HomeMy WebLinkAbout22- MS4 - Stormwater DischargeAgency Use
Permit No.: MTR04
Date Rec’d
Amount Rec’d
Check No.
Rec’d By
FORM NOI-04
Notice of Intent (NOI) Storm Water Discharges Associated with MS4s MTR040000
The NOI-04 form must be completed by the owner or operator of a permitted Small Municipal Separate Storm Sewer System (MS4) eligible for coverage under the Montana Department of Environmental Quality’s (DEQ) General Permit for Storm Water Discharges Associated with Small MS4s. Please read the attached instructions before completing this form. You must print or type legibly; forms that are not legible, not complete, or unsigned will be returned. You must maintain a copy of the completed NOI-04 form for your records.
Section A – NOI-04 Status (If no prior NOI-04 was submitted, DEQ will assign a permit number)
Permit Number: M T R 0 4 __ __ __ __ New Resubmitted Renewal Modification
Section B – Applicant Information
Small MS4 Name
Contact Person, (name, title)
Mailing Address PO Box 1230
City, State, and Zip Code Bozeman, MT 59715 ___________________________________________________
Phone Number, Email Address 406-582-2916__________________________________________________________
Applying as a Co-permittee? Yes: _________________________________ No(If, yes provide Co-permittee MS4 name in the blank provided. Each co-permittee must submit a separate complete NOI.)
Section C – Small MS4 Information
MS4 Boundary Description _________________________________________________________________
Residential Population _________________________________________________________________
Approximate Square Miles _________________________________________________________________
Link to storm water website and current version of the Storm Water Management Program (SWMP) describing implemented Best Management Practices (BMPs) _________________________________________________________________ (New applicants may skip this requirement if a SWMP or website has not been established)
Attach an organizational chart identifying the primary SWMP coordinator and positions responsible for implementing requirements of the permit. Attached Not Attached
MAP: Include reference to a topographic map extending at least one mile beyond MS4 boundaries that identifies applicable boundaries, drainage patterns, receiving surface water bodies, and all outfalls or point source discharges.
Electronic GIS Hard copy PDFs Link to Shapefiles emailed to: attached herein online maps: _____________________________________________ DEQMPDESDataManagement@mt.gov
Water Protection Bureau
Montana Pollutant Discharge Elimination System
Adam Oliver
City of Bozeman
See SWMP Section 1.5
https://gisweb.bozeman.net/Html5Viewer/?viewer=infrastructure
https://www.bozeman.net/departments/utilities/stormwater
21 sq mi
The area encompassed within City Limits (See attached MS4 Boundary Map)
53,293
0 0 0 2
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DocuSign Envelope ID: F71115DE-6924-4051-96F1-3B0A5E933CB8
Section D – Outfall Descriptions and Locations for Monitoring
Identify current monitoring locations and receiving waters: (If applying as a new MS4 without established monitoring, skip this section)
Outfall Name Latitude Longitude Monitoring Purpose
(select all that apply) Name of Receiving Water
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Storm Event
TMDL-Related
Section E – Additional Information
Is the MS4 sharing responsibility? If yes, attach written acceptance and explanation of shared obligation(s). Yes No
Does the MS4 maintain a list of permits/approvals received or applied for from state or federal agencies? Yes No
I certify that all point source discharges of storm water have been tested or evaluated for the presence of non-storm water discharges that are not covered by an MPDES permit. (Attach a description of any analytical testing or sampling based on the NOI-04 instructions.)
Section F – Certification
All Applicants Must Complete the Following 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, 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. [75-5-633, MCA].
Name (Type or Print)
Title (Type or Print) Phone Number
Signature Date Signed
406-582-2300City Manager
Jeff Mihelich
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See SWMP Sections 2 and 8
See SWMP Section 8
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DocuSign Envelope ID: F71115DE-6924-4051-96F1-3B0A5E933CB8
4/20/2022