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Home My WebLink AboutDWQ-2024-005106STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY 195 North 1950 West, P.O. Box 144870, Salt Lake City, Utah 84114-4870 (801)536-4300 Municipal Separate Storm Sewer Systems (MS4’s) Individual Permit Application INSTRUCTIONS ON BACK PAGE Existing Permit No. _______ Submission of this application constitutes notice that the party identified in Section I of this form intends to be authorized by a UPDES permit issued for storm water discharges from Municipal Separate Storm Sewers in the State of Utah. Becoming a permittee obligates such discharger to comply with the terms and conditions of the permit. ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM. Part I. General Information Governmental Entity Name: _______________________________________________________________ Mailing Address: Street __________________________________________________________________ City _________________________________________________State ____Zip Code ________-______ Operator Status (Mark One): Operator Contact Person: Name ______________________________________________________________ Title ______________________________________ Telephone Number ______________________________ Latitude/Longitude at Center of land for which you are requesting authorization to discharge: Latitude __________________________________ Longitude _______________________________________ Population served by your MS4: ____________________ People Storm Water Management Program Responsible Person: Name ________________________________________ Title _______________________________________ Telephone Number _____________________________________ Part II: Outfalls and Receiving Waters Receiving Waters: List all separate storm water outfall receiving waters (all discharges to waters under the definition of waters of the State). If all receiving waters are not known at the time of the application submittal, list known outfalls and update the list on annual reports. (ATTACH ADDITIONAL SHEETS AS NEEDED) OutfallEntity Receiving Water 1. 2. 3. 4. 5. 6. Hospital Prison Military Base College/UniversityOperator Type (Mark One): City County Flood Control District AssociationUDOTSewer District Drainage District Other (list) _____________________________________________________________ Federal State Local Other Public Entity (list) ___________________ Part III. Initial Identification of Best Management Practices (ATTACH ADDITIONAL SHEETS AS NEEDED) 1. Public Education and Outreach on Storm Water Impacts Outreach Techniques Management Practices to Encourage Classroom education/school programs Outreach to commercial entities Printed material Media campaign Classroom educational materials Events and Programs Displays Speakers to community groups Economic incentives Promotional giveaways Others ………………………………………………………………………… Proper lawn and garden care (fertilizer and pesticide use, sweeping, etc.) Low impact development Pet waste management Pollution prevention for businesses Proper disposal of household hazardous wastes Water Conservation Practices Others …………………………………………………………………………… 2. Public Involvement/Participation Involvement Techniques Participation Activities Advisory/partner committees Local storm water contact Public access to documents and information Public review of plans and annual reports Watershed organizations Attitude surveys Community hot lines Stakeholder meetings Others ………………………………………………………………………. Adopt-a-stream Storm drain stenciling Stream/roadway cleanup Volunteer monitoring Wetland plantings Others …………………………………………………………………………… 3. Illicit Discharge Detection and Elimination Detection and Elimination Activities Type of Discharges to Target System mapping Regulatory Control Program Identifying and Eliminating illicit connection procedures Dye testing/Tracing Procedures System inspections Dry Weather Screening Program/ Field Testing Others ……………………………………………………………………… Failing septic systems Illegal dumping Industrial/business connections Recreational sewage Sanitary sewer overflows Wastewater connections to the storm drain system Others ………………………………………………………………………… 4.Construction Site Storm Water Runoff Control Program Activities Best Management Practices Regulatory Control Program Erosion and Sediment Control BMP’s Other Waste Control Program Site Plan Review Procedures Public Information handling Procedures Site Inspection/Enforcement Procedures Other Construction Site Runoff Controls Contractor certification and inspector training Others ……………………………………………………………………… Construction Entrance/Exit Stabilization Perimeter Controls Sediment Retention Structure Requirements Sediment filters and sediment chambers Mulching Requirements Temporary/Permanent Stabilization Requirements Vehicle maintenance and washing areas Cement Truck Washout Area OtherBMP’s ………………………………………………………………………… 5.Post-Construction Storm Water Management in New Development and Redevelopment Community Control Strategy Regulatory Control Program Long Term O& M Procedures Pre-Construction Review of BMP Designs Site Inspections During Construction Post Construction Inspections Others ………………………………………………………………………… Infiltration trench/basin Infrastructure planning storm water inlet specifications Narrower residential streets Open space design Ordinances for post construction runoff Storm water wetland Zoning Others: …………………………………………………………………………… 6. Pollution Prevention/Good Housekeeping for Municipal Operations Employee Training Program Inspection and Maintenance Program Municipal Operations Storm Water Control Others ………………………………………………………………………… Municipal Operations Waste Disposal Flood Management/Assessment Guidelines Others: …………………………………………………………………………. Part IV. Initial Identification of Measurable Goals (Attach additional sheets as needed) 1. Public Education and Outreach on Storm Water Impacts Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: 4. Construction Site Storm Water Runoff Control Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: 2. Public Involvement/Participation Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: 5. Post-Construction Storm Water Management in New Development and Redevelopment Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: 3. Illicit Discharge Detection and Elimination Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: 6. Pollution Prevention/Good Housekeeping for MunicipalOperations Measurable goals (with start and end dates): .................................. ........................................................................................................ ........................................................................................................ ........................................................................................................ ........................................................................................................ Milestones: Year 1: Year 2: Year 3: Year 4: Year 5: Part V. Certification 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 gather and evaluate 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, I certify that 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. Print Name: ____________________________________________________________________________ Signature: _________________________________________________________ Date: ___________________ Part VI: Contract Certification for Co-Permittee SWMP Implementation (ATTACH ADDITIONAL SHEETS AS NEEDED) List entity names responsible for implementation of the SWMP 1._________________________________________2._________________________________________ 3._________________________________________4._________________________________________ 5._________________________________________6._________________________________________ The above entities have entered into an agreement or contract to satisfy the implementation requirements of the Storm Water Management Program listed in the application As stated in the existing agreements (MOU’s) or contracts, the entities have agreed to the following responsibilities. Check the entity numbers (entity numbers correspond to entity name numbers listed above) corresponding with responsibilities, or portions thereof, of each entity entering into this agreement in the table below: RESPONSIBILITY ENTITY a. Public Education and Outreach 1. 2. 3. 4. 5. 6. b. Public Involvement and Participation 1. 2. 3. 4. 5. 6. c. Illicit Discharge Detection and Elimination 1. 2. 3. 4. 5. 6. d. Construction Site Run-off Control 1. 2. 3. 4. 5. 6. e. Post-Construction Storm Water Management in New Development and Redevelopment 1. 2. 3. 4. 5. 6. f. Pollution Prevention/Good Housekeeping for Municipal Operations 1. 2. 3. 4. 5. 6. If any entity is agreeing to accomplish only a portion of a responsibility in the table then explain the responsibility portion (e.g. entity 1 is responsible for storm drain stenciling program in the MS4 area, entity 2 is responsible for conducting phone surveys for item (a) in the table etc.) on a separate sheet. The following statement and the accompanying signatures serve as certification that the agreements (MOU’s) or contracts have been developed and agreed upon for the implementation of the Operator’s (Identified in Part I of the application) SWMP. 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 gather and evaluate 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, I certify that 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. Entity Authorized Signature Date Entity Authorized Signature Date 1. ________________________ 2. ________________________ 3. ________________________ 4. ________________________ 5. ________________________ 6. ________________________ Instructions for Completing the MUNICIPAL SEPARATE STORM SEWER SYSTEMS (MS4) Individual Permit Application Who Must File a MS4 Individual Permit Application If you are an operator of a regulated Phase I MS4 designated for permitting, you must apply for coverage under a UPDES permit, or apply for a modification of an existing UPDES permit. If you have questions about whether you need a permit under the UPDES Storm Water Program, contact the Utah Division of Water Quality. This application must be submitted in accordance with the deadlines established in Part 6.3. of the UPDES MS4 General Permit. When to File the Permit Application DO NOT FILE THE APPLICATION UNTIL YOU HAVE READ A COPY OF YOUR MUNICIPAL SEPARATE STORM SEWER SYSTEM PERMIT. You will need to determine your eligibility, prepare your storm water management plan, and correctly answer all questions on the application form, all of which must be done before you can sign the certification statement on the application in good faith (and without risk of committing perjury). Where to File the Application Form Please submit the original form with signature via the DWQ Electronic Documents Submission Portal: https://deq.utah.gov/water-quality/water-quality-electronic-submissions You can also send by mail or hand deliver to the below address. Remember to retain a copy for your records. Division of Water QualityDepartment of Environmental Quality195 North 1950 WestPO Box 144870Salt Lake City, UT 84114-4870 Completing the Application Form 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. Attach additional pages as needed for detailed explanations of items on the form. Part I. MS4 General Information Provide the legal name of the person, partnership, co-partnership, firm, company, corporation, association, joint stock company, trust, estate, governmental entity, or other legal entity that operates the MS4 described in this application. The responsible party is the legal entity that controls the MS4's operation. Provide the telephone number of the MS4 operator. Provide the mailing address of the MS4 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 MS4 address in Section B. Enter the official or legal name of the MS4. Enter the city or cities, county or counties, and state in which the MS4 is located. Enter the latitude and longitude of the approximate center of the MS4 in degrees/ minutes/seconds. Latitude and longitude can be obtained from U.S. Geological Survey (USGS) quadrangle or topographic maps or by using a GPS unit, calling 1- (888) ASK-USGS, searching for your Facility’s address on several commercial map sites on the Internet, or searching the U.S. Census Bureau database at http:// www.census.gov/cgi-bin/gazetteer. Additionally, estimate the acreage of land area that drains to the MS4. This estimate can be made using topographic maps or topographic data in a geographic information system. Indicate the legal status of the MS4 operator as a Federal, State, private, or other public entity (other than Federal or State). This refers only to the operator, not the owner of the land on which the MS4 is located. Indicate whether the MS4 discharges storm water into one or more receiving water(s). Enter the name(s) of the receiving water(s). Indicate whether the MS4 discharges storm water into one or more receiving water(s). Enter the name(s) of the receiving water(s). Part II. Outfalls and Receiving Waters Indicate all major outfalls (by outfall description) and the receiving water body for each outfall. Indicate whether any of the receiving water bodies are included on the 303(d) list for water quality impairments. Part III. Initial Identification of Management Practices Check the management practices that you have selected to meet each of the minimum measures. If a selected practice is not on the list, check “Other” and write the name of the practice in the space provided. Part IV. Identification of Initial Measurable Goals List the person(s) responsible for implementing or coordinating the storm water management program. Provide a narrative description of the measurable goals that will be used for each of the storm water minimum control measures. Indicate the month and year in which you will start and fully implement each of the minimum control measures, or indicate the frequency of the action in the description. Attach additional pages as necessary. Part V. Certification Certification statement and signature. (CAUTION: An unsigned or undated application form will prevent the granting of permit coverage.) State statutes provide for severe penalties for submitting false information on this application form. State regulations require this application to be signed by either a principal executive or ranking elected official as described in Part 6.8. of the MS4 Permit. Part VI. Contract Certification for Co-Permittee SWMP Implementation Contract certification is required when more than one entity will be implementing the SWMP for the operator filing the application. The form must be completely filled out to clearly identify all coordinating agencies. Additional pages shall be used as necessary to define the responsibilities for each entity in preparation and implementation of the SWMP. The form must be signed by all coordinating entities, certifying that local agreements and/or contracts have been developed and agreed upon.