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VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 1 of 7 USVI Department of Planning and Natural Resources DISCHARGE MONITORING REPORT (DMR) FORM for For Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the 2017 TPDES Multi-Sector General Permit (VI MSGP) No. VIR050000 Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to the 2017 TPDES Stormwater Multi-Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that the operator identified in Section C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI. A. Approval to Use Paper DMR Form 1. Have you been granted a waiver from electronic reporting from VIDPNR*? YES NO If yes, check which waiver you have been granted, the name of the VIDPNR staff person who granted the waiver, and the date of approval: Waiver granted: The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as under-served for broadband Internet access in the most recent report from the Federal Communications Commission. The owner/operator has issues regarding available computer access or computer capability. Name of VIDPNR staff person that granted the waiver: __________________________________________________________ Date approval obtained: * Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper DMR form. If you have not obtained a waiver, you must file this form electronically using the NetDMR at http://www.epa.gov/netdmr/ B. Permit Information 1. TPDES ID: 2. Reason(s) for Submission (Check all that apply): Submitting monitoring data (Fill in all Sections). Reporting no discharge for all outfalls for this monitoring period (Fill in Sections A, B, C, D, E.1, and G). Reporting that your site status has changed to inactive and unstaffed (Fill in Sections A, B, C, D, F, and include date of status change in comment field in Section F.4). Reporting that your site status has changed to active (Fill in all Sections and include date of status change in comment field in Section F.4). Reporting that no further pollutant reductions are achievable for all outfalls and for all pollutants via Part 6.2.1.2 of the VI MSGP (Fill in Sections A, B, C, D, and G). VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 2 of 7 C. Facility Operator Information 1. OPERATOR Information: Operator Name _______________________________________________________________________________ Mailing Address _______________________________________________________________________ _______________________________________________________________________ Phone (_____)_______________ Fax: (_____)_______________ Email ____________________________________________________________________________________ 2. OPERATOR Point of Contact Information: First, Middle Initial, Last Name: ___________________________________________________________________ Title: _______________________________________________________ Mailing Address: _______________________________________________________________________ _______________________________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ 3. DMR Preparer Information (Complete if DMR was prepared by someone other than the certifier): First, Middle Initial, Last Name: ___________________________________________________________________ Organization: _______________________________________________________ Phone : (_____)_______________ Fax: (_____)_______________ Email: ____________________________________________________________________________________ VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 3 of 7 D. Facility Information 1. Facility Name _____________________________________________________________________________ 2. Facility Physical Address _____________________________________________________________________________ _____________________________________________________________________________ E. Discharge Information 1.Identify the monitoring period for which you are submitting data: Check appropriate monitoring period Check here if proposing alternative monitoring period due to irregular stormwater runoff. Identify which period you are reporting monitoring data for (beginning month and ending month). Quarter 1 (January 1 – March 31) Quarter 1: From To Quarter 2 (April 1 – June 30) Quarter 2: From To Quarter 3 (July 1 – September 30) Quarter 2: From To Quarter 4 (October 1 – December 31) Quarter 2: From To 2. Are you required to monitor for cadmium, copper, chromium, lead, nickel, silver, or zinc in freshwater? Yes (Skip to 3) No (Skip to 4) 3. What is the hardness level of the receiving water? _______ mg/L 4. Does your facility discharge into any saltwater receiving waters? Yes No VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 4 of 7 F. Monitoring Information Note: Make additional copies of this form as necessary. 1. Is this discharge comprised solely of rainfall? YES NO *Note: If you cannot select yes, the discharge is not permitted under the VI MSGP. 2. a. Duration of the rainfall event (hours): b. Rainfall amount (inches): . c. Time since previous measurable storm event (days): 3.a. Outfall ID (list the same 2- digit outfalls identified on the NOI Form) 3.b. Check if any Outfalls Are Substantially Identical to Other Outfalls Listed 3.c Check if No Discharge 3.d. Monitoring Type QBM, ELG, I, O* 3.e. Parameter 3.f. Quality or Concentration 3.g. Units 3.h. Results Description 3.l. Collection Date 3.j. Exceedance due to natural background pollutant levels 3.k. No further pollutant reductions achievable? Substantially identical to Outfall: _______ Substantially identical to Outfall: _______ Substantially identical to Outfall: _______ Substantially identical to Outfall: _______ Substantially identical to Outfall: _______ Substantially identical to Outfall: _______ * (QBM) - Quarterly benchmark monitoring; (ELG) - Annual effluent limitations guidelines monitoring; (I) - Impaired waters monitoring; (O) -Other monitoring as required by VIDPNR 4. Comment and/or Explanation of Any Violations (Reference all attachments here) St. Thomas: 8100 Lindberg Bay, Ste. #61 Cyril E. King Airport Terminal Bldg., 2nd Floor St. Thomas, VI 00802 St. Croix: 45 Mars Hill Frederiksted, VI 00841 USVI Department of Planning and Natural Resources DISCHARGE MONITORING REPORT (DMR) FORM VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 5 of 7 G. 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 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, 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. Name: ________________________________________________________________ Title: ________________________________________________________________ Signature: ________________________________________________________________ Date: ______________ Email: __________________________________________________ VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 6 of 7 Instructions for Completing the Discharge Monitoring Report (DMR) Form For Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the VIDPNR TPDES Multi-Sector General Permit (VI MSGP) Who Must File A Discharge Monitoring Report (DMR) Form. Facilities covered under the VI Multi-Sector General Permit (VI MSGP or permit) that are required to monitor pursuant to Parts 6.2 and 8 of the permit must submit Discharge Monitoring Reports (DMRs) consistent with the reporting requirements specified in Part 7.1 of the permit. Completing the Form Obtain and read a copy of this form and a copy of the 2017 VI MSGP, viewable at http://dpnr.vi.gov/environmental- protection/water-pollution-control-program/. A copy of the forms can also be obtained by contacting DPNR-DEP-WPC at (340) 773-1082 in St. Croix or (340) 774-3320 in St. Thomas. To complete this form, type or print, using uppercase letters, in the appropriate areas only. Please place each character between the marks. Abbreviate if necessary to stay within the number of characters allowed for each item. Use only one space for breaks between words, but not for punctuation marks unless they are needed to clarify your response. Please submit original document with signature in ink - do not send a photocopied signature. Photocopy your DMR form for your records before you send the completed original form to the appropriate address. Where To File NOI Form. NOIs must be submitted to VI DPNR at the office in the district where the facility operates, as follows: St. Croix Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 45 Mars Hill Frederiksted, VI 00841 St. Thomas Department of Planning and Natural Resources Division of Environmental Protection Water Pollution Control Program 8100 Lindberg Bay, Ste. #61 Cyril E. King Airport Terminal Bldg., 2nd Floor St. Thomas, VI 00802 Section A. Approval to Use Paper DMR Form You must indicate whether you have been granted a waiver from electronic reporting from the VIDPNR Office. Note that you are not authorized to use this paper DMR form unless VIDPNR has approved its use. Where you have obtained approval to use this form, indicate the waiver that you have been granted, the name of the VIDPNR staff person who granted the waiver, and the date that approval was provided. Section B: Permit Information Provide the TPDES ID (i.e., Permit tracking number) assigned to the facility for which this DMR is being submitted. Indicate your reason(s) for submitting this DMR by checking all boxes that apply. The reasons for submission are defined as follows: • Submitting monitoring data: For each storm sampled, submit one DMR form with data for all outfalls sampled. Select this reason even if you only have monitoring data for some of your outfalls (i.e., some outfalls did not discharge). If you select this reason you are required to complete all Sections of the form. • Reporting no discharge for all outfalls for this monitoring period: Indicates that there were no discharges from all outfalls during this monitoring period. If you select this reason you are only required to complete Sections A, B, C, D, E.1, and G. • Reporting that your site status has changed to inactive and unstaffed: Indicates that your facility is currently inactive and unstaffed (See Part 6.2.1.3 of the permit for more information). If you select this reason you are only required to complete Sections A, B, C, D, and F and include date of status change in comment field in Section F.4 • Reporting that your site status has changed from inactive to active: Indicates that your facility is currently active (See Part 6.2.1.3 of the permit for more information). If you select this reason you are required to complete all Sections of the form and include date of status change in the comment field in Section F.4. • Reporting that no further reductions are achievable for all outfalls and for all pollutants via Part 6.2.1.2 of the permit: Indicates that you have determined that no further pollutant reductions are technologically and economically practicable in light of best industry practice to meet the technology- based effluent limits or are necessary to meet the water- quality-based effluent limitations in Parts 2 of the permit (See Part 6.2.1.2 of the permit for more information). If you select this reason you are required to complete Sections A, B, C, D and G. However, if you can make this finding for some outfalls and pollutants, but not for others, you cannot select this reason; you will instead be able to identify which outfalls and which pollutants you can make this finding for in Section F. Section C: Facility Operator Information Provide the legal name of the person, firm, public organization, or any other entity that operates the facility for which this DMR is being submitted. An operator of a facility is the legal entity that controls the operation of the facility. Refer to Appendix A of the permit for the definition of “operator”. Provide the operator’s mailing address, phone number, and e-mail. The operator information in this Section should match the operator information provided on your NOI form. Provide the name, organization, phone number, an email address for the person who prepared this DMR form. Section D: Facility Information Enter the official or legal name and complete street address, including city, state, ZIP code, and county or similar government subdivision of the facility. If the facility lacks a street address, indicate the general location of the facility. Complete facility information must be provided for permit coverage to be granted. The facility information in this Section should match the facility information provided on your NOI form. VIDPNR Permit No: VIR050000 – Discharge Monitoring Report (DMR) Form Page 7 of 7 Section E: Discharge Information Indicate the appropriate monitoring period (Quarter 1, 2, 3, or 4) covered by the DMR. “Alternative” monitoring periods can apply to facilities located in arid and semi-arid areas. To use alternative monitoring periods, you must provide a revised monitoring schedule here. If using alternative monitoring periods, identify the first day of the monitoring period through the last day of the monitoring period for each of the four periods. The dates should be displayed as month (Mo) / day (Day). See Parts 6.1.6 and 6.1.7 of the permit for more information. If you are submitting benchmark monitoring data, identify if your facility is required to collect benchmark samples for one or more hardness-dependent metals (i.e., cadmium, copper, lead, nickel, silver, and zinc). If you select “yes” to this question provide the hardness level of the receiving water (in mg/L)). If you select “no” to this question, you must identify if your facility discharges into any saltwater receiving waters. Section F: Monitoring Information For the reported monitoring event indicate whether the discharge is solely rainfall. If you select “YES” then indicate the duration (in hours) of the rainfall event, rainfall total (in inches) for that rainfall event, and time (in days) since the previous measurable storm event in line items 2.a-c. If you select “NO”, you cannot submit a DMR for this discharge, unless the non-rainfall discharge is explicitly permitted in the VI MSGP. You must identify the date of collection for the monitoring event in column 3.i. of the table. To report multiple monitoring events in the same reporting period, copy this form and enter each monitoring event separately with data for all outfalls sampled. Identify all the outfalls from your facility that discharge stormwater. Each outfall must be assigned a unique 3-digit number (e.g., 001, 002, 003), and should match the outfalls identified on your NOI form. If any outfalls are substantially identical, check the box in 3.b and identify the outfall that the outfall in 3.a is substantially identical to. In 3.d – k, you only need to provide benchmark monitoring data for one of the outfalls. For any outfall for which there was no discharge during the monitoring period, check the box in 3. In 3.d, identify the type of monitoring using the specified codes, in parentheses, below: • (QBM) – Quarterly benchmark monitoring • (ELG) – Annual effluent limitations guidelines monitoring; • (I) – Impaired waters monitoring; or • (O) – Other monitoring as required by VIDPNR. In 3.e, enter each “parameter” (or “pollutant”) monitored. For QBM and ELG monitoring, use the same parameter name as in Part 8 of the permit. In 3.f., enter a sample measurement value for each parameter analyzed and required to be reported. Enter “ND” (i.e., not detected) for any sample results below the method detection limit or “BQL” (i.e., below quantitation limit) for sample results above the detection limit but below the quantitation limit. In 3.g., enter the units for sample measurement values (i.e., “mg/L” for milligrams per liter) for each parameter analyzed and required to be reported. For monitoring results reported as ND or BQL this space will be left blank and the units will be reported in Column 3.f. 3.h. must be completed for any monitoring results reported as ND or BQL in the “Quality or Concentration” column. For ND, report the laboratory detection level and units in this column. For BQL, report the laboratory quantitation limit and units in this column. In 3.i. identify the sampling date for each parameter monitoring result reported on this form. 3.h. Exceedance due to natural background pollutant levels: Check box if following the first 4 quarters of benchmark monitoring (or sooner if the exceedance is triggered by less than 4 quarters of data) you have determined that the exceedance of the benchmark is attributable solely to the presence of that pollutant in the natural background for that outfall and any substantially identical outfalls, or for impaired waters monitoring, the presence of the pollutant is caused solely by natural background. See Part 6.2.1.2 and 6.2.4.1 of the permit for more information. In 3.j .check the box if after collection of 4 quarterly samples (or sooner if the exceedance is triggered by less than 4 quarters of data), the average of the 4 monitoring values for any parameter exceeds the benchmark and you have made the determination that no further pollutant reductions are technologically available and economically practicable and achievable in light of best industry practice to meet the technology-based effluent limits or are necessary to meet the water-quality-based effluent. Where violations of the permit requirements are reported, include a brief explanation to describe the cause and corrective actions taken, and reference each violation by date. Also, this section should include any additional comments such as are required when changing site status from inactive and unstaffed to active or vice versa. Attach additional pages if you need more space. Attach additional copies of Section F as necessary to address all outfalls and parameters. Section I: Certification Certification statement and signature (see Section 11 of Appendix B of the MSGP for more information). Enter certifier’s printed name, title and email address. Sign and date the form. (CAUTION: An unsigned or undated NOI form will prevent the granting of permit coverage.) Territorial statutes provide for severe penalties for submitting false information on this application form. Territorial regulations require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) president, secretary, treasurer, or 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 (ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures; For a partnership or sole proprietorship: by a general partner or the proprietor; or For a municipal, State, Federal, or other public facility: by either a principal executive or ranking elected official.