[Permittee]
NPDES MS4 Permit Application
[Date]
Appendix XX
[Permittee] Facilities & Structural Controls
Facility Name
Located in
MS4 or
Combined
System
MS4
Amount of Urban
Pollutants & Type
Public Works Building
Complex
Police Station
MS4
High
MS4
Road salt, sediment,
oil, chemicals
Road salt, sediment
Fire Station
MS4
Road salt, sediment
Low
______________ Park
MS4
Road salt, sediment,
chlorine
High
______________ Park
MS4
Road salt, sediment,
Fertilizers/pesticides
Medium
XX Catch Basins
MS4
Varies
N/A
City Streets & Lots
MS4
Varies
N/A
XX Permittee-Owned Outfalls
MS4
Varies
N/A
Administration Building
Address/Crossroads
Proximity to
Waterbodies
Road salt, sediment,
fertilizers/pesticides
Road salt, sediment,
Fertilizers/pesticides,
Potential for
Pollutant Runoff
(High, Medium,
Low)
Medium
Low
Discharge of
Pollutants of Concern
to Impaired Waters
Priority
Cleaning
Schedule
Salt, Sediment,
Fertilizers/Pesticides
runoff to storm sewer
system
Salt, Sediment runoff to
storm sewer system
Salt, Sediment runoff to
storm sewer system
Salt, Sediment runoff to
storm sewer system
Road salt, sediment,
chlorine runoff to Lake
St. Clair
Salt, Sediment,
Fertilizers/Pesticides
runoff to storm sewer
system
Salt, Sediment, Oils,
Leaves,
Fertilizers/Pesticides
runoff to storm sewer
system
Salt, Sediment, Oils,
Leaves,
Fertilizers/Pesticides
runoff to storm sewer
system
Salt, Sediment, Oils,
Leaves,
Fertilizers/Pesticides
Medium
High
Low
Low
High
Medium
High
Medium
High
[Permittee]
NPDES MS4 Permit Application
[Date]
Appendix XX
[Permittee] Facilities & Structural Controls