DEQ Form 605-R04 "Notice of Intent (Noi) for Stormwater Discharges From Small Municipal Separate Storm Sewer Systems (Ms4s) Under Opdes General Permit Okr04" - Oklahoma

What Is DEQ Form 605-R04?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DEQ Form 605-R04 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 605-R04 "Notice of Intent (Noi) for Stormwater Discharges From Small Municipal Separate Storm Sewer Systems (Ms4s) Under Opdes General Permit Okr04" - Oklahoma

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Oklahoma Department of Environmental Quality
DEQ FORM
Notice of Intent (NOI) for Stormwater Discharges from
605-R04
Small Municipal Separate Storm Sewer Systems (MS4s)
November 1, 2015
Under OPDES General Permit OKR04
Please print or type: All items should be completed as accurately as possible and in their entirety. Please refer to Part 4 of the
permit OKR04 for information about the required items. An original signature of the applicant is required according to PART VI.H in
the permit OKR04. Use additional pages to fully describe your responses.
Note: Municipality is defined as a federal, state, city, town, county, district, association, or other public body (created by or pursuant
to Oklahoma or Federal law), including special districts under State law such as a storm sewer district, flood control or drainage
district, or similar entity, or a designated and approved management agency under Section 208 of the CWA.
1. Name and address of the permit applicant and local contact:
Circle the appropriate letter to indicate the
legal status of the operator of the facility:
Name of the Small MS4: ____________________________________________
= Federal;
= State;
F
S
Municipal (public other than Federal or
M
Address: ________________________________________________________
=
State, i.e. as city, county);
= Private
P
City: ____________________________________________________________
F
S
M
P
County: ____________________________________ State: _________________
ZIP Code: ___________________
Telephone Number: _________________________ E-mail Address: _________________________________________
Name and Title of Stormwater Management Program Manager: __________________________________________________
2. Co-permittee: Are you co-permitting with another entity? Yes
If yes, complete the following:
No
__________________________________________
________________________________________________________
Name of the Co-permittee
Name and Title of Stormwater Management Program Manager
________________________________________________
_______________________
__________________
Mailing Address
City
ZIP Code
Telephone Number: __________________________ E-mail Address: ________________________________________
F
S
M
P
Circle the letter for type of facility: Federal, State, Municipal, Private
Certification by the co-permittee is required in Section 9.
Latitude: ____________________ Longitude: ______________________
3. Facility/Site Location: Attach a map showing your MS4 boundaries. Your MS4 jurisdiction shall cover the entire area within the
corporate boundary of the municipality if your city is not located entirely within an Urbanized Area.
Name of the Small MS4: ___________________________________________ County: _________________________
Street Address: ________________________________________ City: ___________________________________
Latitude: _________________ Longitude: ___________________ Approximate area of the MS4: _____________ square miles
Latitude/Longitude: If you do not have this information, go to the DEQ Flexviewer at http://gis.deq.ok.gov/flexviewer/.
4. Will another entity provide services to perform some portion or all of the Best Management Practices (BMPs) for the six
minimum control measures (PART IV.C) or TMDL supplemental conditions (PART III.B)?
Yes
No
If yes, attach a statement listing their name and the service they will be providing.
Oklahoma Department of Environmental Quality
DEQ FORM
Notice of Intent (NOI) for Stormwater Discharges from
605-R04
Small Municipal Separate Storm Sewer Systems (MS4s)
November 1, 2015
Under OPDES General Permit OKR04
Please print or type: All items should be completed as accurately as possible and in their entirety. Please refer to Part 4 of the
permit OKR04 for information about the required items. An original signature of the applicant is required according to PART VI.H in
the permit OKR04. Use additional pages to fully describe your responses.
Note: Municipality is defined as a federal, state, city, town, county, district, association, or other public body (created by or pursuant
to Oklahoma or Federal law), including special districts under State law such as a storm sewer district, flood control or drainage
district, or similar entity, or a designated and approved management agency under Section 208 of the CWA.
1. Name and address of the permit applicant and local contact:
Circle the appropriate letter to indicate the
legal status of the operator of the facility:
Name of the Small MS4: ____________________________________________
= Federal;
= State;
F
S
Municipal (public other than Federal or
M
Address: ________________________________________________________
=
State, i.e. as city, county);
= Private
P
City: ____________________________________________________________
F
S
M
P
County: ____________________________________ State: _________________
ZIP Code: ___________________
Telephone Number: _________________________ E-mail Address: _________________________________________
Name and Title of Stormwater Management Program Manager: __________________________________________________
2. Co-permittee: Are you co-permitting with another entity? Yes
If yes, complete the following:
No
__________________________________________
________________________________________________________
Name of the Co-permittee
Name and Title of Stormwater Management Program Manager
________________________________________________
_______________________
__________________
Mailing Address
City
ZIP Code
Telephone Number: __________________________ E-mail Address: ________________________________________
F
S
M
P
Circle the letter for type of facility: Federal, State, Municipal, Private
Certification by the co-permittee is required in Section 9.
Latitude: ____________________ Longitude: ______________________
3. Facility/Site Location: Attach a map showing your MS4 boundaries. Your MS4 jurisdiction shall cover the entire area within the
corporate boundary of the municipality if your city is not located entirely within an Urbanized Area.
Name of the Small MS4: ___________________________________________ County: _________________________
Street Address: ________________________________________ City: ___________________________________
Latitude: _________________ Longitude: ___________________ Approximate area of the MS4: _____________ square miles
Latitude/Longitude: If you do not have this information, go to the DEQ Flexviewer at http://gis.deq.ok.gov/flexviewer/.
4. Will another entity provide services to perform some portion or all of the Best Management Practices (BMPs) for the six
minimum control measures (PART IV.C) or TMDL supplemental conditions (PART III.B)?
Yes
No
If yes, attach a statement listing their name and the service they will be providing.
5. Receiving waters for discharges of stormwater from your MS4: Use additional pages if needed.
Name of Waterbodies
Impaired?
Impairment
Source of Impairment
________________________________
Yes
No
__________
___________________________
________________________________
Yes
No
__________
___________________________
________________________________
Yes
No
__________
___________________________
Do you discharge into waterbodies on the Oklahoma 303(d) list of impaired waters?
Yes
No
If yes, you must ensure that impairment caused by identified pollutants in your receiving waters will, in future discharges, not cause,
have the reasonable potential to cause, or contribute to an in-stream exceedance of WQ standards and comply with PART III.A.1
Do you discharge into receiving waterbodies with an established TMDL or watershed plan?
Yes
No
If yes, you must adopt any Wasteload Allocation (WLA) assigned to your discharges specified in the TMDL as measurable goals
and include any limitations, conditions, monitoring, and other requirements associated with a TMDL implementation plan within
specified timeframes.
Do you discharge into an Outstanding Resource Water (ORW)?
Yes
No
If yes, you must document in your SWMP how you will comply with WQ standard prohibitions (PART III.C).
6. Outline of Measurable Goals and BMPs
Attach an updated description of your Stormwater Management Program (SWMP). You shall include details of BMPs that will
be implemented and the measurable goals for each of the six stormwater minimum control measures, the month and year in which
the MS4 operator will start and fully implement each of the control measures or the frequency of the action, and the name of the
person(s) responsible for implementing or coordinating the SWMP.
7. Endangered Species
Based on the requirements of Part I. E and Exhibit 1, does your municipality discharge into an Aquatic Resource of Concern?
Yes
No
If yes, which criterion listed in Part I.E is your municipality using to meet eligibility requirements?
Criterion _____________________
Certification of this NOI will constitute your certification of compliance with the endangered species requirements of this Permit.
8. Construction by the Permitted Municipality
You have the option to develop permit requirements (PART VIII) that allow the municipality to cover all municipalities owned and
operated construction sites under this Permit rather than filing a separate OKR10 NOI with the DEQ for each such project.
Will the municipality include the optional permit requirements into your SWMP and permit? Yes
No
9. Certification of Permittee
“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 gathered and evaluated 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 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.”
______________________________________
___________________________________
Signature of Applicant
Date Signed
______________________________________
____________________________________
Name (print)
Title
Certification of Co-Permittee (if applicable)
_______________________________________
____________________________________
Signature of Co-Permittee
Date Signed
________________________________________
____________________________________
Name (print)
Title
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