NPDES
Form
3510-6
&ER&
United States Environmental Protection Agency
Washington, DC 20460
Notice of Intent for Storm Water Discharges Associated with
INDUSTRIAL ACTIVITY Under the Multi-sector NPDES General Permit
Form Approved
OMB No. 2040-0086
Submission of this completed Notice of Intent (NOI) constitutes notice that the entitiy in Section B intends to be authorized
to discharge pollutants to waters of the United States, from the facility or site identified in Section C, under EPA's Storm
Water Multi-sector General Permit (MSGP). Submission of the NOI also constitutes notice that the party identified in
Section B of this form has read, understands, and meets the eligibility conditions of Part I of the MSGP; agrees to comply
with all applicable terms and conditions of the MSGP; understands that continued authorization under the MSGP is contigent
on maintaining eligibility for coverage, and that implementation of the permittee's pollution prevention plan is required two
days after a complete NOI is mailed. In order to be granted coverage, all information required on this form must be
completed. Please read and make sure you comply with all permit requirements, including the requirement to prepare and
implement a storm water pollution prevention plan.
A. Permit Selection
If new, enter generic permit, otherwise enter previous permit: L
I I I I
_L
New Permit Number
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Instructions for Completing the Notice of Intent for Storm Water Discharges Associated with
INDUSTRIAL ACTIVITY Under the Multi-sector General Permit
Who Must File a Notice of Intent?
Under the provisions of section 402(p) of the Clean Water Act (CWA) and regulations at 40 CFR
Part 122, Federal law prohibits "point source" discharges of storm water associated with indus-
trial activity to waters of the U.S. without a National Pollutant Discharge Elimination System
(NPDES) permit. If you operate a facility which is described in Part 1.2.1. of the Multi-sector
General Permit (MSGP) or if you have been designated as needing permit coverage for your storm
water discharges by your NPDES permitting authority, and you meet the eligibility requirements
in Part 1 of the permit, you may satisfy your CWA obligation for permit coverage by submitting a
completed NOI to obtain coverage under the MSGP. If you have questions about whether you need
a permit under the NPDES Storm Water Program, contact your NPDES permitting authority (i.e.,
your EPA Regional storm water coordinator or your State water pollution control agency).
One NOI must be submitted for each facility or site for which you are seeking permit coverage.
Only one NOI need be submitted to apply for coverage for all of your activities at each facility (e.g.,
you do not need to submit a separate NOI for each type of industrial activity located at a facility
or industrial complex, provided your storm water pollution prevention plan covers each area for
which you are an operator). Finally, the NOI must be submitted in accordance with the deadlines
established in Part 2.1 of the MSGP.
When to File the NOI Form
DO NOT FILE THE NOI UNTIL YOU HAVE OBTAINED A COPY OF THE MULTI-SECTOR
GENERAL PERMIT. You will need it to determine your eligibility, prepare your storm water pollu-
tion prevention plan, and correctly answer all questions on the NOI form — all of which must be
done before you can sign the certification statement on the NOI in good faith (and without risk of
committing perjury).
If you have a new facility or are the new operator of an existing facility, this form must be
postmarked at least 48 hours before you need permit coverage. If your facility was covered under
the 1995 Multi-sector General Permit or if you are currently operating without a permit, see Part 2.1
of the MSGP for your deadlines. CAUTION: You must allow enough lead time to gather the
information necessary to complete the NOI (especially that related to determining eligibility with
regards to endangered species and historic properties) and prepare the pollution prevention plan
required by Part 4 of the MSGP prior to submitting your NOI.
Where to File the NOI Form (NOI Procesing Center's Toll Free Number: (866) 352-7755)
Do not send Storm Water Pollution Prevention Plans (SWPPPs) to these addresses.
NOIs sent reglar mail: NOIs sent overnight/express:
Storm Water Notice of Intent (4203M) Storm Water Notice of Intent
USEPA EPA East Building, Rm. 7420
1200 Pennsylvania Avenue, NW 1201 Constitution Avenue, NW
Washington, DC 20460 Washington, DC 20004
(For overnight/express delivery of NOIs, add the phone number (202) 564-9545)
NOTE: While not currently available, EPA is exploring the possibility of offering the option to
complete the NOI form electronically online via the Internet. If this option does become available,
directions will be posted on EPAs web site. To check on the availability of the alternative Online
NOI, please visit http://www.epa.gov/hpdes/stontiwater. If the Online NOI is not available,
you must file the NOI at the above address.
If your facility discharges through a municipal separate storm sewer system (MS4) that is
permitted as a medium or large MS4 underthe NPDES Storm Water Program, you must also submit
a signed copy of the NOI to the operator of that MS4, in accordance with the deadlines established
in Part 2.1 of the permit.
Completing the NOI 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 one space for breaks between words. Please
make sure you have addressed all applicable questions and have made a photocopy for your
records before sending the completed form to the address above. Please submit original docu-
ment with signature in ink—DO NOT send copies.
Section A. Permit Selection
If your facility was previously covered by the MSGP 1995 Permit, and you are transferring to
the October 29,2000 version of the MSGP (MSGP 2000), then you must indicate the MSGP 1995
permit number assigned to you by the Storm Water Notice of Intent Center.
If your facility was not previously covered by the MSGP 1995 Permit, and you are applying
for new coverage under the MSGP 2000 Permit, you must indicate the "generic" permit number
covering your facility area. You will find your generic permit number in the MSGP 2000 Permit,
Federal Register, Vol. 65, No. 210, Monday, October 30, 2000, on pages 64802-64803. (As an
example, the generic permit number for an industrial site in Puerto Rico would be PRR05*###.)
The MSGP 2000 Permit is available online at:
http://cfpub epa gov/npdes/stormwater/msgp cfm?program_id=6
Section B. Facility Operator Information
1. Provide the legal name of the person, partnership, co-partnership, firm, company, corboration,
association, joint stock company, trust, estate, governmental entity, or other legal entity that
operates the facility or site described in this application. The name of the operator may or may
not be the same as the name of the facility. The responsible party is the legal entity that controls
the facility's operation, rather than the plant or site manager.
2. Provide the telephone number of the facility operator.
3. Provide the mailing address of the facility operator. Include the street address or P.O. Box, city,
state, and zip code. All correspondence regarding the permit will be sent to this address, not
the facility address in Section C.
4. Indicate the legal status of the facility operator as a Federal, State, Tribal private, or other
public entity (other than Federal or State). This refers only to the operator, not the owner or the
land the facility or site is located upon.
Section C. Facility/Site Information
1. Enter the official or legal name of the facility or site.
2. Enter the complete street address (if no street address exists, provide a geographic description
[e.g., Intersection of Routes 9 and 55]), city county, state, and zip code. Do not use a P.O. Box.
Enter the latitude and longitude of the approximate center of the facility or site in degrees/
minutes/seconds. Latitude and longitude can be obtained from U.S. Geological Survey (USGS
quadrangle or topographic maps, by using a GPS unit, by calling 1-(888) ASK-USGS, by search-
ing for your facility's address on several commercial "map" sites on the Internet, or by access-
ing the the Census Bureau Internet site: http://www.census.gov/cgi-bin/gazetteer.
3. If you are filing as a co-permittee and a storm water general permit number has been issued to
the co-permittee, enter the number in the space provided.
4. Indicate whether the facility is located on Indian Country lands (e.g., a federally recognized
reservation, etc,).
5. Indicate whether the facility or site discharges storm water into a receiving water(s)
and/or a municipal separate storm sewer system (MS4). Enter the name(s) of the closest receiv-
ing water(s) and/or the MS4 (An MS4 is defined as a conveyance or system of conveyances
(including roads with drainage systems, municipal streets, catch basins, curbs, gutters, ditches,
man-made channels, or storm drains) that is owned or operated by a state, city, town, borough,
county, parish, district, association, or other public body and is designed or used for collecting
or conveying storm water.)
6. List your primary and secondary four 4-digit Standard Industrial Classification (SIC) codes or
2-character Activity Codes that best describe the principal products or services provided at the
facility or site identified in Section C of this application. For industrial activities defined in 40
CFR 122.26(b)(lf)(i)-(ix) and (xi) that do not have SIC codes that accurately describe the prin-
cipal products produced or services provided, use the following 2-character Activity Codes:
HZ = Hazardous waste treatment, storage, or disposal facilities, including those that are oper-
ating under interim status or a permit under subtitle C of RCRA [40 CFR 122.26(b)(lf)(iv)j;
LF = Landfills, land application sites, and open dumps that receive or have received any
industrial wastes, including those that are subject to regulation under subtitle D of RCRA [40
CFR122.26(b)(lf)(v)J;
SE = Steam electric power generating facilities, including coal handling sites [40 CFR
122.26(b)(lf)(vii)j;
TW = Treatment works treating domestic sewage or any other sewage sludge or wastewater
treatment device or system, used in the storage, treatment, recycling, and reclamation of mu-
nicipal or domestic sewage [40 CFR 122.26(b)(lf)(ix)j; or
Alternatively, if your facility or site was specifically designated by your NPDES permitting
authority (EPA), enter "AD."
Section D. Certification
Certification statement and signature. (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) president, secretary, treasurer, or vice-president of the corporation in charge of a principal busi-
ness 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 recommen-
dations, and initiating and directing other comprehensive measures to assure long term environ-
mental 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; or
For a municipal, State, Federal, or other public facility: by either a principal executive or
ranking elected official.
Paperwork Reduction Act Notice
Public reporting burden for this certification is estimated to average 3.7 hours per certification,
including time for reviewing instructions, searching existing data sources, gathering and maintain-
ing the data needed, and completing and reviewing the collection of information. Burden means the
total time, effort, or financial resources expended by persons to generate, maintain, retain, or
disclose to provide information to or for a Federal agency. This includes the time needed to review
instructions; develop, acquire, install, and utilize technology and systems for the purposes of
collecting, validating, and verifying information, processing and maintaining information, and dis-
closing and providing information; adjust the existing ways to comply with any previously appli-
cable instructions and requirements; train personnel to be able to respond to a collection.of infor-
mation; search data sources; complete and review the collection of information; and transmit or
otherwise disclose the information. 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. Send comments regarding the burden estimate, any other aspect of the collection of
information, or suggestions for improving this form, including any suggestions which may increase
or reduce this burden to: Director, Office of Environmental Information Services, Collection Ser-
vices Division (2823), USEPA, 1200 Pennsylvania Avenue, NW, Washington, DC 20460. Include
the OMB control number of this form on any correspondence. Do not send the completed NOI form
to this address.
EPA Form 3510-6 (Revised 08-2000, Expires 04-2003)
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