Form DEEP-WPED-REG-021A "Ms4 Annual Report Transmittal Form for the General Permit to Discharge Stormwater From Small Municipal Separate Storm Sewer Systems (Ms4)" - Connecticut

What Is Form DEEP-WPED-REG-021A?

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

Form Details:

  • Released on January 30, 2018;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • 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 printable version of Form DEEP-WPED-REG-021A by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEEP-WPED-REG-021A "Ms4 Annual Report Transmittal Form for the General Permit to Discharge Stormwater From Small Municipal Separate Storm Sewer Systems (Ms4)" - Connecticut

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MS4 Annual Report
CPPU USE ONLY
Transmittal Form
App #:________________________________
Doc #:________________________________
For the General Permit to Discharge Stormwater
from Small Municipal Separate Storm Sewer
Check #:______________________________
Systems (MS4)
______________________________________
Print or type unless otherwise noted. Please submit this
Program: Stormwater Permits
completed transmittal form, fee, and the MS4 Annual Report as
indicated at the end of this form.
Part I: Annual Report General Information
1.
Reporting Period (Calendar Year):
2.
Provide the registration number for the existing general permit registration:
3.
Registrant Type (check one):
Fees
state institution/agency
$375.00
[713]
federal institution/agency
$375.00
[713]
municipality
$187.50
[713]
4.
Municipality name or Municipality name where institution is located:
The annual report will not be processed without the fee. The fee shall be non-refundable and shall be paid by
check or money order to the Department of Energy and Environmental Protection (DEEP) or by such other
method as the commissioner may allow.
Part II: Registrant Information
1. Registrant (Name of Municipality or State or Federal Institution/Agency):
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject registration. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
DEEP-WPED-REG-021A
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Rev. 1/30/18
MS4 Annual Report
CPPU USE ONLY
Transmittal Form
App #:________________________________
Doc #:________________________________
For the General Permit to Discharge Stormwater
from Small Municipal Separate Storm Sewer
Check #:______________________________
Systems (MS4)
______________________________________
Print or type unless otherwise noted. Please submit this
Program: Stormwater Permits
completed transmittal form, fee, and the MS4 Annual Report as
indicated at the end of this form.
Part I: Annual Report General Information
1.
Reporting Period (Calendar Year):
2.
Provide the registration number for the existing general permit registration:
3.
Registrant Type (check one):
Fees
state institution/agency
$375.00
[713]
federal institution/agency
$375.00
[713]
municipality
$187.50
[713]
4.
Municipality name or Municipality name where institution is located:
The annual report will not be processed without the fee. The fee shall be non-refundable and shall be paid by
check or money order to the Department of Energy and Environmental Protection (DEEP) or by such other
method as the commissioner may allow.
Part II: Registrant Information
1. Registrant (Name of Municipality or State or Federal Institution/Agency):
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject registration. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
DEEP-WPED-REG-021A
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Rev. 1/30/18
Part II: Registrant Information (continued)
2. Billing contact, if different than the registrant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
3. Primary contact for departmental correspondence and inquiries, if different than the registrant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject registration. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
4. Engineer(s) or other consultant(s) employed or retained to assist in preparing the annual report.
Check here if additional sheets are necessary, and label and attach them to this sheet.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
Service Provided:
5.
Check here if there are adjacent towns or other entities with which implementation of the Stormwater
Management Plan is coordinated for a portion of the subject MS4. If so, provide the names of such
towns or entities:
DEEP-WPED-REG-021A
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Rev. 1/30/18
Part III: Registrant Certification
The registrant and the individual(s) responsible for actually preparing the annual report must sign this part. [If the
registrant is the preparer, please mark N/A in the spaces provided for the preparer.]
“I have personally examined and am familiar with the information submitted in this document and all
attachments thereto, and I certify that based on reasonable investigation, including my inquiry of the
individuals responsible for obtaining the information, the submitted information is true, accurate and complete
to the best of my knowledge and belief.
I certify that this annual report transmittal is on complete and accurate forms as prescribed by the
commissioner without alteration of the text.
I certify that the
following public notice requirements have been met.
Annual Report Availability: At least forty-five (45) days prior to submission of each Annual Report to DEEP,
pursuant to Section 4(d)(3) of the MS4 General Permit, each permittee shall make available for public review and
comment a draft copy of the complete Annual Report. Comments on the Annual Report may be made to the
permittee and are not submitted to DEEP. Reasonable efforts to inform the public of this document shall be
undertaken by the permittee. Such draft copies shall be made available electronically on the permittee’s website for
public inspection and copying, consistent with the federal and state Freedom of Information Acts, and shall be made
available, at a minimum, at one of the following locations: the permittee’s main office or other designated municipal
or institution office, a local library or other central publicly available location. Following submission of the Annual
Report to DEEP, a copy of the final report shall be made available for public inspection during regular business
hours.
I understand that a false statement in the submitted information may be punishable as a criminal offense, in
accordance with section 22a-6 of the General Statutes, pursuant to section 53a-157b of the General Statutes,
and in accordance with any other applicable statute.
I also certify that the signature of the registrant, or a duly authorized representative, being submitted herewith
complies with section 22a-430-3(b)(2)(B) of the Regulations of Connecticut State Agencies.
Signature of Chief Elected official or Principal Executive
Date
Officer
Printed Name of Chief Elected official or Principal Executive Officer
Title (if applicable)
Signature of Preparer (if different than above)
Date
Printed Name of Preparer
Title (if applicable)
Note:
Please submit
1)
this completed Transmittal Form and the Fee to:
CENTRAL PERMIT PROCESSING UNIT
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
2)
a copy of this completed Transmittal Form and the Annual Report electronically to the
following email address: DEEP.StormwaterStaff@ct.gov.
Refer to
www.ct.gov/deep/municipalstormwater
for information on Annual Report Templates or other additional
information concerning the MS4 General Permit.
In the event that electronic submission is not available or possible, please contact the Stormwater Section at 860-424-3025.
DEEP-WPED-REG-021A
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