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RULE 6 NOTICE OF INTENT (NOI) LETTER
State Form 51286 (R5 / 2-08) Form Approved by State Board of Accounts, 2004 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

For questions regarding this form, contact:
IDEM ­ Rule 6 Coordinator 100 North Senate Avenue, Rm 1255 Mail Code 65-42 Indianapolis, IN 46204 Phone: (317) 233-0202 or (800) 451-6027, ext. 30202 (within Indiana) Web Access:
http://www.in.gov/idem/permits/water/wastewater/wetwthr/storm/rule6.html

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. Return this form, required addenda, and payment by mail to the IDEM Rule 6 Coordinator at the address listed in the box on the upper-right.

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.

Facility name: Primary Standard Industrial Classification (SIC) Code for the facility (4 digits): Facility location address:
City Town Village

ZIP: Of:

County:

4.

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. On-site Facility Contact name: On-site Facility Contact title: On-site Facility Contact telephone number:

'

"

°

'

"

On-site Facility Contact facsimile number (if applicable): Yes No IN-

9. On-site Facility Contact e-mail address (if applicable): 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):

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R5 / 2-08)

Rule 6 NOI (Notice of Intent) Letter

PART B: GENERAL INFORMATION FOR RESPONSIBLE INDIVIDUAL 12. Responsible Individual name: 13. Responsible Individual title:
14. Responsible Individual mailing address: City: State:

ZIP:

15. Responsible Individual telephone number: 16. Responsible Individual facsimile number (if applicable): 17. Responsible Individual e-mail address (if applicable): PART C: (CORPORATIONS ONLY) GENERAL INFORMATION FOR REGISTERED AGENT 18. Registered Agent name: 19. Registered Agent title:
20. Registered Agent mailing address: City: State:

ZIP:

21. Registered Agent telephone number: 22. Registered Agent facsimile number (if applicable): 23. Registered Agent e-mail address (if applicable): PART D: GENERAL INFORMATION FOR STORM WATER DISCHARGE(S) FROM FACILITY 24. 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:

25. Identification of any outfalls, listed above in item 24, that are substantially similar (Include reason as to why outfalls are deemed similar):

26. Identification of the outfall(s) to be monitored as representative of all such discharges: 27. Identification of receiving water(s) for the storm water discharge outfall(s) identified above in item 24:

28. Does the facility discharge storm water into a municipal separate storm sewer system (MS4)? (If yes, provide contact person information): Yes No Contact person for the MS4 entity: Phone number for the MS4 entity contact person:

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R5 / 2-08)

Rule 6 NOI (Notice of Intent) Letter

PART E: 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.

PART F: 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 another; Transferable from one (1) person to another; Transferable to any other type of permit issued by IDEM; or Refundable. Unless requested by the responsible individual or registered agent and approved by IDEM within three (3) days of submittal to IDEM or prior to the NOI letter processing by IDEM, whichever is earlier. · · There is also an annual fee of one hundred dollars ($100), for which you will be billed. Pursuant to 327 IAC 15, the NOI letter is NOT: Transferable from one (1) facility location to another (a new NOI letter is required for each facility location); Transferable from one (1) facility name to another at the same location (a new NOI letter is required for a name change to the facility location). Pursuant to 327 IAC 15, the annual fee requirement is terminated: When a written request for the "no exposure" exclusion from the facility is approved by IDEM; When a period of five (5) years passes, from the date of the NOI letter submittal. (Within ninety (90) days from the five (5) year permit term ending, a new, reapplication NOI letter must be submitted.). Allow a minimum of four (4) weeks for processing the NOI letter information and receipt of your Notice of Sufficiency. Make sure you have completed all appropriate sections of this NOI letter and have included all required addenda. Sign and date the NOI letter and return it to the address shown on page one (1) of this NOI letter. Incomplete or incorrect NOI letters will result in a delay in processing and issuance of your Notice of Sufficiency. Unless not applicable, all information requested in this NOI letter is MANDATORY for the administration and processing of your permit pursuant to 327 IAC 15-6. All data received will be regarded as a public record.

· · · ·

·

The persons listed in "Part B: Responsible Individual" must sign the following certification statement:
"By signing this NOI letter, I hereby 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, 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."

Type or print Responsible Individual Name: Signature of Responsible Individual:

Date: (mm/dd/year)

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF WATER QUALITY State Form 51286 (R5 / 2-08)

Rule 6 NOI (Notice of Intent) Letter

APPENDIX A: SUPPLEMENTARY INSTRUCTIONS

Part A, Item #2: Enter the 4-digit Standard Industrial Classification (SIC) code which identifies the facility's primary activity. SIC codes can be obtained from the Standard Industrial Classification Manual, 1987, by accessing the Occupational Safety and Health Administration (OSHA) web site at http://www.osha.gov/oshstats/sicser.html, or by contacting the Indiana Department of Workforce Development at 1-317-232-7458. Part A, Item #4: Enter the longitude and latitude of the approximate center of the facility in degrees/minutes/seconds. Longitude and latitude can be obtained from United States Geological Survey (USGS) quadrangle or topographic maps, by calling 1-888-275-8747, or by accessing a locational web site at http://www.geocode.com and conducting a search based on the facility street address.
Longitude and latitude of the approximate center of the facility must be converted to degrees, minutes, and seconds for proper entry on the NOI letter. To convert decimal longitude and latitude to degrees/minutes/seconds, follow the steps in the following example:

Example: Convert decimal latitude 45.1234567 to degrees, minutes, and seconds
a) b) c) d) e) The numbers to the left of the decimal point are the degrees: 45. To obtain minutes, multiply the first four numbers to the right of the decimal point by 0.006: 1234 x 0.006 = 7.404. The numbers to the left of the decimal point in the result obtained in (b) are the minutes: 7. To obtain seconds, multiply the remaining three numbers to the right of the decimal from the result obtained in (b) by 0.06: 404 x 0.06 = 24.24. Since the numbers to the right of the decimal point are not used, the result is 24 seconds. The conversion for 45.1234567 = 45 degrees, 7 minutes, and 24 seconds.

Part A, Item #11: Enter a brief narrative description of the industrial processes that occur at the facility. This description should include:
a) b) c) raw materials; processes (including general chemical additives) utilized to created intermediary or final products; and products created.

To provide an adequate narrative description, please create a similar text format to the following example:

Example: Lead-acid battery reclamation The facility utilizes a battery breaker and secondary lead smelter to create lead ingots. The lead ingots are sold for use in battery production. The broken battery casings, other solid components, and waste acid are disposed of as wastestreams. Part B: For purposes of this rule, "responsible individual" means:
(A) For a corporation, (1) a president, secretary, treasurer, any 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

(2) the manager of one or more manufacturing, production, or operating facilities employing more than two hundred fifty (250)
persons or having gross annual sales or expenditures exceeding twenty-five million dollars ($25,000,000), if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. (B) For a partnership or sole proprietorship, (1) a general partner or the proprietor, respectively.

Part C: For purposes of this rule, "registered agent" means an individual who:
(A) is the corporation's agent for service of process, notice, or demand required or permitted by law to be served on the corporation;
and

(B) is registered along with a business office with the Indiana Secretary of State's Office.

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