2021 MSGP - Appendix G - NOI

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)

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.

NPDES Form 3510-6

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)
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

NPDES
FORM
3510-6

OMB No. 2040-0004
Exp. Date: 7/31/2026

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.

A. 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 underserved 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 https://www.epa.gov/npdes/stormwater-discharges-industrial-activitiesereporting#accessingmsgp

B. Permit Information
1.

NPDES ID (EPA Use Only):

Master Permit Number:

(see Appendix C of the MSGP for the list of eligible master permit numbers)

 YES  NO (If yes, skip to Part C of this form).

2.

Are you a new discharger or a new source as defined in Appendix A?

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

C. Facility Operator Information
1. Operator Information:
Operator Name:
2. 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:

NPDES Form 3510-6

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)

D. Facility Information
1. Facility Name:
2. Facility Address:
Street/Location:
City:

ZIP Code:

State:

County or Similar Government Subdivision:
3. Latitude/Longitude for the facility
Latitude:

Longitude:

° N (decimal degrees)

 Maps

Latitude/Lontitude Data Source:

° W (decimal degrees)

 GPS

 Other

 NAD 83

 WGS 84

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

 NAD 27

Horizontal Reference Datum:

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?
6. What is the ownership type of the facility?

 YES

 NO

 Federal Facility (U.S.

 Privately Owned Facility

 Municipality

 County Government

 Corporation

 State Government

 Tribal Government

 School District

 District

 Mixed Ownership (e.g.,

 Municipal or Water

Government)

Public/Private)

7. Estimated area of industrial activity at your facility exposed to stormwater:

District

(to the nearest quarter acre)

8. Will you have stormwater discharges from paved surfaces that will be initially sealed or re-sealed with coal-tar sealcoat where industrial activities are located
during coverage under this permit?

YES

NO

9. 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

10.--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):
OR

Primary SIC Code:
Sector:

Primary Activity Code:

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
Sector:

Subsector:

Sector:

Subsector:

Sector:

Subsector:

Sector:

Subsector:

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?
Check the type of ore you mine at your facility:

 Tungsten Ore  Nickel Ore

 YES

 NO

 Aluminum Ore

 Iron Ore
 Platinum Ore
 Titanium Ore
 Molybdenum  Uranium, Radium, and/or Vanadium Ore

NPDES Form 3510-6

 Mercury Ore
 Vanadium Ore
 Ore not listed

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)

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 nonstormwater 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

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



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)
List all of the stormwater
discharge points from
your facility. Each
discharge point must be
identified by a unique 3digit ID (e.g., 001, 002).
Also provide the latitude
and longitude in
degrees decimal for
each discharge point.
Discharge
Point ID
Latitude

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?

TMDL ID:_____

 Freshwater  Tier 2/2.5

Pollutants for
which there is a
TMDL:

 Saltwater

Longitude
Discharge
Point ID
Latitude
Longitude

TMDL ID:_____
Pollutants for
which there is a
TMDL:

Longitude

which there is a
TMDL:

 Tier 3 (Outstanding

National Resource Waters)*

 Freshwater  Tier 2/2.5
 Saltwater

If substantially identical to other discharge point, list identical discharge point ID:
Discharge
TMDL ID:_____
 Freshwater
Point ID
Pollutants for
Latitude

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)?

 Saltwater

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)?

 Still/standing
 Flowing
 Still/standing

 Tier 3 (Outstanding

 Flowing

 Tier 2/2.5

 Still/standing

 Tier 3 (Outstanding

 Flowing

National Resource Waters)*

National Resource Waters)*

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).

NPDES Form 3510-6

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Appendix G – Notice of Intent (NOI) Form (as modified)

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
 NO
coverage pursuant to Part 1.1.7*?  YES
* 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:

NPDES Form 3510-6

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)

F. Stormwater Pollution Prevention Plan (SWPPP) Information
1. Has the SWPPP been prepared in advance of filing this NOI,as required?
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:
A.

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:

B.

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:

C.

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):

D.

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 Step 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.

NPDES Form 3510-6

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2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)



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

NPDES Form 3510-6

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Appendix G – Notice of Intent (NOI) Form (as modified)

2. 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 theproperty:
2. Using the instructions in Appendix F of the MSGP, under which historic properties preservation criterion listed in Part 1.1.5 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:
Title:
Signature:

Date: _______ /________ /________

E-mail:

NPDES Form 3510-6

Page G-8 of 11

2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)
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
This Form Replaces Form 3510-6 (06/15)

Form Approved OMB No. 2040-0004

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:

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).

• 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.

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.

Completing the Form
Obtain and read a copy of the 2021 MSGP, viewable at
http://water.epa.gov/polwaste/npdes/stormwater/EPA-MultiSector-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 https://www.epa.gov/npdes/contact-us-stormwater for a list of
EPA Regional Office contacts.

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.

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.
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 reSection B. Permit Information
sealed with coal-tar where industrial activities are located.
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 the four-digit Standard Industrial Classification (SIC) code or two
list of eligible master permit numbers).
character activity code that best describes the primary industrial
activities performed by your facility under which you are required to
You must indicate whether you are a new discharger or a new source
obtain permit coverage. Your primary industrial activity includes any
(see Appendix A for the definitions). If you are not a new discharger
activities performed on-site which are (1) identified by the facility’s
or a new source, you must indicate whether stormwater discharges
primary SIC code and included in the descriptions of 40 CFR
from your facility have been previously covered under another
122.26(b)(14)(ii), (iii), (vi), or (viii); or (2) included in the narrative
NPDES permit. If yes, you must provide the unique NPDES ID (i.e.,
descriptions of 40 CFR 122.26(b)(14)(i), (iv), (v), (vii), or (ix). See Appendix
permit tracking number) for the previous permit your facility was
D of the MSGP for a complete list of SIC codes and activities codes
covered under.
covered under the MSGP. Also provide the applicable sector and
You must also indicate whether you have a pending enforcement subsector associated with the SIC code or activity code for your primary
industrial activities. For a complete list of sector and subsector codes,
action by EPA, a state, or a citizen, related to industrial stormwater.
see Appendix D of the MSGP.
Section C. Facility Operator Information
Provide the legal name of the person, firm, public organization, or any If your facility has co-located industrial activities that are not identified
other entity that operates the facility described in this NOI. An as your primary industrial activity, identify the sector, subsector, SIC, and
operator of a facility is the legal entity that controls the operation of activity codes that describe these other industrial activities.
the facility. Refer to Appendix A of the permit for the definition of
“operator”. Provide the operator’s mailing address, phone number,

NPDES Form 3510-6

Page G-9 of 11

2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)
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
This Form Replaces Form 3510-6 (06/15)

Form Approved OMB No. 2040-0004

For Sector A facilities (Timber Products), indicate whether you
If your facility is in subsector K1 or G2, you must also indicate, for each
manufacture, use or store creosote or creosote treated wood in
unique discharge point, if the receiving water is still/standing (lentic)
areas that are exposed to precipitation.
(e.g., a lake or impoundment) or flowing (lotic) (e.g., a river or stream).
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).

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.

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.

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.

Identify whether your facility discharges into a Municipal Separate Storm
Sewer System (MS4). If yes, provide the name of the MS4 operator. If you
For Sector G facilities (Metal Mining), check the type of ore(s) mined are uncertain of the MS4 operator, contact your local government for
that information.
at the facility.

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).

NPDES Form 3510-6

If you are subject to benchmark monitoring requirements for hardnessdependent 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.
use
the
mapper
tool
located
at
You
must
also
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 6.4 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.

Page G-10 of 11

2021 MSGP

Appendix G – Notice of Intent (NOI) Form (as modified)
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
This Form Replaces Form 3510-6 (06/15)

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.

For a partnership or sole proprietorship: By a general partner or the
proprietor, respectively; or

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.

An unsigned or undated NOI form will not be considered eligible for
permit coverage.

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
If criterion B is selected, provide the NPDES ID (i.e., permit tracking officer having responsibility for the overall operations of a principal
number) for the other operator who has certified their eligibility under geographic unit of the agency (e.g., Regional Administrator of EPA).
this permit. The NPDES ID was assigned when the operator received Include the name and title of the person signing the form and the date
of signing.
coverage under this permit.

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
If criterion D or E is selected, attach copies of any communications correct or update any fields on this NOI form, you may do so by
between you and the U.S. Fish and Wildlife Service and National indicating changes on this same form.
Marine Fisheries Service to this NOI.
Paperwork Reduction Act Notice
Section H. Historic Preservation
This collection of information is approved by OMB under the Paperwork
If the project is not located in Indian country lands, indicate whether Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2040-0004).
the project is located on a property of religious or cultural significance Responses to this collection of information are mandatory (40 CFR
to an Indian tribe, and if so, provide the name of the Indian tribe 122.26). An agency may not conduct or sponsor, and a person is not
associated with the property. Use the instructions in Appendix F to required to respond to, a collection of information unless it displays a
complete the questions on the NOI form regarding historic currently valid OMB control number. The public reporting and
preservation.
recordkeeping burden for this collection of information is estimated to
be 4.1 hours per response. Send comments on the Agency’s need for
Section I. Certification
Certification statement and signature (see Section B.11 of Appendix this information, the accuracy of the provided burden estimates and
B of the MSGP for more information). Enter certifier’s printed name, any suggested methods for minimizing respondent burden to the
title and email address. Sign and date the form. (CAUTION: An Regulatory Support Division Director, U.S. Environmental Protection
unsigned or undated NOI form will prevent the granting of permit Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
coverage.) Federal statutes provide for severe penalties for Include the OMB control number in any correspondence. Do not send
submitting false information on this application form. Federal the completed form to this address.
regulations require this application to be signed as follows:

Submitting Your Form
For a corporation: by a responsible corporate officer, which means: If you have been granted a waiver from your Regional Office to submit
(i) a president, secretary, treasurer, or vice-president of the a paper NOI form, you must send your NOI by mail to one of the
corporation in charge of a principal business function, or any other following addresses:
person who performs similar policy- or decision-making functions for For Regular U.S. Mail Delivery:
the corporation, or (ii) the manager of one or more manufacturing, Stormwater Notice Processing Center
production, or operating facilities, provided, the manager is Mail Code 4203M, ATTN: 2021 MSGP Reports
authorized to make management decisions which govern the U.S. EPA
operation of the regulated facility including having the explicit or 1200 Pennsylvania Avenue,
implicit duty of making major capital investment recommendations, NW Washington, DC 20460
and initiating and directing other comprehensive measures to assure
long-term environmental compliance with environmental laws and For Overnight/Express Mail Delivery:
regulations; the manager can ensure that the necessary systems are Stormwater Notice Processing Center
established or actions taken to gather complete and accurate William Jefferson Clinton East Building - Room
information for permit application requirements; and where authority 7420 ATTN: 2021 MSGP Reports
to sign documents has been assigned or delegated to the manager U.S. EPA
1201 Constitution Avenue,
in accordance with corporate procedures.
NW Washington, DC 20004
Visit this website for instructions on how to submit electronically:
https://www.epa.gov/npdes/stormwater-discharges-industrialactivities-ereporting

NPDES Form 3510-6

Page G-11 of 11