2021 Multi-Sector General Permit (MSGP) - Appendix I

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2021 MSGP

Appendix I – Annual Report Form (as modified)

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

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2021 MSGP

Appendix I – Annual Report Form (as modified)
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
ANNUAL REPORT FOR STORMWATER DISCHARGES ASSOCIATED WITH
INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT

NPDES
FORM
6100-28

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

A. 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
obtaineda waiver, you must file this form electronically using the NPDES eReporting Tool (NeT) at https://www.epa.gov/npdes/stormwater-dischargesindustrial-activities

B. Permit Information
1. NPDES ID:

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

D. 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.9 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.9 by meeting the numeric effluent limitation for ammonia do not need to include this statement.)

NPDES Form 6100-28

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2021 MSGP

Appendix I – Annual Report Form (as modified)

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 additional implementation measures (AIM) documentation (See Part 5.3 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, Last Name:
Title:
Signature:

Date: ____ /___ /____

E-mail:

NPDES Form 6100-28

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2021 MSGP

Appendix I – Annual Report Form (as modified)
Instructions for Completing EPA Form 6100-28
Annual Report for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
This Form Replaces Form 6100-28 (06/15) OMB No. 2040-0004

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/contactus-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:
1. A summary of your past year’s routine facility inspection
documentation, including inspection dates, required by Part
3.1.6 of the permit.
2. A summary of your past year’s quarterly visual assessment
documentation, including visual assessment dates, required
by Part 3.2.3 of the permit.
3. Information copied or summarized from the corrective action
and/or additional implementation measures (AIM)
documentation required per Part 5.3 (if applicable). If
corrective action and/or additional 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)/ additional 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.

NPDES Form 6100-28

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:
1. The authorization is made in writing by a person described
above;
2. 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
3. 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.
2040-0004). 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.
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2021 MSGP

Appendix I – Annual Report Form (as modified)
Instructions for Completing EPA Form 6100-28
Annual Report for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
This Form Replaces Form 6100-28 (06/15) OMB No. 2040-0004

Submitting Your Form

For Overnight/Express Mail Delivery:

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:

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

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

NPDES Form 6100-28

Visit this website for instructions on how to submit electronically:
https://www.epa.gov/npdes/stormwater-discharges-industrialactivities-ereporting

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