES Form 6100-28 Page I-1 of 5