Rule 6 Notice Of Intent (NOI) Letter {51286}

RULE 6 NOTICE OF INTENT (NOI) LETTER State Form 51286 (R8 / 2-15) Approved by State Board of Accounts, 2010 Mail this form to: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT STORM WATER PROGRAM ­ IGCN, Room 1255 100 North Senate Avenue Indianapolis, IN 46204-2251 Web Access: www.idem.IN.gov/4896.htm INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used to apply for a general NPDES permit pursuant to 327 IAC 15-6. Please type or print in ink. For questions regarding this form, required addenda, and permit requirements contact the IDEM Storm Water Permit Coordinator at telephone number (317) 233-1864 or (800) 451-6027, ext. 31864 (within Indiana) EXCLUSIONS Permit coverage under 327 IAC 15-6 applies to all entities that: 1. 2. 3. 4. 5. are not required to obtain an individual NPDES permit under 327 IAC 15-2-9(b); meet the general permit rule applicability requirements under 327 IAC 15-2-3; have not received an approved "No Exposure" exclusion for storm water permitting; have a discharge composed entirely of storm water and allowed non-storm water contributions; and operate, maintain, or otherwise have responsibility for an industrial facility meeting the applicability requirements of 327 IAC 15-6-2. APPLICATION TYPE (check one) Initial NOI letter Renewal NOI letter Amended NOI letter Was there a change of ownership since the last NOI letter? Yes No PART A: GENERAL INFORMATION FOR FACILITY 1. 2. 3. City: 4. Name of facility Standard Industrial Classification (SIC) Code for the facility (4 digits) Address of facility location ZIP code: County: Longitude and Latitude of the approximate center of the facility to the nearest fifteen (15) seconds Decimal Latitude: LONGITUDE Degrees Minutes Seconds Degrees Decimal Longitude: LATITUDE Minutes Seconds ° 5. 6. 7. 8. 9. Name of On-site Facility Contact Title of On-site Facility Contact ' " ° ' " Telephone number of On-site Facility Contact Facsimile numbr of On-site Facility Contact (if applicable) E-mail address of On-site Facility Contact (if applicable) Yes No IN- 10. Has the facility been issued a past or present NPDES permit? (if yes, provide permit numbers) Permit Number(s): IN- IN- IN- 11. Brief narrative description of the industrial processes performed at the facility (attach additional sheets if necessary) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter PART B: GENERAL INFORMATION FOR RESPONSIBLE INDIVIDUAL 12. Name of Responsible Individual 13. Title of Responsible Individual 14. Mailing address of Responsible Individual City State ZIP code 15. Telephone number of Responsible Individual 16. Facsimile number of Responsible Individual (if applicable) 17. E-mail address of Responsible Individual (if applicable) PART C: GENERAL INFORMATION FOR BILLING CONTACT 18. Name of Billing Contact 19. Title of Billing Contact 20. Mailing address of Billing Contact City State ZIP code 21. Telephone number of Billing Contact 22. Facsimile number of Billing Contact (if applicable) 23. E-mail address of Billing Contact (if applicable) PART D: (CORPORATIONS ONLY) GENERAL INFORMATION FOR REGISTERED AGENT 24. Name of Registered Agent 25. Title of Registered Agent 26. Mailing address of Registered Agent City State ZIP code 27. Telephone number of Registered Agent 28. Facsimile number of Registered Agent (if applicable) 29. E-mail address of Registered Agent (if applicable) PART E: GENERAL INFORMATION FOR STORM WATER DISCHARGE(S) FROM FACILITY 30. Identification of the number and location of each outfall where storm water exposed to industrial activity discharges to a water of the state, including a narrative description of the industrial activity associated with the drainage area of each identified outfall 31. Identification of any outfalls, listed above in item 30, that are substantially similar (Include reason as to why outfalls are deemed similar) 32. Identification of the outfall(s) to be monitored as representative of all such discharges 33. Identification of receiving water(s) for the storm water discharge outfall(s) identified above in item 30 34. Does the facility discharge storm water into a municipal separate storm sewer system (MS4)? (If yes, provide the name of the MS4) Yes No Name of the MS4 entity American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R7 / 11-10) Rule 6 NOI (Notice of Intent) Letter PART F: MATERIALS TO BE SUBMITTED WITH THIS NOI LETTER In addition to the information in Parts A, B, C, and D facility representative must provide the following (check when completed) 1) Proof of publication in a newspaper of largest circulation in the affected area. The proof of publication Must include "(Facility name, address, address of the location of the discharging facility, and the stream(s) receiving the discharge(s)) is submitting an NOI letter to notify the Indiana Department of Environmental Management of our intent to comply with the requirements under 327 IAC 15-6 to discharge storm water exposed to industrial activities." Notices without the proper information will not be sufficient, and IDEM will require that a new notice be place in the newspaper. The actual proof of publication from the newspaper should be submitted. If the proof of publication is not available, a legible photocopy of the article, along with the name of the newspaper and the date(s) that the article was run is also acceptable. Example: "Xert Industries (with corporate offices at 10 Willow Lane, Indianapolis, Indiana 46206) is submitting an NOI letter for our facility (located at 5 South Wet Street, Indianapolis, Indiana 46206) to notify the Indiana Department of Environmental Management of our intent to comply with the requirements under 327 IAC 15-6 to discharge storm water exposed to industrial activities. Run-off from the facility will discharge to the White River. Questions or comments should be directed to Walter Water at the above mentioned Xert Industries corporate address." PART G: FEES, CERTIFICATION, AND SIGNATURE Upon submission of this NOI letter, the responsible individual or registered agent shall pay a fee in the amount of fifty dollars ($50). Make all checks and money orders payable to "IDEM." Pursuant to 327 IAC 15, the fee is NOT: Transferable from one (1) facility location to anoth