4. NPDES MS4 Permit, Annual Report and Public Hearing4
CITY OF
CHANHASSEN
7700 Market Boulevard
PO Box 147
Chanhassen, MN 55317
Administration
Phone: 952.227.1100
Fax: 952.227.1110
Building Inspections
Phone: 952.227.1180
Fax: 952227.1190
Engineering
Phone: 952.227.1160
Fax: 952.227.1170
Finance
Phone: 952.227.1140
Fax: 952.227.1110
Park & Recreation
Phone: 952.227.1120
Fax: 952.227.1110
Recreation Center
2310 Coulter Boulevard
Phone: 952.227.1400
Fax: 952.227.1404
Planning &
Natural Resources
Phone: 952.227.1130
Fax: 952.227.1110
Public Works
1591 Park Road
Phone: 952.227.1300
Fax: 952.227.1310
Senior Center
Phone: 952.227.1125
Fax: 952.227.1110
Web Site
wwadchanhassen.mn.us
MEMORANDUM rr��
V.
To: Paul Oehme, Director of Public Works /City Engineer
From: Terrance Jeffery, Water Resources Coordinator
Date: June 28, 2010 pkP
Re: National Pollutant Discharge Elimination System (NPDES) Phase II Municipal
Separate Storm Sewer System (MS4) Permit 2009 Annual Report — SWMP15
ACTION REQUIRED
Staff is requesting the City Council:
1. Receive public comment on the City's NPDES Phase II MS4 Storm Water Pollution
Prevention Program and 2009 Annual Report; and
2. Approve the Annual Report for 2009; authorize mayor's signature and submittal to
Minnesota Pollution Control Agency (simple majority).
PROPOSED MOTION
The Chanhassen City Council authorizes the Mayor to sign the City's National Pollution
Discharge Elimination System (NPDES) Phase II Annual Report, as attached to this
memorandum, and authorizes the distribution of the Annual Report to the Minnesota
Pollution Control Agency.
BACKGROUND
In June 2002, the Minnesota Pollution Control Agency (MPCA) issued a MS4 general permit
for cities discharging stormwater into waters of the state. Shortly after the permit was issued,
the Minnesota Center for Environmental Advocacy (MCEA) filed an appeal for the permit
indicating that it was inappropriate to issue a general permit in place of individual permits
and because they believed the MPCA failed to address non - degradation and education as part
of the permit. In May 2003, the Minnesota Court of Appeals ruled in favor of the MCEA.
The MPCA has since revised their permit to address additional requirements.
As part of the revised permit, Chanhassen and 29 other communities must address the non -
degradation of all waters. This requirement has been added to determine if any new or
expanded discharges beyond 1988 baseline conditions exist within the selected communities
(MR 7050.0815). The City of Chanhassen submitted a revised application for permit
coverage on May 26, 2006. Chanhassen completed`the Non - degradation Plan in February of
2007 and submitted it to the MPCA for review and comment. The City's permit coverage
was extended on April 22, 2008. The MPCA is going to reissue the permit in 2011.
Attachments: 1. Draft 2009 Annual NPDES MS4,Report
2. MCPA Reporting Form
G:\ENG \Terry\NPDES Phase II\MS4 Permit\2009 Annual Report \061410 2009 NPDES Council Memo_final.doc
Chanhassen is a Community for Life - Providing for Today and Planning for Tomorrow
2009 ANNUAL NPDES MS4 REPORT
CITY OF CHANHASSEN, MN
EXECUTIVE SUMMARY
Objective
This report has been prepared in order to meet the requirements of NPDES (National Pollution
Discharge Elimination System) Permit for Small Municipal Separate Storm Sewer Systems (MS4).
Background
The NPDES program began in 1990 as a means to protect surface water from pollutant loading.
Phase II was implemented in March of 2003 to extend to small MS4 communities located in
urbanized areas as defined by the US Census Bureau. This included the City of Chanhassen.
As a regulated MS4, Chanhassen is required to design our program to reduce discharge of
pollutants to the maximum extent practicable (MEP); protect water quality; and satisfy the
appropriate water quality requirements of the Clean Water Act.' Each MS4 must have six program
elements known as "minimum control measures" (MCM). It is expected that these 6 MCMs, taken in
concert, will result'in significant reductions of pollutants discharged to receiving waters.
In Minnesota, the Pollution Control Agency is responsible for administration of the NPDES Permit
program. In Chanhassen, the Water Resources Coordinator takes the lead role in developing and
administering the permit but ultimately it requires the involvement of all City Departments to
assure that the elements of this permit are met.
2009 Summary
PUBLIC EDUCATION AND OUTREACH
Chanhassen continues to offer educational materials on the City website, through written brochures
and pamphlets and through mailings in utility bills. The City met with Carver County Planning and
Chaska to begin collaborating and sharing educational materials and outreach media. Carver
County has a fulltime education coordinator and the materials and resources created by this
department have added dramatically to the resources available to Chanhassen. Further educational
programming is achieved through the City's membership in, or collaboration with, Metrowater,
Minnesota Cities Stormwater Coalition, Blue Thumb and others.
'EPA 833 -F -00 -002, Stormwater Phase II Final Rule, United States Environmental Protection Agency, January
2000 (revised December 2005)
PUBLIC INVOLVEMENT AND PARTICIPATION
The City of Chanhassen held a public meeting on the NPDES Permit on June 28, 2010. This was
noticed in the Chanhassen Villager on Thursday, June 3, 2010. XXXX comments were received from
the public. The NPDES Permit and SWPPP is available on the City's website at all times and contact
information for the Water Resources Coordinator is also located on the website.
ILLICIT DISCHARGE DETECTION AND ELIMINATION
All known outfalls were located, inspected and incorporated into the City's stormwater map in
2006. These are to be inspected on a five year rotating schedule-011 tfalls are maintained or
replaced, and illicit discharge issues are addressed as needed.
On February 12, 2007, Section 19 -101 & 102 of the Cha# ass'en Ca Code were adopted with the
purpose of regulating the use of the storm sewer systems aatd declare the discharge of pollutant
waters to any storm sewer unlawful. To aid in the City's regulatory enforcement efforts, the City of
Chanhassen has established a Surface Water Tel h he Hotline that residents and witnesses can
call to report any illicit discharges that may be dete
website, along with information on illicit discharge
d. This hotline is also.gsted on the City's
City employees are educated annually on illicit dis
focuses specifically on illicit discharge throlgh nei
and education program, and the City's webst f
c education
teleph
CONSTRUCTION SITE RUNOFF CONTROL
During 2009 there were ,14 active.:constructio
sites were inspected on,a regular bay includi
rainfall event. As a result of ;these inspections
including one (1.) stop work "order.,
es, a volunteer storm -drain marking
(1) acre in size. All of these
and within 48 hours of a
-one (21) Notices of Violation were issued
Prior to:,g4tl prizing earth work,the City eng king department reviews all grading and erosion
controh3lns and, if requareie under fit -PDES Rules,'
Storm Water Pollution Prevention Plan
( SWPPP) as.ell. Any sites trite more than fifty (50) yards of material are displaced requires a
grading permt This requires an erosion ceptrol plan to be developed and implemented.
Training is provided to City staff as it pertains to the NPDES permit for small construction sites.
Chanhassen continues tea contract with the Carver County Soil and Water Conservation District for
inspections of constructian,sites: It is the intention of the City to employ Cartegraph'" in the future
for site inspections. No timeframe has been established for this implementation.
POST- CONSTRUCTION RUNOFF CONTROL
The City of Chanhassen has reviewed existing code and has found it to be generally adequate to
address post- construction site runoff. It may be necessary to clarify the Bluff Creek Overlay District
to eliminate any ambiguities as to what characteristics are needed to be included in the Overlay
District and whether the land should be considered primary or secondary in classification.
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STORM SEWER 0 &M
Through proper maintenance and operation of the City's storm sewer infrastructure the discharge
of pollutants to surface water can be minimized. The Streets Department, and when necessary,
private contractors made numerous repairs to the infrastructure including adjustment of casting
elevations, replacement of castings, replacement of pipes, cleaning culverts, adjustment of grades
and vegetation management on non - structural best management practices (BMPs). A total of 678
man hours were devoted to storm sewer repairs and maintenance in 2009.
POLLUTION PREVENTION AND GOOD HOUSEKEEPING
The City of Chanhassen continues to sweep streets in the spring.and`as needed. In 2009 the streets
department swept nearly 27 miles of streets between Marclsnd April 16 and removed 236 tons
of material. Additional sweeping occurred throughout the year p Fticularly in areas where there
were on -going construction projects or where resident ie were made.
STRUCTURAL CONTROLS 0 &M
Among the various components of the storm sewer and treatrneratsystem, the
structural controls that effect system discharge rates and the c Wl)ty of water discharged.
Structural controls can include retention and detention ox>ds, control weirs, skimmer structures,
sump manholes, environmental manholes, and storm dram�taglets and outfalls.
The City of Chanhassen is required to inspect all 11IS,! outfalls d a : rotating 5 year schedule. The
City of Chanhassen has identified and mapped 64 MS4 ctxfalls. Du the 2009 calendar year, 21
were inspected includini scrq "ng for dry weather dls A e.
m
It is yet to be determltle'd the exact frequency of pond.cleaning necessary but it generally appears to
be between 5 years and ZQ'Years. Thefrequency o:`needed pond dredging is dependent upon a
number of factors including pond de' land use; watershed size, and climatological factors and
will vary from ore pond to the =next.
There aroe,�74 stormwater fonds in'the City of Chanhassen. These are scheduled to be inspected on
a five yea�rgtating schedule 2009, 45 ponds were inspected. The majority were found to be
performing per design with a few minor issues in some of the ponds. The City has not yet
completed evahk on of the data gathered but will use this information to aid in the development of
a pond maintenance- .chedule.
In addition to the 45 p6nds,whieh'were inspected, six ponds were dredged. Prior to dredging, the
sediment materials from e1l'ede4411) ponds were tested for copper, arsenic and polycyclic aromatic
hydrocarbons (PAHs) and f6u =td to be below Soil Resource Value 1(SRV1) in all instances. This
allowed for the materials to be fully recycled. It is the hope of the City that the current battery of
PAH tests will be narrowed done to those most likely to be present as this will offer a significant
reduction in cost.
We are slightly behind schedule on these inspections but with the hire of an intern in 2010 it is
anticipated that 100% of the inspections shall occur by the end of this permit cycle. In addition, all
structural control devices
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NEW PUBLIC WORKS FACILITY
A number of the City's permit requirements were met with the completion of the new Public Works
maintenance facility. The new facility has provided enclosures for the stockpile of soils materials as
well as sand. In addition, the new facility has a dedicated indoor carwash which is physically
separated from the municipal storm sewer system. A new spill response program specific to this
facility will need to be developed but should not differ significantly from the current program.
In 2009, the City of Chanhassen recycled 1,225 gallons of waste oil. All spills are cleaned with floor
dry and absorbent pads. If the spill is greater than five (5) gallons it is reported to the State Duty
Officer. No spills over 5 gallons occurred in 2009.
2010 Objectives
The City of Chanhassen has recently begun working with-f],otegra hTM to develop an asset
management tracking program. This program will allow for efficient.data acquisition, storage,
management and retrieval of stormsewer infrastructure. This same program will be used for
water and sanitary sewer where it will aid in the Ipflow and Infiltration program and Illicit
Discharge and Elimination program among other things. 4 '_ _
In addition, in 2010 the City of Chanhas en
accommodate the 2011 reissuance of the N
include pond maintenance and coal tar "bass
developing a matrix for determining pond -t
location, size of watershed year of
condition of receiving w t r b "Al ,J, esident
Bluff Creek Total M
completed in 2010.
Water Pollution Pr(
will need to `valuate. what changes will _ e needed to
PDES MS4 Permit Two items of particular interest
--d asphalt sealants ;°City staff is in the process of
aeanNC: chedules This will be based upon pond
onstrucd4msual inspection, results of P8 Model,
Daily Load (TMDL) study and implementation plan should be
tDL will n6cessitate chAri to our NPDES MS4 Permit and our Storm
We are currently worki to redesign and update the City Website to make it easier to locate and
retrieve�information as we)J,as to offer a more robots listing of resources and educational materials.
The city is= working with a con�ltant to develop a complaint tracking system that will be web based
and will allow for the dissemin;at�on of cop,ints to the appropriate staff.
The City will cont fige to offer the same educational materials and will continue to partner with
other agencies. Weh ,p tactical to* so, the City will seek to form new partnerships.
This concludes the City of Chaihassen 2010 NPDES MS4 Annual Report. Please direct any
questions to Terry Jeffery, Water Resources Coordinator, 952.227.1168.
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J ���to srq�
5 Q Minnesota Pollution Control Agency 100, Minnesota Pollution
0
! PR NPDES /SDS Small MS4 Report Form Control Agency
, Ot t �
The purpose of this report is to contribute information to an evaluation of the NPDES small municipal separate storm sewer
system (MS4) permit program. Consistent with 40 CFR §122.37 the U.S. Environmental Protection Agency is assessing the
status of the program nation -wide. A "no" answer to a question does not necessarily mean noncompliance with your permit or
with the federal regulations. In order to establish the range of variability in the program it is necessary to ask questions along a
fairly broad performance continuum. Your permitting authority may use some of this information as one component of a
compliance evaluation.
1. MS4 Information
City of Chanhassen
Name of MS4
Terry Jeffery Water Resources Coordinator
Name of Contact Person (First) (Last) (Title)
(952) 227 -1168 tjeffery@ci.chanhassen.mn.us
Telephone (including area code) Email
7700 Market Blvd, PO Box 147
Mailing Address
Chanhassen
City
What size population does your MS4 serve? 24,500
What is the reporting period for this report? (mm/dd/yyyy)
2. Water Quality Priorities
MN 55317
State ZIP code
From 01/61/2009 t 12/31/200 9
A. Does your MS4 discharge to waters listed as impaired on a state 303(d) list? ® Yes ❑ No
B. If yes, identify each impaired water, the impairment, whether a TMDL has been approved by EPA for each, and whether
the TMDL assigns a wasteload allocation to your MS4. Use a new line for each impairment, and attach additional pages as
necessary.
Impaired Water Impairment Approved TMDL TMDL assigns WLA to MS4
Ann Lake Mercury ❑ Yes ® No
❑ Yes
® No
Bluff Creek Turbidity, Fish IBI ❑ Yes ® No
❑ Yes
® No
Christmas Lake Mercury ❑ Yes ® No
❑ Yes
® No
Lotus Lake Mercury, Eutrophication ❑ Yes ® No
❑ Yes
® No
Lucy Lake Mercury ❑ Yes ® No
❑ Yes
® No
Minnewashta Lake Mercury ❑ Yes ® No
❑ Yes
® No
Riley Lake Mercury, Eutrophication ❑ Yes ® No
❑ Yes
® No
Susan Lake Mercury ❑ Yes ® No
❑ Yes
® No
C. What specific sources contributing to the impairment(s) are you targeting in your stormwater
program?
Nutrients, Erosion and sediment
D. Do you discharge to any high - quality waters (e.g., Tier 2, Tier 3, outstanding natural resource ® Yes
❑ No
waters, or other state or federal designation)?
E. Are you implementing additional specific provisions to ensure their continued integrity?
® Yes
❑ No
Small MS4 Annual Report Form (cont) 2
3. Public Education and Public Participation
A. Is your public education program targeting specific pollutants and sources of those pollutants? ® Yes ❑ No
B. If yes, what are the specific sources and/or pollutants addressed by your public education program?
Nutrients (fertilizers, yard waste, etc.), Sediment, Hazardous waste /dumping
C. Note specific successful outcomes (e.g., quantified reduction in fertilizer use; NOT tasks, events, publications) fully
or partially attributable to your public education program during this reporting period.
D. Do you have an advisory committee or other body comprised of the public and other ® Yes ❑ No
stakeholders that provides regular input on your stormwater program?
4. Construction
A. Do you have an ordinance or other regulatory mechanism stipulating:
Erosion and sediment control requirements?
® Yes
❑ No
Other construction waste control requirements?
® Yes
❑ No
Requirement to submit construction plans for review?
® Yes
❑ No
MS4 enforcement authority?
❑ Yes
® No
B. Do you have written procedures for:
Reviewing construction plans?
® Yes
❑ No
Performing inspections?
® Yes
❑ No
Responding to violations?
® Yes
❑ No
C. Identify the number of active construction sites > 1 acre in operation in your jurisdiction at anytime during
the
reporting period. 16
D. How many of the sites identified in 4.0 did you inspect during this reporting period? 16
E. Describe, on average, the frequency with which your program conducts construction site inspections.
MEEK
F. Do you prioritize certain construction sites for more frequent inspections?
® Yes ❑ No
If Yes, based on what criteria? Known violations
G. Identify which of the following types of enforcement actions you used during the reporting period for construction
activities, indicate the number of actions, or note those for which you do not have authority:
® Yes Notice of violation # 21 No Authority ❑
❑ Yes Administrative fines # No Authority ❑
® Yes Stop Work Orders # 1 No Authority ❑
❑ Yes Civil penalties # No Authority ❑
❑ Yes Criminal actions # No Authority
® Yes Administrative orders # 0 No Authority ❑
❑ Yes Other #
H. Do you use an electronic tool (e.g., GIS, data base, spreadsheet) to track the locations, ® Yes ❑ No
inspection results, and enforcement actions of active construction sites in your jurisdiction?
I. What are the 3 most common types of violations documented during this reporting period?
Lack of P erimeter Control or maintenance needed, Vehicle Tracking, and Exposed Soils
J. How often do municipal employees receive training on the construction program? 1/YEAR
Small MS4 Annual Report Form (cont)
5. Illicit Discharge Elimination
A. Have you completed a map of all outfalls and receiving waters of your storm sewer system?
B. Have you completed a map of all storm drain pipes and other conveyances in the storm sewer
system?
C. Identify the number of outfalls in your storm sewer system. 39
® Yes ❑ No
❑ Yes ® No
D. Do you have documented procedures, including frequency, for screening outfalls? ® Yes ❑ No
E. Of the outfalls identified in 5.C, how many were screened for dry weather discharges during this reporting period?
21
F. Of the outfalls identified in 5.C, how many have been screened for dry weather discharges at any time since you obtained
MS4 permit coverage? 39
G. What is your frequency for screening outfalls for illicit discharges? Describe any variation based on size /type.
20% Annually
H. Do you have an ordinance or other regulatory mechanism that effectively prohibits illicit ® Yes ❑ No
discharges?
I. Do you have an ordinance or other regulatory mechanism that provides authority for you to ® Yes ❑ No
take enforcement action and/or recover costs for addressing illicit discharges?
J. During this reporting period, how many illicit discharges /illegal connections have you discovered? 0
K. Of those illicit discharges /illegal connections that have been discovered or reported, how many have been eliminated?
L. How often do municipal employees receive training on the illicit discharge program? Annually
6. Stormwater Management for Municipal Operations
A. Have stormwater pollution prevention plans (or an equivalent plan) been developed for:
3
I. If so, how frequently and/or under what circumstances? - 1 /year and as updates arise.
All public parks, ball fields, other recreational facilities and other open spaces
® Yes
❑ No
All municipal construction activities, including those disturbing less than 1 acre
® Yes
❑ No
All municipal turf grass /landscape management activities
® Yes
❑ No
All municipal vehicle fueling, operation and maintenance activities
® Yes
❑ No
All municipal maintenance yards
® Yes
❑ No
All municipal waste handling and disposal areas
® Yes
❑ No
Other
B.
Are stormwater inspections conducted at these facilities?
® Yes
❑ No
C.
If Yes, at what frequency are inspections conducted? 1/WK for construction sites, otherwise as needed.
D.
List activities for which operating procedures or management practices specific to stormwater management have been
developed (e.g., road repairs, catch basin cleaning).
Street sweeping (2x/yr and as needed), road reconstruction, catch basin cleaning (as needed), etc.
E.
Do you prioritize certain municipal activities and/or facilities for more frequent inspection?
® Yes
❑ No
F.
If Yes, which activities and/or facilities receive most frequent inspections? Construction sites, sensitive sites
G.
Do all municipal employees and contractors overseeing planning and implementation of
® Yes
❑ No
stormwater- related activities receive comprehensive training on stormwater management?
H.
If yes, do you also provide regular updates and refreshers?
® Yes
❑ No
3
I. If so, how frequently and/or under what circumstances? - 1 /year and as updates arise.
Small MS4 Annual Report Form (cont)
7. Long -term (Post- Construction) Stormwater Measures
A. Do you have an ordinance or other regulatory mechanism to require:
Site plan reviews for stormwater /water quality of all new and re- development projects? ® Yes ❑ No
Long -term operation and maintenance of stormwater management controls? ® Yes ❑ No
Retrofitting to incorporate long -term stormwater management controls? ❑ Yes ® No
B. If you have retrofit requirements, what are the circumstances /criteria?
C. What are your criteria for determining which new /re- development stormwater plans you will review (e.g., all projects,
projects disturbing greater than one acre, etc.) All projects
D. Do you require water quality or quantity design standards or performance standards, either
directly or by reference to a state or other standard, be met for new development and ® Yes ❑ No
re- development?
E. Do these performance or design standards require that pre- development hydrology be met for:
Flow volumes ® Yes ❑ No
Peak discharge rates ® Yes ❑ No
Discharge frequency ❑ Yes ® No
Flow duration ® Yes ❑ No
F. Please provide the URL /reference where all post - construction stormwater management standards can be found, or e-mail
to MS4PermitProgram .PCA @state.mn.us an electronic copy of the ordinance or other regulatory mechanism as specified
in Part V.G.5 of the permit.
http: / /www.ci.chanhassen.mn.us /inside /code.htmi
G. How many development and redevelopment project plans were reviewed during the reporting period to assess impacts to
water quality and receiving stream protection?
H. How many of the plans identified in 7.G were approved?
I. How many privately owned permanent stormwater management practices /facilities were inspected during the reporting
period? 12
J. How many of the practices /facilities identified in I were found to have inadequate maintenance? 3
K. How long do you give operators to remedy any operation and maintenance deficiencies identified during inspections?
No deadline
L. Do you have authority to take enforcement action for failure to properly operate and maintain ® yes ❑ No
stormwater practices /facilities?
M. How many formal enforcement actions (i.e., more than a verbal or written warning) were taken for failure to adequately
operate and/or maintain stormwater management practices? 0
N. Do you use an electronic tool (e.g., GIS, database, spreadsheet) to track post - construction ❑ Yes ® No
BMPs, inspections and maintenance?
O. Do all municipal departments and/or staff (as relevant) have access to this tracking system? ❑ Yes ® No
P. How often do municipal employees receive training on the post - construction program? Annual
8. Program Resources
A. What was the annual expenditure to implement MS4 permit requirements this reporting period? 411,125
B. What is next year's budget for implementing the requirements of your MS4 NPDES permit? 406,200
4
Small MS4 Annual Report Form (cont)
C. This year what is /are your source(s) of funding for the stormwater program, and annual revenue (amount or percentage)
derived from each?
Source: Surface Water Fee
Source: Connection Charges
Amount $ 450,000 OR % 56
Amount $ 200,000 OR %25
Source: Other Revenue (Interest, utility penalties, permit Amount $ 159,000 OR % 19
D. How many FTEs does your municipality devote to the stormwater program (specifically for implementing the stormwater
program; not municipal employees with other primary responsibilities)? 2
E. Do you share program implementation responsibilities with any other entities?
® Yes ❑ No
Entity Activity/Task/Responsibility Your Oversight/Accountability Mechanism
Carver SWCD Construction Inspections Co- inspections, enforce City ordinances
9. Evaluating /Measuring Progress
A. What indicators do you use to evaluate the overall effectiveness of your stormwater management program, how long have
you been tracking them, and at what frequency? These are not measurable goals for individual management practices or
tasks, but large -scale or long -term metrics for the overall program, such as macroinvertebrate community indices,
measures of effective impervious cover in the watershed, indicators of in- stream hydrologic stability, etc.
Indicator
Lake Water Quality (CAMP)
Bluff Creek Monitoring Data & TMDL
Number of
Frequency Locations
Weekly for duration of open water 6
Varies up to continuous. 1(4)
B. What environmental quality trends have you documented over the duration of your stormwater program? Reports or
summaries can be attached electronically, or provide the URL to where they may be found on the Web.
http://www.ci.chanhassen.mn.us/serv/nresourc/camp.html
Began Tracking
(year)
2001
1992
http: / /www. pca.state. mn. us /i ndex. php /water /water- types- and -prog ramslminnesota -s -im paired- waters - and - tmdls /tmdl
- projects /m innesota- river -basi n -tmd I- projects /underway -tmdl -bl uff- creek -tmdl— turbidity-and - fish - biota. html
Small MS4 Annual Report Form (cont)
10. Additional Information
In the space below, please include any additional information on the performance of your MS4 program. If providing
clarification to any of the questions on this form, please provide the question number (e.g., 2C) in your response.
Certification Statement and Signature
I certify that all information provided in this report is, to the best of my knowledge and belief, true,
accurate and complete. E] Yes
Federal regulations require this application to be signed as follows: For a municipal, State, Federal, or other public facility: by either a principal
executive or ranking elected official.
Name of Certifying Official, Title
Date (mm/dd/yyyy)
0