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United States
Environmental Protection
Agency
Office of
Enforcement
Washington, DC 20460
EPA Form 3510-1
Revised August 1990
Permits Division
Application Form 1 – General
Information
Consolidated Permits Program
This form must be completed by all persons applying for a
permit under EPA’s Consolidated Permits Program. See
the general instructions to Form 1 to determine which
other application forms you will need.
DESCRIPTION OF CONSOLIDATED
PERMIT APPLICATION FORMS
FORM 1 PACKAGE
TABLE OF CONTENTS
Section A. General Instructions
The Consolidated Permit Application Forms are:
Form 1 – General Information (included in this part);
Section B. Instructions for Form 1
Form 2 – Discharges to Surface Water (NPDES Permits):
Section C. Activities Which Do Not Require Permits
Section D. Glossary
2A. Publicly owned Treatment Works (Reserved - not included in
this package),
Form 1 (two copies)
2B. Concentrated Animal Feeding Operations and Aquatic Animal
Production Facilities (not included in this package),
2C. Existing Manufacturing, Commercial, Mining, and Silvicultural
Operations (not included in this package), and
2D. New Manufacturing, Commercial, Mining, and Silvicultural
Operations (Reserved - not included in this package);
Form 3 – Hazardous Waste Application Form (RCRA Permits - not
included in this package);
Form 4 – Underground Injection of Fluids (UIC Permits - Reserved not included in this package); and
Form 5 – Air Emissions in Attainment Areas (PSD Permits - Reserved - not included in this package).
SECTION A – GENERAL INSTRUCTIONS
needed under each of the above programs. Item II of Form 1 will
guide you to the appropriate supplementary forms.
Who Must Apply
With the exceptions described in Section C of these instructions,
Federal laws prohibit you from conducting any of the following activities without a permit.
You should note that there are certain exclusions to the permit requirements listed above. The exclusions are described in detail In
Section C of these instructions. If your activities are excluded from
permit requirements then you do not need to complete and return
any forms.
NPDES (National Pollutant Discharge Elimination System Under the
Clean Water Act, 33 U.S.C. 1251). Discharge of pollutants into the
waters of the United States.
NOTE: Certain activities not listed above also are subject to EPA
administered environmental permit requirements. These include
permits for ocean dumping, dredged or fill material discharging, and
certain types of air emissions. Contact your EPA Regional office for
further information.
RCRA (Resource Conservation and Recovery Act, 42 U.S.C. 6901).
Treatment, storage, or disposal of hazardous wastes.
UIC (Underground Injection Control Under the Safe Drinking Water
Act, 42 U.S.C. 300f). Injection of fluids underground by gravity flow
or pumping.
Table 1. Addresses of EPA Regional Contacts and States Within
the Regional Office Jurisdictions
PSD (Prevention of Significant Deterioration Under the Clean Air Act,
72 U.S.C 7401). Emission of an air pollutant by a new or modified
facility in or near an area which has attained the National Ambient Air
Quality Standards for that pollutant.
REGION 1
Permit Contact, Environmental and Economic Impact Office, U.S.
Environmental Protection Agency, 1 Congress St., Suite 1100,
Boston, MA 02114-2023, Phone: (617) 918-1111, Fax: (617) 9181809, Toll free within Region 1: (888) 372-7341,
http://www.epa.gov/region01/.
Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island, and Vermont.
Each of the above permit programs is operated in any particular
State by either the United States Environmental Protection Agency
(EPA) or by an approved State agency. You must use this application form to apply for a permit for those programs administered by
EPA. For those programs administered by approved states, contact
the State environmental agency for the proper forms.
REGION 2
Permit Contact, Permits Administration Branch, U.S. Environmental Protection Agency, 290 Broadway, New York, NY 100071866, Phone: (212) 637-3000, Fax: (212) 637-3526,
http://www.epa.gov/region02/.
New Jersey, New York, Virgin Islands, and Puerto Rico.
If you have any questions about whether you need a permit under
any of the above programs, or if you need information as to whether
a particular program is administered by EPA or a State agency, or if
you need to obtain application forms, contact your EPA Regional
office (listed in Table 1).
Upon your request, and based upon information supplied by you,
EPA will determine whether you are required to obtain a permit for a
particular facility. Be sure to contact EPA if you have a question,
because Federal laws provide that you may be heavily penalized if
you do not apply for a permit when a permit is required.
REGION 3
Permit Contact (3 EN 23), U.S. Environmental Protection Agency,
1650 Arch Street, Philadelphia, PA 19103-2029, Phone: (215)
814-5000, Fax: (215) 814-5103, Toll free: (800) 438-2474,
http://www.epa.gov/region03/.
Delaware, District of Columbia, Maryland, Pennsylvania,
Virginia, and West Virginia.
Form 1 of the EPA consolidated application forms collects general
information applying to all programs. You must fill out Form 1 regardless of which permit you are applying for. In addition, you must fill out
one of the supplementary forms (Forms 2 – 5) for each permit
1-1
SECTION A – GENERAL INSTRUCTIONS
Table 2. Filing Dates for Permits
FORM (permit)
REGION 4
Permit Contact, Permits Section, U.S. Environmental Protection
Agency, Atlanta Federal Center, 61 Forsyth Street, SW, Atlanta,
GA 30303-3104, Phone: (404) 562-9900, Fax: (404) 562-8174,
Toll free: (800) 241-1754, http://www.epa.gov/region04/.
Alabama, Florida, Georgia, Kentucky, Mississippi,
North Carolina, South Carolina, and Tennessee.
WHEN TO FILE
2A (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires.
2B (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires2,
or 180 days prior to startup if you are a new facility.
2C (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires2.
2D (NPDES) . . . . . . . . . . 180 days prior to startup.
3 (Hazardous Waste) . . . Existing facility: Six months following publication of
regulations listing hazardous wastes.
New facility: 180 days before commencing physical
construction.
4 (UIC) . . . . . . . . . . . . . . A reasonable time prior to construction for new wells;
as directed by the Director for existing wells.
5 (PSD). . . . . . . . . . . . . Prior to commencement of construction.
REGION 5
Permit Contact (5EP), U.S. Environmental Protection Agency, 77
West Jackson Boulevard, Chicago, IL 60604-3507, Phone: (312)
353-2000, Fax: (312) 353-4135, Toll free within Region 5: (800)
621-8431, http://www.epa.gov/region5/.
Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.
1
Please note that some of these forms are not yet available for use and are listed
as “Reserved” at the beginning of these instructions. Contact your EPA Regional
office for information on current application requirements and forms.
REGION 6
Permit Contact (6AEP), U.S. Environmental Protection Agency,
Fountain Place 12th Floor, Suite 1200, 1445 Ross Avenue, Dallas,
TX 75202-2733, Phone: (214) 665-2200, Fax: (214) 665-7113,
Toll free within Region 6: (800) 887-6063,
http://www.epa.gov/region06/.
Arkansas, Louisiana, New Mexico, Oklahoma, and Texas.
2
If your present permit expires on or before November 30, 1980, the filing date is
the date on which your permit expires. If your permit expires during the period
December 1, 1980–May 31, 1981, the filing date is 90 days before your permit
expires.
Federal regulations provide that you may not begin to construct a
new source in the NPDES program, a new hazardous waste management facility, a new injection well, or a facility covered by the
PSD program before the issuance of a permit under the applicable
program. Please note that if you are required to obtain a permit
before beginning construction, as described above, you may need to
submit your permit application well in advance of an applicable
deadline listed in Table 2.
REGION 7
Permit Contact, Permits Branch, U.S. Environmental Protection
Agency, 901 North 5th Street, Kansas City, KS 66101, Phone:
(913) 551-7003, Toll free: (800) 223-0425,
http://www.epa.gov/region07/.
Iowa, Kansas, Missouri, and Nebraska.
Fees
The U.S. EPA does not require a fee for applying for any permit
under the consolidated permit programs. (However, some States
which administer one or more of these programs require fees for the
permits which they issue.)
REGION 8
Permit Contact (8E-WE), U.S. Environmental Protection Agency,
999 18th Street, Suite 500, Denver, CO 80202-2466, Phone: (303)
312-6312, Fax: (303) 312-6339, Toll free: (800) 227-8917,
http://www.epa.gov/region08/.
Colorado, Montana, North Dakota, South Dakota, Utah, and
Wyoming.
Availability of Information to Public
Information contained in these application forms will, upon request,
be made available to the public for inspection and copying. However,
you may request confidential treatment for certain information which
you submit on certain supplementary forms. The specific instructions
for each supplementary form state what information on the form, if
any, may be claimed as confidential and what procedures govern the
claim. No information on Forms 1 and 2A through 2D may be
claimed as confidential.
REGION 9
Permit Contact, Permits Branch (E-4), U.S. Environmental Protection Agency, 75 Hawthorne Street, San Francisco, CA 94105,
Phone: (415) 947-8000, Fax: (415) 947-3553, Toll free within Region 9: (866) EPA-WEST, http://www.epa.gov/region09/.
Arizona, California, Hawaii, Nevada, Guam, American Samoa,
and Trust Territories.
Completion of Forms
Unless otherwise specified in instructions to the forms, each item in
each form must be answered. To indicate that each item has been
considered, enter “NA,” for not applicable, if a particular item does
not fit the circumstances or characteristics of your facility or activity.
REGION 10
Permit Contact (M/S 521), U.S. Environmental Protection Agency,
1200 Sixth Avenue, Seattle, WA 98101, Phone: (206) 553-1200,
Fax: (206) 553-2955, Toll free: (800) 424-4372,
http://www.epa.gov/region10/.
Alaska, Idaho, Oregon, and Washington.
If you have previously submitted information to EPA or to an approved State agency which answers a question, you may either
repeat the information in the space provided or attach a copy of the
previous submission. Some items in the form require narrative explanation. If more space is necessary to answer a question, attach a
separate sheet entitled “Additional Information.”
Where to File
The application forms should be mailed to the EPA Regional office
whose Region includes the State in which the facility is located (see
Table 1).
If the State in which the facility is located administers a Federal
permit program under which you need a permit, you should contact
the appropriate State agency for the correct forms. Your EPA Regional office (Table 1) can tell you to whom to apply and can provide
the appropriate address and phone number.
Financial Assistance for Pollution Control
There are a number of direct loans, loan guarantees, and grants
available to firms and communities for pollution control expenditures.
These are provided by the Small Business Administration, the Economic Development Administration, the Farmers Home Administration, and the Department of Housing and Urban Development, Each
EPA Regional office (Table 1) has an economic assistance coordinator who can provide you with additional information.
When to File
Because of statutory requirements, the deadlines for filing applications vary according to the type of facility you operate and the type of
permit you need. These deadlines are as follows:1
EPA’s construction grants program under Title II of the Clean Water
Act is an additional source of assistance to publicly owned treatment
works. Contact your EPA Regional office for details.
1-2
SECTION B – FORM 1 LINE BY LINE INSTRUCTIONS
Table 3 (continued)
Petroleum storage and transfer units with a total storage capacity
exceeding 300,000 barrels;
Taconite ore processing plants;
Glass fiber processing plants; and
Charcoal production plants.
This form must be completed by all applicants.
Completing This Form
Please type or print in the unshaded areas only. Some items have
small graduation marks in the fill-in spaces. These marks indicate the
number of characters that may be entered into our data system. The
marks are spaced at 1/6" intervals which accommodate elite type (12
characters per inch). If you use another type you may ignore the
marks. If you print, place each character between the marks. Abbreviate if necessary to stay within the number of characters allowed for
each item. Use one space for breaks between words, but not for
punctuation marks unless they are needed to clarify your response.
Item III
Enter the facility’s official or legal name. Do not use a colloquial name.
Item IV
Give the name, title, and work telephone number of a person who is
thoroughly familiar with the operation of the facility and with the facts
reported in this application and who can be contacted by reviewing
offices if necessary.
Item I
Space is provided at the upper right hand corner of Form 1 for insertion of your EPA Identification Number. If you have an existing facility, enter your Identification Number. If you don’t know your EPA
Identification Number, please contact your EPA Regional office
(Table 1), which will provide you with your number. If your facility is
new (not yet constructed), leave this item blank.
Item V
Give the complete mailing address of the office where correspondence should be sent. This often is not the address used to designate the location of the facility or activity.
Item II
Answer each question to determine which supplementary forms you
need to fill out. Be sure to check the glossary in Section D of these
instructions for the legal definitions of the bold faced words. Check
Section C of these instructions to determine whether your activity is
excluded from permit requirements.
Item VI
Give the address or location of the facility identified in Item III of this
form. If the facility lacks a street name or route number, give the
most accurate alternative geographic information (e.g., section
number or quarter section number from county records or at intersection of Rts. 425 and 22).
If you answer “no” to every question, then you do not need a permit,
and you do not need to complete and return any of these forms.
Item VII
List, in descending order of significance, the four 4-digit standard
industrial classification (SIC) codes which best describe your facility
in terms of the principal products or services you produce or provide.
Also, specify each classification in words. These classifications may
differ from the SIC codes describing the operation generating the
discharge, air emissions, or hazardous wastes.
If you answer “yes” to any question, then you must complete and file
the supplementary form by the deadline listed in Table 2 along with
this form. (The applicable form number follows each question and is
enclosed in parentheses.) You need not submit a supplementary
form if you already have a permit under the appropriate Federal
program, unless your permit is due to expire and you wish to renew
your permit.
SIC code numbers are descriptions which may be found in the
“Standard Industrial Classification Manual” prepared by the Executive Office of the President, Office of Management and Budget,
which is available from the Government Printing Office, Washington,
D.C. Use the current edition of the manual. If you have any questions
concerning the appropriate SIC code for your facility, contact your
EPA Regional office (see Table 1).
Questions (I) and (J) of Item II refer to major new or modified
sources subject to Prevention of Significant Deterioration (PSD)
requirements under the Clean Air Act. For the purpose of the PSD
program, major sources are defined as: (A) Sources listed in Table 3
which have the potential to emit 100 tons or more per year emissions; and (B) All other sources with the potential to emit 250 tons or
more per year. See Section C of these instructions for discussion of
exclusions of certain modified sources.
Item VIII-A
Give the name, as it is legally referred to, of the person, firm, public
organization, or any other entity which operates the facility described
in this application. This may or may not be the same name as the
facility. The operator of the facility is the legal entity which controls
the facility’s operation rather than the plant or site manager. Do not
use a colloquial name.
Table 3. 28 Industrial Categories Listed In Section 169(1) of the
Clean Air Act of 1977
Fossil fuel-fired steam generators of more than 250 million BTU per
hour heat input;
Coal cleaning plants (with thermal dryers);
Kraft pulp mills;
Portland cement plants;
Primary zinc smelters;
Iron and steel mill plants;
Primary aluminum ore reduction plants;
Primary copper smelters;
Municipal incinerators capable of charging more than 250 tons of
refuse per day;
Hydrofluoric acid plants;
Nitric acid plants;
Sulfuric acid plants;
Petroleum refineries;
Lime plants;
Phosphate rock processing plants;
Coke oven batteries;
Sulfur recovery plants;
Carbon black plants (furnace process);
Primary lead smelters;
Fuel conversion plants;
Sintering plants;
Secondary metal production plants;
Chemical process plants;
Fossil fuel boilers (or combination thereof) totaling more than 250
million BTU per hour heat input;
Item VIII-B
Indicate whether the entity which operates the facility also owns it by
marking the appropriate box.
Item VIII-C
Enter the appropriate letter to indicate the legal status of the operator
of the facility. Indicate “public” for a facility solely owned by local
government(s) such as a city, town, county, parish, etc.
Items VIII-D-H
Enter the telephone number and address of the operator identified in
Item VIII-A.
Item IX
Indicate whether the facility is located on Indian Lands.
Item X
Give the number of each presently effective permit issued to the
facility for each program or, if you have previously filed an application
but have not yet received a permit, give the number of the application, if any. Fill in the unshaded area only. If you have more than one
currently effective permit for your facility under a particular permit
program, you may list additional permit numbers on a separate sheet
of paper. List any relevant environmental Federal (e.g., permits
1-3
SECTION B – FORM 1 LINE BY LINE INSTRUCTIONS
Item XII
Briefly describe the nature of your business (e.g., products produced
or services provided).
under the Ocean Dumping Act, Section 404 of the Clean Water Act
or the Surface Mining Control and Reclamation Act), State (e.g.,
State permits for new air emission sources in nonattainment areas
under Part D of the Clean Air Act or State permits under Section 404
of the Clean Water Act), or local permits or applications under
“other.”
Item XIII
Federal statues provide for severe penalties for submitting false
information on this application form.
Item XI
Provide a topographic map or maps of the area extending at least to
one mile beyond the property boundaries of the facility which clearly
show the following:
18 U.S.C. Section 1001 provides that “Whoever, in any matter within
the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick,
scheme, or device a material fact, or makes or uses any false writing
or document knowing some to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or
imprisoned not more than five years, or both.”
The legal boundaries of the facility;
The location and serial number of each of your existing and proposed intake and discharge structures;
Section 309(c)(2) of the Clean Water Act and Section 113(c)(2) of
the Clean Air Act each provide that “Any person who knowingly
makes any false statement, representation, or certification in any
application, . . . shall upon conviction, be punished by a fine of no
more than $10,000 or by imprisonment for not more than six months,
or both.”
All hazardous waste management facilities;
Each well where you inject fluids underground; and
All springs and surface water bodies in the area, plus all drinking
water wells within 1/4 mile of the facility which are identified in the
public record or otherwise known to you.
In addition, Section 3008(d)(3) of the Resource Conservation and
Recovery Act provides for a fine up to $25,000 per day or imprisonment up to one year, or both, for a first conviction for making a false
statement in any application under the Act, and for double these
penalties upon subsequent convictions.
If an intake or discharge structure, hazardous waste disposal site, or
injection well associated with the facility is located more than one
mile from the plant, include it on the map, if possible. If not, attach
additional sheets describing the location of the structure, disposal
site, or well, and identify the U.S. Geological Survey (or other) map
corresponding to the location.
FEDERAL REGULATIONS REQUIRE THIS APPLICATION TO BE
SIGNED AS FOLLOWS:
On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude at the nearest whole second. On all
maps of rivers, show the direction of the current, and in tidal waters,
show the directions of the ebb and flow tides. Use a 7-1/2 minute
series map published by the U.S. Geological Survey, which may be
obtained through the U.S. Geological Survey Offices listed below, If
a 7-1/2 minute series map has not been published for your facility
site, then you may use a 15 minute series map from the U.S. Geological Survey. If neither a 7-1/2 nor 15 minute series map has been
published for your facility site, use a plat map or other appropriate
map, including all the requested information; in this case, briefly
describe land uses in the map area (e.g., residential, commercial).
A. For a corporation, by a principal executive officer of at least the
level of vice president. However, if the only activity in Item II which
is marked “yes” is Question G, the officer may authorize a person
having responsibility for the overall operations of the well or well
field to sign the certification. In that case, the authorization must
be written and submitted to the permitting authority.
B. For partnership or sole proprietorship, by a general partner or
the proprietor, respectively; or
C. For a municipality, State, Federal, or other public facility, by either a principal executive officer or ranking elected official.
You may trace your map from a geological survey chart, or other
map meeting the above specifications. If you do, your map should
bear a note showing the number or title of the map or chart it was
traced from. Include the names of nearby towns, water bodies, and
other prominent points. An example of an acceptable location map is
shown in Figure 1-1 of these instructions. (NOTE: Figure 1-1 is
provided for purposes of illustration only, and does not represent any
actual facility.)
U.S.G.S. OFFICES
AREA SERVED
Eastern Mapping Center
National Cartographic Information Center
U.S.G.S.
536 National Center
Reston, VA 22092
Phone No. (703) 860-6336
Ala., Conn., Del., D.C., Fla.,
Ga., Ind., Ky., Maine, Md.,
Mass., N.H., N.J., N.Y., N.C.,
S.C., Ohio, Pa., Puerto Rico,
R.I., Tenn., Vt., Va., W. Va.,
and Virgin Islands
Mid Continent Mapping Center
National Cartographic Information Center
U.S.G.S.
1400 Independence Road
Rolla, MO 65401
Phone No. (314) 341-0851
Ark.. Ill., Iowa, Kans., La.,
Mich., Minn., Miss., Mo.,
N. Dak., Nebr., Okla., S. Dak.,
and Wis.
Rocky Mountain Mapping Center
National Cartographic Information Center
U.S.G.S.
Stop 504, Box 25046 Federal Center
Denver, CO 80225
Phone No. (303) 234-2326
Alaska, Colo., Mont., N. Mex.,
Tex., Utah, and Wyo.
Western Mapping Center
National Cartographic Information Center
U.S.G.S.
345 Middlefield Road
Menlo Park, CA 94025
Phone No. (415) 323-8111
Ariz., Calif., Hawaii, Idaho,
Nev., Oreg., Wash., American
Samoa, Guam, and Trust
Territories
1-4
SECTION C – ACTIVITIES WHICH DO NOT REQUIRE PERMITS
II. Hazardous Waste Permits Under the Resource Conservation
and Recovery Act. You may be excluded from the requirement to
obtain a permit under this program if you fall into one of the following
categories:
1. National Pollutant Discharge Elimination System Permits
Under the Clean Water Act. You are not required to obtain an
NPDES permit if your discharge is in one of the following categories,
as provided by the Clean Water Act (CWA) and by the NPDES
regulations (40 CFR Parts 122-125). However, under Section 510 of
CWA a discharge exempted from the federal NPDES requirements
may still be regulated by a State authority; contact your State environmental agency to determine whether you need a State permit.
Generators who accumulate their own hazardous waste on-site for
less than 90 days as provided in 40 CFR 262.34;
Farmers who dispose of hazardous waste pesticide from their own
use as provided in 40 CFR 262.51;
A. DISCHARGES FROM VESSELS. Discharges of sewage from
vessels, effluent from properly functioning marine engines, laundry, shower, and galley sink wastes, and any other discharge incidental to the normal operation of a vessel do not require NPDES
permits. However, discharges of rubbish, trash, garbage, or other
such materials discharged overboard require permits, and so do
other discharges when the vessel is operating in a capacity other
than as a means of transportation, such as when the vessel is being used as an energy or mining facility, a storage facility, or a
seafood processing facility, or is secured to the bed of the ocean,
contiguous zone, or waters of the United States for the purpose of
mineral or oil exploration or development.
Certain persons treating, storing, or disposing of small quantities
of hazardous waste as provided in 40 CFR 261.4 or 261.5; and
Owners and operators of totally enclosed treatment facilities as
defined in 40 CFR 260.10.
Check with your Regional office for details. Please note that even if
you are excluded from permit requirements, you may be required by
Federal regulations to handle your waste in a particular manner.
III. Underground Injection Control Permits Under the Safe Drinking Water Act. You are not required to obtain a permit under this
program if you:
B. DREDGED OR FILL MATERIAL. Discharges of dredged or fill
material into waters of the United States do not need NPDES
permits if the dredging or filling is authorized by a permit issued by
the U.S. Army Corps of Engineers or an EPA approved State under Section 404 of CWA.
Inject into existing wells used to enhance recovery of oil and gas
or to store hydrocarbons (note, however, that these underground
injections are regulated by Federal rules); or
Inject into or above a stratum which contains, within 1/4 mile of the
well bore, an underground source of drinking water (unless your
injection is the type identified in Item II-H, for which you do need a
permit). However, you must notify EPA of your injection and submit certain required information on forms supplied by the Agency,
and your operation may be phased out if you are a generator of
hazardous wastes or a hazardous waste management facility
which uses wells or septic tanks to dispose of hazardous waste.
C. DISCHARGES INTO PUBLICLY OWNED TREATMENT
WORKS (POTW), The introduction of sewage, industrial wastes,
or other pollutants into a POTW does not need an NPDES permit.
You must comply with all applicable pretreatment standards
promulgated under Section 307(b) of CWA, which may be included in the permit issued to the POTW. If you have a plan or an
agreement to switch to a POTW in the future, this does not relieve
you of the obligation to apply for and receive an NPDES permit
until you have stopped discharging pollutants into waters of the
United States.
IV. Prevention of Significant Deterioration Permits Under the
Clean Air Act. The PSD program applies to newly constructed or
modified facilities (both of which are referred to as “new sources”)
which increase air emissions. The Clean Air Act Amendments of
1977 exclude small new sources of air emissions from the PSD
review program. Any new source in an industrial category listed in
Table 3 of these instructions whose potential to emit is less than 100
tons per year is not required to get a PSD permit. In addition, any
new source in an industrial category not listed in Table 3 whose
potential to emit is less than 250 tons per year is exempted from the
PSD requirements.
(NOTE: Dischargers into privately owned treatment works do not
have to apply for or obtain NPDES permits except as otherwise
required by the EPA Regional Administrator. The owner or operator of the treatment works itself, however, must apply for a permit
and identify all users in its application. Users so identified will receive public notice of actions taken on the permit for the treatment
works.)
D. DISCHARGES FROM AGRICULTURAL AND SILVICULTURAL ACTIVITIES. Most discharges from agricultural and silvicultural activities to waters of the United States do not require
NPDES permits. These include runoff from orchards, cultivated
crops, pastures, range lands, and forest lands. However, the discharges listed below do require NPDES permits. Definitions of the
terms listed below are contained in the Glossary section of these
instructions.
Modified sources which increase their net emissions (the difference
between the total emission increases and total emission decreases
at the source) less than the significant amount set forth in EPA
regulations are also exempt from PSD requirements. Contact your
EPA Regional office (Table 1) for further information.
1. Discharges from Concentrated Animal Feeding Operations.
(See Glossary for definitions of “animal feeding operations” and
“concentrated animal feeding operations.” Only the latter require
permits.)
2. Discharges from Concentrated Aquatic Animal Production
Facilities. (See Glossary for size cutoffs.)
3. Discharges associated with approved Aquaculture Projects.
4. Discharges from Silvicultural Point Sources. (See Glossary
for the definition of “silvicultural point source.”) Nonpoint source
silvicultural activities are excluded from NPDES permit requirements. However, some of these activities, such as stream
crossings for roads, may involve point source discharges of
dredged or fill material which may require a Section 404 permit.
See 33 CFR 209.120.
E. DISCHARGES IN COMPLIANCE WITH AN ON-SCENE COORDINATOR'S INSTRUCTIONS.
1-5
SECTION D – GLOSSARY
NOTE: This Glossary includes terms used in the instructions and in Forms 1, 2B, 2C, and 3. Additional terms will be included in the future when
other forms are developed to reflect the requirements of other parts of the Consolidated Permits Program. If you have any questions concerning the
meaning of any of these terms, please contact your EPA Regional office (Table 1)
.
been set for sulfur oxides, particulate matter, nitrogen dioxide, carbon monoxide, ozone, lead, and hydrocarbons. For purposes of the
Glossary, “attainment area” also refers to “unclassifiable area,” which
means, for any pollutants, an area designated under Section 107 as
unclassifiable with respect to that pollutant due to insufficient Information.
ALIQUOT means a sample of specified volume used to make up a
total composite sample.
ANIMAL FEEDING OPERATION means a lot or facility (other than
an aquatic animal production facility) where the following conditions
are met;
A. Animals (other than aquatic animals) have been, are, or will be
stabled or confined and fed or maintained for a total of 45 days or
more in any 12 month period; and
BEST MANAGEMENT PRACTICES (BMP) means schedules of
activities, prohibitions of practices, maintenance procedures, and
other management practices to prevent or reduce the pollution of
waters of the United States. BMP’s include treatment requirements,
operation procedures, and practices to control plant site runoff,
spillage or leaks, sludge or waste disposal, or drainage from raw
material storage.
B. Crops, vegetation, forage growth, or post-harvest residues are
not sustained in the normal growing season over any portion of
the lot or facility.
Two or more animal feeding operations under common ownership
are a single animal feeding operation if they adjoin each other or if
they use a common area or system for the disposal of wastes.
BIOLOGICAL MONITORING TEST means any test which includes
the use of aquatic algal, invertebrate, or vertebrate species to measure acute or chronic toxicity, and any biological or chemical measure
of bioaccumulation.
ANIMAL UNIT means a unit of measurement for any animal feeding
operation calculated by adding the following numbers: The number
of slaughter and feeder cattle multiplied by 1.0; Plus the number of
mature dairy cattle multiplied by 1.4; Plus the number of swine
weighing over 25 kilograms (approximately 55 pounds) multiplied by
0.4; Plus the number of sheep multiplied by 0.1; Plus the number of
horses multiplied by 2.0.
BYPASS means the intentional diversion of wastes from any portion
of a treatment facility.
CONCENTRATED ANIMAL FEEDING OPERATION means an
animal feeding operation which meets the criteria set forth in either
(A) or (B) below or which the Director designates as such on a
case-by-case basis:
APPLICATION means the EPA standard national forms for applying
for a permit, including any additions, revisions, or modifications to the
forms; or forms approved by EPA for use in approved States, including any approved modifications or revisions. For RCRA, “application”
also means “Application, Part B.”
A. More than the numbers of animals specified in any of the following categories are confined:
1. 1,000 slaughter or feeder cattle,
APPLICATION, PART A means that part of the Consolidated Permit
Application forms which a RCRA permit applicant must complete to
qualify for interim status under Section 3005(e) of RCRA and for
consideration for a permit. Part A consists of Form 1 (General Information) and Form 3 (Hazardous Waste Application Form).
2. 700 mature dairy cattle (whether milked or dry cows),
3. 2,500 swine each weighing over 25 kilograms (approximately
55 pounds),
4. 500 horses,
APPLICATION, PART B means that part of the application which a
RCRA permit applicant must complete to be issued a permit. (NOTE:
EPA is not developing a specific form for Part B of the permit application, but an instruction booklet explaining what Information must
be supplied is available from the EPA Regional office.)
5. 10,000 sheep or lambs,
6. 55,000 turkeys,
7. 100,000 laying hens or broilers (if the facility has a continuous overflow watering),
APPROVED PROGRAM or APPROVED STATE means a State
program which has been approved or authorized by EPA under 40
CFR Part 123.
8. 30,000 laying hens or broilers (if the facility has a liquid manure handling system),
9. 5,000 ducks, or
AQUACULTURE PROJECT means a defined managed water area
which uses discharges of pollutants into that designated area for the
maintenance or production of harvestable freshwater, estuarine, or
marine plants or animals. “Designated area” means the portions of
the waters of the United States within which the applicant plans to
confine the cultivated species, using a method of plan or operation
(including, but not limited to, physical confinement) which, on the
basis of reliable scientific evidence, is expected to ensure the specific individual organisms comprising an aquaculture crop will enjoy
increased growth attributable to the discharge of pollutants and be
harvested within a defined geographic area.
10. 1,000 animal units; or
B. More than the following numbers and types of animals are confined:
1. 300 slaughter or feeder cattle,
2. 200 mature dairy cattle (whether milked or dry cows),
3. 750 swine each weighing over 25 kilograms (approximately
55 pounds),
4. 150 horses,
AQUIFER means a geological formation, group of formations, or part
of a formation that is capable of yielding a significant amount of
water to a well or spring.
5. 3,000 sheep or lambs,
6.16,500 turkeys,
AREA OF REVIEW means the area surrounding an injection which is
described according to the criteria set forth in 40 CFR Section
146.06.
7. 30,000 laying hens or broilers (if the facility has continuous
overflow watering),
AREA PERMIT means a UIC permit applicable to all or certain wells
within a geographic area, rather than to a specified well, under 40
CFR Section 122.37.
8. 9,000 laying hens or broilers (if the facility has a liquid manure handling system),
9. 1,500 ducks, or
ATTAINMENT AREA means, for any air pollutant, an area which has
been designated under Section 107 of the Clean Air Act as having
ambient air quality levels better than any national primary or secondary ambient air quality standard for that pollutant. Standards have
10. 300 animal units; AND
1-6
SECTION D – GLOSSARY
and Discharges through pipes, sewers, or other conveyances, leading into privately owned treatment works. This term does not include
an addition of pollutants by any indirect discharger.
Either one of the following conditions are met: Pollutants are
discharged into waters of the United States through a manmade
ditch, flushing system or other similar manmade device (“manmade” means constructed by man and used for the purpose of
transporting wastes); or Pollutants are discharged directly into
waters of the Unites States which originate outside of and pass
over, across, or through the facility or otherwise come into direct
contact with the animals confined in the operation.
DISPOSAL (in the RCRA program) means the discharge, deposit,
injection, dumping, spilling, leaking, or placing of any hazardous
waste into or on any land or water so that the hazardous waste or
any constituent of it may enter the environment or be emitted into the
air or discharged into any waters, including ground water.
Provided, however, that no animal feeding operation is a concentrated animal feeding operation as defined above if such
animal feeding operation discharges only in the event of a 25
year, 24 hour storm event.
DISPOSAL FACILITY means a facility or part of a facility at which
hazardous waste is intentionally placed into or on land or water, and
at which hazardous waste will remain after closure.
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY
means a hatchery, fish farm, or other facility which contains, grows
or holds aquatic animals in either of the following categories, or
which the Director designates as such on a case-by-case basis:
EFFLUENT LIMITATION means any restriction imposed by the
Director on quantities, discharge rates, and concentrations of pollutants which are discharged from point sources into waters of the
United States, the waters of the continguous zone, or the ocean.
EFFLUENT LIMITATION GUIDELINE means a regulation published
by the Administrator under Section 304(b) of the Clean Water Act to
adopt or revise effluent limitations.
A. Cold water fish species or other cold water aquatic animals including, but not limited to, the Salmonidae family of fish (e.g., trout
and salmon) in ponds, raceways or other similar structures which
discharge at least 30 days per year but does not include:
ENVIRONMENTAL PROTECTION AGENCY (EPA) means the
United States Environmental Protection Agency.
1. Facilities which produce less than 9,090 harvest weight kilograms (approximately 20,000 pounds) of aquatic animals per
year; and
EPA IDENTIFICATION NUMBER means the number assigned by
EPA to each generator, transporter, and facility.
2. Facilities which feed less than 2,272 kilograms (approximately 5,000 pounds) of food during the calendar month of
maximum feeding.
EXEMPTED AQUIFER means an aquifer or its portion that meets
the criteria in the definition of USDW, but which has been exempted
according to the procedures in 40 CFR Section 122.35(b).
B. Warm water fish species or other warm water aquatic animals
including, but not limited to, the Ameiuridae, Cetrarchiclae, and
Cyprinidae families of fish (e.g., respectively, catfish, sunfish, and
minnows) in ponds, raceways, or other similar structures which
discharge at least 30 days per year, but does not include;
EXISTING HWM FACILITY means a Hazardous Waste Management
facility which was in operation, or for which construction had commenced, on or before October 21, 1976. Construction had commenced if (A) the owner or operator had obtained all necessary
Federal, State, and local preconstruction approvals or permits, and
either (B1) a continuous on-site, physical construction program had
begun, or (B2) the owner or operator had entered into contractual
obligations, which could not be cancelled or modified without substantial loss, for construction of the facility to be completed within a
reasonable time.
1. Closed ponds which discharge only during periods of excess
runoff; or
2. Facilities which produce less than 45,454 harvest weight
kilograms (approximately 100,000 pounds) of aquatic animals
per year.
(NOTE: This definition reflects the literal language of the statute.
However, EPA believes that amendments to RCRA now in conference will shortly be enacted and will change the date for determining when a facility is an “existing facility” to one no earlier than
May of 1980; indications are the conferees are considering October 30, 1980. Accordingly, EPA encourages every owner or operator of a facility which was built or under construction as of the
promulgation date of the RCRA program regulations to file Part A
of its permit application so that it can be quickly processed for interim status when the change in the law takes effect. When those
amendments are enacted, EPA will amend this definition.)
CONTACT COOLING WATER means water used to reduce temperature which comes into contact with a raw material, intermediate
product, waste product other than heat, or finished product.
CONTAINER means any portable device in which a material is
stored, transported, treated, disposed of, or otherwise handled.
CONTIGUOUS ZONE means the entire zone established by the
United States under article 24 of the convention of the Territorial Sea
and the Contiguous Zone.
CWA means the Clean Water Act (formerly referred to the Federal
Water Pollution Control Act) Pub. L. 92-500, as amended by Pub. L.
95-217 and Pub. L. 95-576, 33 U.S.C. 1251 et seq.
EXISTING SOURCE or EXISTING DISCHARGER (in the NPDES
program) means any source which is not a new source or a new
discharger.
DIKE means any embankment or ridge of either natural or manmade
materials used to prevent the movement of liquids, sludges, solids,
or other materials.
EXISTING INJECTION WELL means an injection well other than a
new injection well.
FACILITY means any HWM facility, UIC underground injection well,
NPDES point source, PSD stationary source, or any other facility or
activity (including land or appurtenances thereto) that is subject to
regulation under the RCRA, UIC, NPDES, or PSD programs.
DIRECT DISCHARGE means the discharge of a pollutant as defined
below.
DIRECTOR means the EPA Regional Administrator or the State
Director as the context requires.
FLUID means material or substance which flows or moves whether
in a semisolid, liquid, sludge, gas, or any other form or state.
DISCHARGE (OF A POLLUTANT) means:
A. Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or
GENERATOR means any person by site, whose act or process
produces hazardous waste identified or listed in 40 CFR Part 261.
B. Any addition of any pollutant or combination of pollutants to the
waters of the contiguous zone or the ocean from any point source
other than a vessel or other floating craft which is being used as a
means of transportation.
GROUNDWATER means water below the land surface in a zone of
saturation.
HAZARDOUS SUBSTANCE means any of the substances designated under 40 CFR Part 116 pursuant to Section 311 of CWA.
(NOTE: These substances are listed in Table 2c-4 of the instructions
to Form 2C.)
This definition includes discharges into waters of the United States
from: Surface runoff which is collected or channelled by man; Discharges through pipes, sewers, or other conveyances owned by a
State, municipality, or other person which do not lead to POTW’s;
1-7
SECTION D – GLOSSARY
B. After proposal of standards of performance in accordance with
Section 306 of CWA which are applicable to such source, but only
if the standards are promulgated in accordance with Section 306
within 120 days of their proposal.
HAZARDOUS WASTE means a hazardous waste as defined in 40
CFR Section 261.3 published May 19, 1980.
HAZARDOUS WASTE MANAGEMENT FACILITY (HWM facility)
means all contiguous land, structures, appurtenances, and improvements on the land, used for treating, storing, or disposing of hazardous wastes. A facility may consist of several treatment, storage, or
disposal operational units (for example, one or more landfills, surface
impoundments, or combinations of them).
NON-CONTACT COOLING WATER means water used to reduce
temperature which does not come into direct contact with any raw
material, intermediate product, waste product (other than heat), or
finished product.
IN OPERATION means a facility which is treating, storing, or disposing of hazardous waste.
OFF-SITE means any site which is not “on-site”.
ON-SITE means on the same or geographically contiguous property
which may be divided by public or private right(s)-of-way, provided
the entrance and exit between the properties is at a cross-roads
intersection, and access is by crossing as opposed to going along,
the right(s)-of-way. Non-contiguous properties owned by the same
person, but connected by a right-of-way which the person controls
and to which the public does not have access, is also considered
on-site property.
INCINERATOR (in the RCRA program) means an enclosed device
using controlled flame combustion, the primary purpose of which is
to thermally break down hazardous waste. Examples of incinerators
are rotary kiln, fluidized bed, and liquid injection incinerators.
INDIRECT DISCHARGER means a nondomestic discharger introducing pollutants to a publicly owned treatment works.
INJECTION WELL means a well into which fluids are being injected.
OPEN BURNING means the combustion of any material without the
following characteristics;
INTERIM AUTHORIZATION means approval by EPA of a State
hazardous waste program which has met the requirements of Section 3006(c) of RCRA and applicable requirements of 40 CFR Part
123, Subparts A, B, and F.
A. Control of combustion air to maintain adequate temperature for
efficient combustion;
B. Containment of the combustion-reaction in an enclosed device
to provide sufficient residence time and mixing for complete combustion; and
LANDFILL means a disposal facility or part of a facility where hazardous waste is placed in or on land and which is not a land treatment facility, a surface impoundment, or an injection well.
C. Control of emission of the gaseous combustion products.
LAND TREATMENT FACILITY (in the RCRA program) means a
facility or part of a facility at which hazardous waste is applied onto
or incorporated into the soil surface; such facilities are disposal
facilities if the waste will remain after closure.
(See also “incinerator” and “thermal treatment”).
OPERATOR means the person responsible for the overall operation
of a facility.
LISTED STATE means a State listed by the Administrator under
Section 1422 of SDWA as needing a State UIC program.
OUTFALL means a point source.
MGD means millions of gallons per day.
OWNER means the person who owns a facility or part of a facility.
MUNICIPALITY means a city, village, town, borough, county, parish,
district, association, or other public body created by or under State
law and having jurisdiction over disposal of sewage, industrial
wastes, or other wastes, or an Indian tribe or an authorized Indian
tribal organization, or a designated and approved management
agency under Section 208 of CWA.
PERMIT means an authorization, license, or equivalent control
document issued by EPA or an approved State to implement the
requirements of 40 CFR Parts 122, 123, and 124.
PHYSICAL CONSTRUCTION (in the RCRA program) means excavation, movement of earth, erection of forms or structures, or similar
activity to prepare a HWM facility to accept hazardous waste.
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
(NPDES) means the national program for issuing modifying, revoking
and reissuing, terminating, monitoring, and enforcing permits and
imposing and enforcing pretreatment requirements, under Sections
307, 318, 402, and 405 of CWA. The term includes an approved
program.
PILE means any noncontainerized accumulation of solid, nonflowing
hazardous waste that is used for treatment or storage.
POINT SOURCE means any discernible, confined, and discrete
conveyance, including but not limited to any pipe, ditch, channel,
tunnel, conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, vessel or other floating craft from
which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture.
NEW DISCHARGER means any building, structure, facility, or installation: (A) From which there is or may be a new or additional discharge of pollutants at a site at which on October 18, 1972, it had
never discharged pollutants; (B) Which has never received a finally
effective NPDES permit for discharges at that site; and (C) Which is
not a “new source.” This definition includes an indirect discharger
which commences discharging into waters of the United States. It
also includes any existing mobile point source, such as an offshore
oil drilling rig, seafood processing vessel, or aggregate plant that
begins discharging at a location for which it does not have an existing permit.
POLLUTANT means dredged spoil, solid waste, incinerator residue,
filter backwash, sewage, garbage, sewage sludge, munitions,
chemical waste, biological materials, radioactive materials (except
those regulated under the Atomic Energy Act of 1954, as amended
[42 U.S.C. Section 2011 et seq.]), heat, wrecked or discarded
equipment, rocks, sand, cellar dirt and Industrial, municipal, and
agriculture waste discharged into water. It does not mean:
A. Sewage from vessels; or
NEW HWM FACILITY means a Hazardous Waste Management
facility which began operation or for which construction commenced
after October 21, 1976.
B. Water, gas, or other material which is injected into a well to facilitate production of oil or gas, or water derived in association with
oil and gas production and disposed of in a well, if the well used
either to facilitate production or for disposal purposes is approved
by authority of the State in which the well is located, and if the
State determines that the injection or disposal will not result in the
degradation of ground or surface water resources.
NEW INJECTION WELL means a well which begins injection after a
UIC program for the State in which the well is located is approved.
NEW SOURCE (in the NPDES program) means any building, structure, facility, or installation from which there is or may be a discharge
of pollutants, the construction of which commenced:
(NOTE: Radioactive materials covered by the Atomic Energy Act
are those encompassed in its definition of source, byproduct, or
special nuclear materials. Examples of materials not covered include radium and accelerator produced isotopes. See Train v.
Colorado Public Interest Research Group, Inc., 426 U.S. 1 [1976].)
A. After promulgation of standards of performance under Section
306 of CWA which are applicable to such source; or
1-8
SECTION D – GLOSSARY
of RCRA), and the Commonwealth of the Northern Mariana Islands
(except in the case of CWA).
PREVENTION OF SIGNIFICANT DETERIORATION (PSD) means
the national permitting program under 40 CFR 52.21 to prevent
emissions of certain pollutants regulated under the Clean Air Act
from significantly deteriorating air quality in attainment areas.
STATIONARY SOURCE (in the PSD program) means any building,
structure, facility, or installation which emits or may emit any air
pollutant regulated under the Clean Air Act. “Building, structure,
facility, or installation” means any grouping of pollutant-emitting
activities which are located on one or more contiguous or adjacent
properties and which are owned or operated by the same person (or
by persons under common control).
PRIMARY INDUSTRY CATEGORY means any industry category
listed in the NRDC Settlement Agreement (Natural Resources Defense Council v. Train, 8 ERC 2120 [D.D.C. 1976], modified 12 ERC
1833 [D.D.C. 1979]).
PRIVATELY OWNED TREATMENT WORKS means any device or
system which is: (A) Used to treat wastes from any facility whose
operator is not the operator of the treatment works; and (B) Not a
POTW.
STORAGE (in the RCRA program) means the holding of hazardous
waste for a temporary period at the end of which the hazardous
waste is treated, disposed, or stored elsewhere.
PROCESS WASTEWATER means any water which, during manufacturing or processing, comes into direct contact with or results from
the production or use of any raw material, intermediate product,
finished product, byproduct, or waste product.
STORM WATER RUNOFF means water discharged as a result of
rain, snow, or other precipitation.
SURFACE IMPOUNDMENT or IMPOUNDMENT means a facility or
part of a facility which is a natural topographic depression, manmade
excavation, or diked area formed primarily of earthen materials
(although it may be lined with manmade materials), which is designed to hold an accumulation of liquid wastes or wastes containing
free liquids, and which is not an injection well. Examples of surface
impoundments are holding, storage, settling, and aeration pits,
ponds, and lagoons.
PUBLICLY OWNED TREATMENT WORKS or POTW means any
device or system used in the treatment (including recycling and
reclamation) of municipal sewage or industrial wastes of a liquid
nature which is owned by a State or municipality. This definition
includes any sewers, pipes, or other conveyances only if they convey
wastewater to a POTW providing treatment.
RENT means use of another’s property in return for regular payment.
TANK (in the RCRA program) means a stationary device, designed
to contain an accumulation of hazardous waste which is constructed
primarily of non-earthen materials (e.g., wood, concrete, steel, plastic) which provide structural support.
RCRA means the Solid Waste Disposal Act as amended by the
Resource Conservation and Recovery Act of 1976 (Pub. L. 94-580,
as amended by Pub. L. 95-609, 42 U.S.C. Section 6901 at seq.).
THERMAL TREATMENT (in the RCRA program) means the treatment of hazardous waste in a device which uses elevated temperature as the primary means to change the chemical, physical, or
biological character or composition of the hazardous waste. Examples of thermal treatment processes are incineration, molten salt,
pyrolysis, calcination, wet air oxidation, and microwave discharge.
(See also “incinerator” and “open burning”).
ROCK CRUSHING AND GRAVEL WASHING FACILITIES are facilities which process crushed and broken stone, gravel, and riprap (see
40 CFR Part 436, Subpart B, and the effluent limitations guidelines
for these facilities).
SDWA means the Safe Drinking Water Act (Pub. L 95-523, as
amended by Pub. L. 95-1900, 42 U.S.C. Section 300[f] et seq.).
TOTALLY ENCLOSED TREATMENT FACILITY (in the RCRA program) means a facility for the treatment of hazardous waste which is
directly connected to an industrial production process and which is
constructed and operated in a manner which prevents the release of
any hazardous waste or any constituent thereof into the environment
during treatment. An example is a pipe in which waste acid is neutralized.
SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.
SEWAGE FROM VESSELS means human body wastes and the
wastes from toilets and other receptacles intended to receive or
retain body wastes that are discharged from vessels and regulated
under Section 312 of CWA, except that with respect to commercial
vessels on the Great Lakes this term includes graywater. For the
purposes of this definition, “graywater” means galley, bath, and
shower water,
TOXIC POLLUTANT means any pollutant listed as toxic under Section 307(a)(1) of CWA.
TRANSPORTER (in the RCRA program) means a person engaged
in the off-site transportation of hazardous waste by air, rail, highway,
or water.
SEWAGE SLUDGE means the solids, residues, and precipitate
separated from or created in sewage by the unit processes of a
POTW. “Sewage” as used in this definition means any wastes,
including wastes from humans, households, commercial establishments, industries, and storm water runoff, that are discharged to or
otherwise enter a publicly owned treatment works.
TREATMENT (in the RCRA program) means any method, technique,
or process, including neutralization, designed to change the physical,
chemical, or biological character or composition of any hazardous
waste so as to neutralize such waste, or so as to recover energy or
material resources from the waste, or so as to render such waste
non-hazardous, or less hazardous; safer to transport, store, or dispose of; or amenable for recovery, amenable for storage, or reduced
in volume.
SlLVICULTURAL POINT SOURCE means any discernable, confined, and discrete conveyance related to rock crushing, gravel
washing, log sorting, or log storage facilities which are operated in
connection with silvicultural activities and from which pollutants are
discharged into waters of the United States. This term does not
include nonpoint source silvicultural activities such as nursery operations, site preparation, reforestation and subsequent cultural treatment, thinning, prescribed burning, pest and fire control, harvesting
operations, surface drainage, or road construction and maintenance
from which there is natural runoff. However, some of these activities
(such as stream crossing for roads) may involve point source discharges of dredged or fill material which may require a CWA Section
404 permit. “Log sorting and log storage facilities” are facilities
whose discharges result from the holding of unprocessed wood, e.g.,
logs or roundwood with bark or after removal of bark in
self-contained bodies of water (mill ponds or log ponds) or stored on
land where water is applied intentionally on the logs (wet decking).
(See 40 CFR Part 429, Subpart J, and the effluent limitations guidelines for these facilities.)
UNDERGROUND INJECTION means well injection.
UNDERGROUND SOURCE OF DRINKING WATER or USDW
means an aquifer or its portion which is not an exempted aquifer
and:
A. Which supplies drinking water for human consumption; or
B. In which the ground water contains fewer than 10,000 mg/l total
dissolved solids.
UPSET means an exceptional incident in which there is unintentional
and temporary noncompliance with technology-based permit effluent
limitations because of factors beyond the reasonable control of the
permittee. An upset does not include noncompliance to the extent
caused by operational error, improperly designed treatment facilities,
inadequate treatment facilities, lack of preventive maintenance, or
careless or improper operation.
STATE means any of the 50 States, the District of Columbia, Guam,
the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Trust Territory of the Pacific Islands (except in the case
1-9
SECTION D – GLOSSARY
WATERS OF THE UNITED STATES means:
A. All waters which are currently used, were used in the past, or
may be susceptible to use in interstate or foreign commerce, including all waters which are subject to the ebb and flow of the tide;
B. All interstate waters, including interstate wetlands;
C. All other waters such as intrastate lakes, rivers, streams (including intermittent streams), mudflats, sandflats, wetlands,
sloughs, prairie potholes, wet meadows, playa lakes, and natural
ponds, the use, degradation, or destruction of which would or
could affect interstate or foreign commerce including any such waters;
1. Which are or could be used by interstate or foreign travelers
for recreational or other purposes,
2. From which fish or shellfish are or could be taken and sold in
interstate or foreign commerce,
3. Which are used or could be used for industrial purposes by
industries in interstate commerce;
D. All impoundments of waters otherwise defined as waters of the
United States under this definition;
E. Tributaries of waters identified in paragraphs (A) – (D) above;
F. The territorial sea; and
G. Wetlands adjacent to waters (other than waters that are themselves wetlands) identified in paragraphs (A) – (F) of this definition.
Waste treatment systems, including treatment ponds or lagoons
designed to meet requirement of CWA (other than cooling ponds as
defined In 40 CFR Section 423.11(m) which also meet the criteria of
this definition) are not waters of the United States. This exclusion
applies only to manmade bodies of water which neither were originally created in waters of the United States (such as a disposal area
in wetlands) nor resulted from the impoundments of waters of the
United States.
WELL INJECTION or UNDERGROUND INJECTION means the
subsurface emplacement of fluids through a bored, drilled, or driven
well; or through a dug well, where the depth of the dug well is greater
than the largest surface dimension.
WETLANDS means those areas that are inundated or saturated by
surface or groundwater at a frequency and duration sufficient to
support, and that under normal circumstances do support, a prevalence of vegetation typically adapted for life in saturated soil conditions. Wetlands generally include swamps, marshes, bogs, and
similar areas.
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Please print or type in the unshaded areas only.
Form Approved. OMB No. 2040-0086.
FORM
U.S. ENVIRONMENTAL PROTECTION AGENCY
1
GENERAL INFORMATION
I. EPA I.D. NUMBER
S
Consolidated Permits Program
(Read the “General Instructions” before starting.)
GENERAL
EPA I.D. NUMBER
III.
FACILITY NAME
V.
FACILITY MAILING
ADDRESS
VI.
FACILITY LOCATION
C
D
1
2
13
14
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GENERAL INSTRUCTIONS
If a preprinted label has been provided, affix it in the
designated space. Review the information carefully; if any of it
is incorrect, cross through it and enter the correct data in the
appropriate fill-in area below. Also, if any of the preprinted data
is absent (the area to the left of the label space lists the
information that should appear), please provide it in the proper
fill-in area(s) below. If the label is complete and correct, you
need not complete Items I, III, V, and VI (except VI-B which
must be completed regardless). Complete all items if no label
has been provided. Refer to the instructions for detailed item
descriptions and for the legal authorizations under which this
data is collected.
LABEL ITEMS
I.
T/A
F
PLEASE PLACE LABEL IN THIS SPACE
II. POLLUTANT CHARACTERISTICS
INSTRUCTIONS: Complete A through J to determine whether you need to submit any permit application forms to the EPA. If you answer “yes” to any questions, you must
submit this form and the supplemental form listed in the parenthesis following the question. Mark “X” in the box in the third column if the supplemental form is attached. If
you answer “no” to each question, you need not submit any of these forms. You may answer “no” if your activity is excluded from permit requirements; see Section C of the
instructions. See also, Section D of the instructions for definitions of bold-faced terms.
Mark “X”
YES
SPECIFIC QUESTIONS
NO
Mark “X”
FORM
ATTACHED
SPECIFIC QUESTIONS
18
B. Does or will this facility (either existing or proposed)
include a concentrated animal feeding operation or
aquatic animal production facility which results in a
discharge to waters of the U.S.? (FORM 2B)
A. Is this facility a publicly owned treatment works which
results in a discharge to waters of the U.S.? (FORM 2A)
16
C. Is this a facility which currently results in discharges to
waters of the U.S. other than those described in A or B
above? (FORM 2C)
22
17
23
24
E. Does or will this facility treat, store, or dispose of
hazardous wastes? (FORM 3)
28
G. Do you or will you inject at this facility any produced water
or other fluids which are brought to the surface in
connection with conventional oil or natural gas production,
inject fluids used for enhanced recovery of oil or natural
gas, or inject fluids for storage of liquid hydrocarbons?
(FORM 4)
I. Is this facility a proposed stationary source which is one
of the 28 industrial categories listed in the instructions and
which will potentially emit 100 tons per year of any air
pollutant regulated under the Clean Air Act and may affect
or be located in an attainment area? (FORM 5)
29
30
D. Is this a proposed facility (other than those described in A
or B above) which will result in a discharge to waters of
the U.S.? (FORM 2D)
F. Do you or will you inject at this facility industrial or
municipal effluent below the lowermost stratum
containing, within one quarter mile of the well bore,
underground sources of drinking water? (FORM 4)
YES
NO
FORM
ATTACHED
19
20
21
25
26
27
31
32
33
37
38
39
43
44
45
H. Do you or will you inject at this facility fluids for special
processes such as mining of sulfur by the Frasch process,
solution mining of minerals, in situ combustion of fossil
fuel, or recovery of geothermal energy? (FORM 4)
34
40
35
41
36
42
J. Is this facility a proposed stationary source which is
NOT one of the 28 industrial categories listed in the
instructions and which will potentially emit 250 tons per
year of any air pollutant regulated under the Clean Air Act
and may affect or be located in an attainment area?
(FORM 5)
III. NAME OF FACILITY
C
1
15
SKIP
16 – 29
30
69
IV. FACILITY CONTACT
A. NAME & TITLE (last, first, & title)
B. PHONE (area code & no.)
C
2
15
16
45
46
48
49
51
52-
55
V. FACILTY MAILING ADDRESS
A. STREET OR P.O. BOX
C
3
15
16
45
B. CITY OR TOWN
C. STATE
D. ZIP CODE
C
4
15
16
40
41
42
47
51
VI. FACILITY LOCATION
A. STREET, ROUTE NO. OR OTHER SPECIFIC IDENTIFIER
C
5
15
16
45
B. COUNTY NAME
46
70
C. CITY OR TOWN
D. STATE
F. COUNTY CODE (if known)
E. ZIP CODE
C
6
15
16
EPA Form 3510-1 (8-90)
40
41
42
47
51
52
-54
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
VII. SIC CODES (4-digit, in order of priority)
A. FIRST
C
(specify)
7
15
16
-
B. SECOND
C
(specify)
7
19
15
16
-
19
C. THIRD
7
15
D. FOURTH
(specify)
C
16
-
(specify)
C
7
19
15
16
-
19
VIII. OPERATOR INFORMATION
B. Is the name listed in Item
VIII-A also the owner?
A. NAME
C
8
15
YES NO
55 66
16
C. STATUS OF OPERATOR (Enter the appropriate letter into the answer box: if “Other,” specify.)
F = FEDERAL
S = STATE
P = PRIVATE
D. PHONE (area code & no.)
(specify)
M = PUBLIC (other than federal or state)
O = OTHER (specify)
c
A
56
15
6
-
18
19
-
21
22
-
26
E. STREET OR P.O. BOX
26
55
F. CITY OR TOWN
G. STATE
H. ZIP CODE
C
YES
B
15
16
40 41
X. EXISTING ENVIRONMENTAL PERMITS
A. NPDES (Discharges to Surface Water)
C
T
16
17
18
30
C
T
T
I
9
P
15
16
C
9 U
15
16
17
18
17
T
16
51
NO
52
T
I
16
17
30
9
18
30
I
15
C
9 R
15
-
E. OTHER (specify)
(specify)
18
C. RCRA (Hazardous Wastes)
C
47
I
B. UIC (Underground Injection of Fluids)
C
42
D. PSD (Air Emissions from Proposed Sources)
I
9 N
15
IX. INDIAN LAND
Is the facility located on Indian lands?
T
I
16
17
30
E. OTHER (specify)
(specify)
9
17
18
30
15
18
30
XI. MAP
Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the
location of each of its existing and proposed intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it
injects fluids underground. Include all springs, rivers, and other surface water bodies in the map area. See instructions for precise requirements.
XII. NATURE OF BUSINESS (provide a brief description)
XIII. CERTIFICATION (see instructions)
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my
inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate, and complete. I
am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.
A. NAME & OFFICIAL TITLE (type or print)
B. SIGNATURE
C. DATE SIGNED
COMMENTS FOR OFFICIAL USE ONLY
C
C
15
16
EPA Form 3510-1 (8-90)
55
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
FACILITY NAME AND PERMIT NUMBER:
FORM
2A
Form Approved 1/14/99
OMB Number 2040-0086
NPDES FORM 2A APPLICATION OVERVIEW
NPDES
APPLICATION OVERVIEW
Form 2A has been developed in a modular format and consists of a "Basic Application Information" packet and
a "Supplemental Application Information" packet. The Basic Application Information packet is divided into two
parts. All applicants must complete Parts A and C. Applicants with a design flow greater than or equal to 0.1
mgd must also complete Part B. Some applicants must also complete the Supplemental Application
Information packet. The following items explain which parts of Form 2A you must complete.
BASIC APPLICATION INFORMATION:
A.
Basic Application Information for all Applicants. All applicants must complete questions A.1 through A.8. A treatment
works that discharges effluent to surface waters of the United States must also answer questions A.9 through A.12.
B.
Additional Application Information for Applicants with a Design Flow > 0.1 mgd. All treatment works that have design
flows greater than or equal to 0.1 million gallons per day must complete questions B.1 through B.6.
C.
Certification. All applicants must complete Part C (Certification).
SUPPLEMENTAL APPLICATION INFORMATION:
D.
Expanded Effluent Testing Data. A treatment works that discharges effluent to surface waters of the United States and
meets one or more of the following criteria must complete Part D (Expanded Effluent Testing Data):
1. Has a design flow rate greater than or equal to 1 mgd,
2. Is required to have a pretreatment program (or has one in place), or
3. Is otherwise required by the permitting authority to provide the information.
E.
Toxicity Testing Data. A treatment works that meets one or more of the following criteria must complete Part E (Toxicity
Testing Data):
1. Has a design flow rate greater than or equal to 1 mgd,
2. Is required to have a pretreatment program (or has one in place), or
3. Is otherwise required by the permitting authority to submit results of toxicity testing.
F.
Industrial User Discharges and RCRA/CERCLA Wastes. A treatment works that accepts process wastewater from any
significant industrial users (SIUs) or receives RCRA or CERCLA wastes must complete Part F (Industrial User Discharges and
RCRA/CERCLA Wastes). SIUs are defined as:
1. All industrial users subject to Categorical Pretreatment Standards under 40 Code of Federal Regulations (CFR) 403.6 and
40 CFR Chapter I, Subchapter N (see instructions); and
2. Any other industrial user that:
a. Discharges an average of 25,000 gallons per day or more of process wastewater to the treatment works (with certain
exclusions); or
b. Contributes a process wastestream that makes up 5 percent or more of the average dry weather hydraulic or organic
capacity of the treatment plant; or
c. Is designated as an SIU by the control authority.
G.
Combined Sewer Systems. A treatment works that has a combined sewer system must complete Part G (Combined Sewer
Systems).
ALL APPLICANTS MUST COMPLETE PART C (CERTIFICATION)
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 1 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
BASIC APPLICATION INFORMATION
PART A. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS:
All treatment works must complete questions A.1 through A.8 of this Basic Application Information packet.
A.1. Facility Information.
Facility name
Mailing Address
Contact person
Title
Telephone number
Facility Address
(not P.O. Box)
A.2. Applicant Information. If the applicant is different from the above, provide the following:
Applicant name
Mailing Address
Contact person
Title
Telephone number
Is the applicant the owner or operator (or both) of the treatment works?
owner
operator
Indicate whether correspondence regarding this permit should be directed to the facility or the applicant.
facility
applicant
A.3. Existing Environmental Permits. Provide the permit number of any existing environmental permits that have been issued to the treatment
works (include state-issued permits).
NPDES
PSD
UIC
Other
RCRA
Other
A.4. Collection System Information. Provide information on municipalities and areas served by the facility. Provide the name and population of
each entity and, if known, provide information on the type of collection system (combined vs. separate) and its ownership (municipal, private,
etc.).
Name
Population Served
Type of Collection System
Ownership
Total population served
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 2 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
A.5. Indian Country.
a. Is the treatment works located in Indian Country?
Yes
No
b. Does the treatment works discharge to a receiving water that is either in Indian Country or that is upstream from (and eventually flows
through) Indian Country?
Yes
No
A.6. Flow. Indicate the design flow rate of the treatment plant (i.e., the wastewater flow rate that the plant was built to handle). Also provide the
average daily flow rate and maximum daily flow rate for each of the last three years. Each year's data must be based on a 12-month time
period with the 12th month of "this year" occurring no more than three months prior to this application submittal.
a. Design flow rate _______________ mgd
Two Years Ago
Last Year
This Year
b. Annual average daily flow rate
mgd
c.
mgd
Maximum daily flow rate
A.7. Collection System. Indicate the type(s) of collection system(s) used by the treatment plant. Check all that apply. Also estimate the percent
contribution (by miles) of each.
Separate sanitary sewer
%
Combined storm and sanitary sewer
%
A.8. Discharges and Other Disposal Methods.
a. Does the treatment works discharge effluent to waters of the U.S.?
Yes
No
Yes
No
If yes, list how many of each of the following types of discharge points the treatment works uses:
i.
Discharges of treated effluent
ii.
Discharges of untreated or partially treated effluent
iii. Combined sewer overflow points
iv. Constructed emergency overflows (prior to the headworks)
v.
Other
b. Does the treatment works discharge effluent to basins, ponds, or other surface
impoundments that do not have outlets for discharge to waters of the U.S.?
If yes, provide the following for each surface impoundment:
Location:
Annual average daily volume discharged to surface impoundment(s)
Is discharge
c.
continuous or
mgd
intermittent?
Does the treatment works land-apply treated wastewater?
Yes
No
Yes
No
If yes, provide the following for each land application site:
Location:
Number of acres:
Annual average daily volume applied to site:
Is land application
continuous or
Mgd
intermittent?
d. Does the treatment works discharge or transport treated or untreated wastewater to another
treatment works?
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 3 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
If yes, describe the mean(s) by which the wastewater from the treatment works is discharged or transported to the other treatment
works (e.g., tank truck, pipe).
If transport is by a party other than the applicant, provide:
Transporter name:
Mailing Address:
Contact person:
Title:
Telephone number:
For each treatment works that receives this discharge, provide the following:
Name:
Mailing Address:
Contact person:
Title:
Telephone number:
If known, provide the NPDES permit number of the treatment works that receives this discharge.
Provide the average daily flow rate from the treatment works into the receiving facility.
e. Does the treatment works discharge or dispose of its wastewater in a manner not included in
A.8.a through A.8.d above (e.g., underground percolation, well injection)?
mgd
Yes
No
If yes, provide the following for each disposal method:
Description of method (including location and size of site(s) if applicable):
Annual daily volume disposed of by this method:
Is disposal through this method
continuous or
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
intermittent?
Page 4 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
WASTEWATER DISCHARGES:
If you answered "yes" to question A.8.a, complete questions A.9 through A.12 once for each outfall (including bypass points) through
which effluent is discharged. Do not include information on combined sewer overflows in this section. If you answered "no" to question
A.8.a, go to Part B, “Additional Application Information for Applicants with a Design Flow Greater than or Equal to 0.1 mgd.”
A.9. Description of Outfall.
a. Outfall number
b. Location
c.
(City or town, if applicable)
(Zip Code)
(County)
(State)
(Latitude)
(Longitude)
Distance from shore (if applicable)
ft.
d. Depth below surface (if applicable)
ft.
e. Average daily flow rate
mgd
f.
Does this outfall have either an intermittent or a
periodic discharge?
Yes
No
(go to A.9.g.)
If yes, provide the following information:
Number of times per year discharge occurs:
Average duration of each discharge:
Average flow per discharge:
mgd
Months in which discharge occurs:
g. Is outfall equipped with a diffuser?
Yes
No
A.10. Description of Receiving Waters.
a. Name of receiving water
b. Name of watershed (if known)
United States Soil Conservation Service 14-digit watershed code (if known):
c.
Name of State Management/River Basin (if known):
United States Geological Survey 8-digit hydrologic cataloging unit code (if known):
d. Critical low flow of receiving stream (if applicable):
acute
cfs
chronic ______________ cfs
e. Total hardness of receiving stream at critical low flow (if applicable): _______________ mg/l of CaCO3
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 5 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
A.11. Description of Treatment.
a. What levels of treatment are provided? Check all that apply.
Primary
Secondary
Advanced
Other.
Describe:
b. Indicate the following removal rates (as applicable):
Design BOD removal or Design CBOD removal
%
Design SS removal
%
Design P removal
%
Design N removal
%
Other
%
5
c.
5
What type of disinfection is used for the effluent from this outfall? If disinfection varies by season, please describe.
If disinfection is by chlorination, is dechlorination used for this outfall?
d. Does the treatment plant have post aeration?
Yes
No
Yes
No
A.12. Effluent Testing Information. All Applicants that discharge to waters of the US must provide effluent testing data for the following
parameters. Provide the indicated effluent testing required by the permitting authority for each outfall through which effluent is
discharged. Do not include information on combined sewer overflows in this section. All information reported must be based on data
collected through analysis conducted using 40 CFR Part 136 methods. In addition, this data must comply with QA/QC requirements
of 40 CFR Part 136 and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136.
At a minimum, effluent testing data must be based on at least three samples and must be no more than four and one-half years apart.
Outfall number:
PARAMETER
MAXIMUM DAILY VALUE
Value
Units
pH (Minimum)
s.u.
pH (Maximum)
s.u.
AVERAGE DAILY VALUE
Value
Units
Number of Samples
Flow Rate
Temperature (Winter)
Temperature (Summer)
* For pH please report a minimum and a maximum daily value
MAXIMUM DAILY
DISCHARGE
POLLUTANT
Conc.
Units
AVERAGE DAILY DISCHARGE
Conc.
Units
ANALYTICAL
METHOD
ML / MDL
Number of
Samples
CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS.
BIOCHEMICAL OXYGEN
BOD-5
DEMAND (Report one)
CBOD-5
FECAL COLIFORM
TOTAL SUSPENDED SOLIDS (TSS)
END OF PART A.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 6 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
BASIC APPLICATION INFORMATION
PART B.
ADDITIONAL APPLICATION INFORMATION FOR APPLICANTS WITH A DESIGN FLOW GREATER THAN OR
EQUAL TO 0.1 MGD (100,000 gallons per day).
All applicants with a design flow rate > 0.1 mgd must answer questions B.1 through B.6. All others go to Part C (Certification).
B.1. Inflow and Infiltration. Estimate the average number of gallons per day that flow into the treatment works from inflow and/or infiltration.
___________________gpd
Briefly explain any steps underway or planned to minimize inflow and infiltration.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
B.2. Topographic Map. Attach to this application a topographic map of the area extending at least one mile beyond facility property boundaries.
This map must show the outline of the facility and the following information. (You may submit more than one map if one map does not show
the entire area.)
a. The area surrounding the treatment plant, including all unit processes.
b. The major pipes or other structures through which wastewater enters the treatment works and the pipes or other structures through which
treated wastewater is discharged from the treatment plant. Include outfalls from bypass piping, if applicable.
c.
Each well where wastewater from the treatment plant is injected underground.
d. Wells, springs, other surface water bodies, and drinking water wells that are: 1) within 1/4 mile of the property boundaries of the treatment
works, and 2) listed in public record or otherwise known to the applicant.
e. Any areas where the sewage sludge produced by the treatment works is stored, treated, or disposed.
f.
If the treatment works receives waste that is classified as hazardous under the Resource Conservation and Recovery Act (RCRA) by
truck, rail, or special pipe, show on the map where that hazardous waste enters the treatment works and where it is treated, stored, and/or
disposed.
B.3. Process Flow Diagram or Schematic. Provide a diagram showing the processes of the treatment plant, including all bypass piping and all
backup power sources or redundancy in the system. Also provide a water balance showing all treatment units, including disinfection (e.g,
chlorination and dechlorination). The water balance must show daily average flow rates at influent and discharge points and approximate daily
flow rates between treatment units. Include a brief narrative description of the diagram.
B.4. Operation/Maintenance Performed by Contractor(s).
Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works the responsibility of a
contractor?
____Yes ____No
If yes, list the name, address, telephone number, and status of each contractor and describe the contractor's responsibilities (attach additional
pages if necessary).
Name:
Mailing Address:
Telephone Number:
Responsibilities of Contractor:
B.5. Scheduled Improvements and Schedules of Implementation. Provide information on any uncompleted implementation schedule or
uncompleted plans for improvements that will affect the wastewater treatment, effluent quality, or design capacity of the treatment works. If the
treatment works has several different implementation schedules or is planning several improvements, submit separate responses to question
B.5 for each. (If none, go to question B.6.)
a.
List the outfall number (assigned in question A.9) for each outfall that is covered by this implementation schedule.
__________________________________________________________________________
b.
Indicate whether the planned improvements or implementation schedule are required by local, State, or Federal agencies.
____Yes ____No
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 7 of 21
FACILITY NAME AND PERMIT NUMBER:
c
Form Approved 1/14/99
OMB Number 2040-0086
If the answer to B.5.b is “Yes,” briefly describe, including new maximum daily inflow rate (if applicable).
____________________________________________________________________________________
d.
e.
Provide dates imposed by any compliance schedule or any actual dates of completion for the implementation steps listed below, as
applicable. For improvements planned independently of local, State, or Federal agencies, indicate planned or actual completion dates, as
applicable. Indicate dates as accurately as possible.
Schedule
Actual Completion
Implementation Stage
MM / DD / YYYY
MM / DD / YYYY
– Begin construction
___/ ___/ _____
___/ ___/ _____
– End construction
___/ ___/ _____
___/ ___/ _____
– Begin discharge
___/ ___/ _____
___/ ___/ _____
– Attain operational level
___/ ___/ _____
___/ ___/ _____
Have appropriate permits/clearances concerning other Federal/State requirements been obtained?
____Yes
____No
Describe briefly: ________________________________________________________
________________________________________________________
B.6. EFFLUENT TESTING DATA (GREATER THAN O.1 MGD ONLY).
Applicants that discharge to waters of the US must provide effluent testing data for the following parameters. Provide the indicated effluent
testing required by the permitting authority for each outfall through which effluent is discharged. Do not include information on combined sewer
overflows in this section. All information reported must be based on data collected through analysis conducted using 40 CFR Part 136
methods. In addition, this data must comply with QA/QC requirements of 40 CFR Part 136 and other appropriate QA/QC requirements for
standard methods for analytes not addressed by 40 CFR Part 136. At a minimum, effluent testing data must be based on at least three
pollutant scans and must be no more than four and one-half years old.
Outfall Number:________________
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc.
Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Number of
Samples
ANALYTICAL
METHOD
ML / MDL
CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS.
AMMONIA (as N)
CHLORINE (TOTAL
RESIDUAL, TRC)
DISSOLVED OXYGEN
TOTAL KJELDAHL
NITROGEN (TKN)
NITRATE PLUS NITRITE
NITROGEN
OIL and GREASE
PHOSPHORUS (Total)
TOTAL DISSOLVED
SOLIDS (TDS)
OTHER
END OF PART B.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 8 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
BASIC APPLICATION INFORMATION
PART C. CERTIFICATION
All applicants must complete the Certification Section. Refer to instructions to determine who is an officer for the purposes of this certification. All
applicants must complete all applicable sections of Form 2A, as explained in the Application Overview. Indicate below which parts of Form 2A you
have completed and are submitting. By signing this certification statement, applicants confirm that they have reviewed Form 2A and have completed
all sections that apply to the facility for which this application is submitted.
Indicate which parts of Form 2A you have completed and are submitting:
_____ Basic Application Information packet
Supplemental Application Information packet:
______ Part D (Expanded Effluent Testing Data)
______ Part E (Toxicity Testing: Biomonitoring Data)
______ Part F (Industrial User Discharges and RCRA/CERCLA Wastes)
______ Part G (Combined Sewer Systems)
ALL APPLICANTS MUST COMPLETE THE FOLLOWING 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 gather and evaluate 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 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 and official title
_____________________________________________________________________________
Signature
____________________________________________________________________________
Telephone number
_____________________________________________________________________________
Date signed
______________________________________________________________________________
Upon request of the permitting authority, you must submit any other information necessary to assess wastewater treatment practices at the treatment
works or identify appropriate permitting requirements.
SEND COMPLETED FORMS TO:
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 9 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
SUPPLEMENTAL APPLICATION INFORMATION
PART D. EXPANDED EFFLUENT TESTING DATA
Refer to the directions on the cover page to determine whether this section applies to the treatment works.
Effluent Testing: 1.0 mgd and Pretreatment Treatment Works. If the treatment works has a design flow greater than or equal to 1.0 mgd or it has
(or is required to have) a pretreatment program, or is otherwise required by the permitting authority to provide the data, then provide effluent testing
data for the following pollutants. Provide the indicated effluent testing information and any other information required by the permitting authority for
each outfall through which effluent is discharged. Do not include information on combined sewer overflows in this section. All information reported
must be based on data collected through analyses conducted using 40 CFR Part 136 methods. In addition, these data must comply with QA/QC
requirements of 40 CFR Part 136 and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136.
Indicate in the blank rows provided below any data you may have on pollutants not specifically listed in this form. At a minimum, effluent testing data
must be based on at least three pollutant scans and must be no more than four and one-half years old.
Outfall number: _________________ (Complete once for each outfall discharging effluent to waters of the United States.)
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc. Units Mass Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Mass
Units
Number
of
Samples
ANALYTICAL
METHOD
ML/ MDL
METALS (TOTAL RECOVERABLE), CYANIDE, PHENOLS, AND HARDNESS.
ANTIMONY
ARSENIC
BERYLLIUM
CADMIUM
CHROMIUM
COPPER
LEAD
MERCURY
NICKEL
SELENIUM
SILVER
THALLIUM
ZINC
CYANIDE
TOTAL PHENOLIC COMPOUNDS
HARDNESS (AS CaCO3)
Use this space (or a separate sheet) to provide information on other metals requested by the permit writer.
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 10 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.)
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc. Units Mass Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Mass
Units
Number
of
Samples
ANALYTICAL
METHOD
ML/ MDL
VOLATILE ORGANIC COMPOUNDS.
ACROLEIN
ACRYLONITRILE
BENZENE
BROMOFORM
CARBON TETRACHLORIDE
CLOROBENZENE
CHLORODIBROMO-METHANE
CHLOROETHANE
2-CHLORO-ETHYLVINYL
ETHER
CHLOROFORM
DICHLOROBROMO-METHANE
1,1-DICHLOROETHANE
1,2-DICHLOROETHANE
TRANS-1,2-DICHLORO-ETHYLENE
1,1-DICHLOROETHYLENE
1,2-DICHLOROPROPANE
1,3-DICHLORO-PROPYLENE
ETHYLBENZENE
METHYL BROMIDE
METHYL CHLORIDE
METHYLENE CHLORIDE
1,1,2,2-TETRACHLORO-ETHANE
TETRACHLORO-ETHYLENE
TOLUENE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 11 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.)
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc. Units Mass Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Mass
Units
Number
of
Samples
ANALYTICAL
METHOD
ML/ MDL
1,1,1-TRICHLOROETHANE
1,1,2-TRICHLOROETHANE
TRICHLORETHYLENE
VINYL CHLORIDE
Use this space (or a separate sheet) to provide information on other volatile organic compounds requested by the permit writer.
ACID-EXTRACTABLE COMPOUNDS
P-CHLORO-M-CRESOL
2-CHLOROPHENOL
2,4-DICHLOROPHENOL
2,4-DIMETHYLPHENOL
4,6-DINITRO-O-CRESOL
2,4-DINITROPHENOL
2-NITROPHENOL
4-NITROPHENOL
PENTACHLOROPHENOL
PHENOL
2,4,6-TRICHLOROPHENOL
Use this space (or a separate sheet) to provide information on other acid-extractable compounds requested by the permit writer.
BASE-NEUTRAL COMPOUNDS.
ACENAPHTHENE
ACENAPHTHYLENE
ANTHRACENE
BENZIDINE
BENZO(A)ANTHRACENE
BENZO(A)PYRENE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 12 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.)
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc. Units Mass Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Mass
Units
Number
of
Samples
ANALYTICAL
METHOD
ML/ MDL
3,4 BENZO-FLUORANTHENE
BENZO(GHI)PERYLENE
BENZO(K)FLUORANTHENE
BIS (2-CHLOROETHOXY)
METHANE
BIS (2-CHLOROETHYL)-ETHER
BIS (2-CHLOROISO-PROPYL)
ETHER
BIS (2-ETHYLHEXYL) PHTHALATE
4-BROMOPHENYL PHENYL ETHER
BUTYL BENZYL PHTHALATE
2-CHLORONAPHTHALENE
4-CHLORPHENYL PHENYL ETHER
CHRYSENE
DI-N-BUTYL PHTHALATE
DI-N-OCTYL PHTHALATE
DIBENZO(A,H) ANTHRACENE
1,2-DICHLOROBENZENE
1,3-DICHLOROBENZENE
1,4-DICHLOROBENZENE
3,3-DICHLOROBENZIDINE
DIETHYL PHTHALATE
DIMETHYL PHTHALATE
2,4-DINITROTOLUENE
2,6-DINITROTOLUENE
1,2-DIPHENYLHYDRAZINE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 13 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.)
POLLUTANT
MAXIMUM DAILY
DISCHARGE
Conc. Units Mass Units
AVERAGE DAILY DISCHARGE
Conc.
Units
Mass
Units
Number
of
Samples
ANALYTICAL
METHOD
ML/ MDL
FLUORANTHENE
FLUORENE
HEXACHLOROBENZENE
HEXACHLOROBUTADIENE
HEXACHLOROCYCLOPENTADIENE
HEXACHLOROETHANE
INDENO(1,2,3-CD)PYRENE
ISOPHORONE
NAPHTHALENE
NITROBENZENE
N-NITROSODI-N-PROPYLAMINE
N-NITROSODI- METHYLAMINE
N-NITROSODI-PHENYLAMINE
PHENANTHRENE
PYRENE
1,2,4-TRICHLOROBENZENE
Use this space (or a separate sheet) to provide information on other base-neutral compounds requested by the permit writer.
Use this space (or a separate sheet) to provide information on other pollutants (e.g., pesticides) requested by the permit writer.
END OF PART D.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 14 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
SUPPLEMENTAL APPLICATION INFORMATION
PART E. TOXICITY TESTING DATA
POTWs meeting one or more of the following criteria must provide the results of whole effluent toxicity tests for acute or chronic toxicity for each of
the facility’s discharge points: 1) POTWs with a design flow rate greater than or equal to 1.0 mgd; 2) POTWs with a pretreatment program (or those
that are required to have one under 40 CFR Part 403); or 3) POTWs required by the permitting authority to submit data for these parameters.
•
At a minimum, these results must include quarterly testing for a 12-month period within the past 1 year using multiple species (minimum of
two species), or the results from four tests performed at least annually in the four and one-half years prior to the application, provided the
results show no appreciable toxicity, and testing for acute and/or chronic toxicity, depending on the range of receiving water dilution. Do
not include information on combined sewer overflows in this section. All information reported must be based on data collected through
analysis conducted using 40 CFR Part 136 methods. In addition, this data must comply with QA/QC requirements of 40 CFR Part 136
and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136.
•
In addition, submit the results of any other whole effluent toxicity tests from the past four and one-half years. If a whole effluent toxicity
test conducted during the past four and one-half years revealed toxicity, provide any information on the cause of the toxicity or any results
of a toxicity reduction evaluation, if one was conducted.
•
If you have already submitted any of the information requested in Part E, you need not submit it again. Rather, provide the information
requested in question E.4 for previously submitted information. If EPA methods were not used, report the reasons for using alternate
methods. If test summaries are available that contain all of the information requested below, they may be submitted in place of Part E.
If no biomonitoring data is required, do not complete Part E. Refer to the Application Overview for directions on which other sections of the form to
complete.
E.1. Required Tests.
Indicate the number of whole effluent toxicity tests conducted in the past four and one-half years.
____chronic
____acute
E.2. Individual Test Data. Complete the following chart for each whole effluent toxicity test conducted in the last four and one-half years. Allow one
column per test (where each species constitutes a test). Copy this page if more than three tests are being reported.
Test number:________
Test number:________
Test number:________
a. Test information.
Test species & test method number
Age at initiation of test
Outfall number
Dates sample collected
Date test started
Duration
b. Give toxicity test methods followed.
Manual title
Edition number and year of publication
Page number(s)
c. Give the sample collection method(s) used. For multiple grab samples, indicate the number of grab samples used.
24-Hour composite
Grab
d. Indicate where the sample was taken in relation to disinfection. (Check all that apply for each)
Before disinfection
After disinfection
After dechlorination
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 15 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Test number:________
Test number:________
Test number:________
e. Describe the point in the treatment process at which the sample was collected.
Sample was collected:
f. For each test, include whether the test was intended to assess chronic toxicity, acute toxicity, or both.
Chronic toxicity
Acute toxicity
g. Provide the type of test performed.
Static
Static-renewal
Flow-through
h. Source of dilution water. If laboratory water, specify type; if receiving water, specify source.
Laboratory water
Receiving water
i. Type of dilution water. It salt water, specify “natural” or type of artificial sea salts or brine used.
Fresh water
Salt water
j. Give the percentage effluent used for all concentrations in the test series.
k. Parameters measured during the test. (State whether parameter meets test method specifications)
pH
Salinity
Temperature
Ammonia
Dissolved oxygen
l. Test Results.
Acute:
Percent survival in 100%
effluent
%
%
%
95% C.I.
%
%
%
Control percent survival
%
%
%
LC50
Other (describe)
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 16 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
Chronic:
NOEC
%
%
%
IC25
%
%
%
Control percent survival
%
%
%
Other (describe)
m. Quality Control/Quality Assurance.
Is reference toxicant data available?
Was reference toxicant test within
acceptable bounds?
What date was reference toxicant test
run (MM/DD/YYYY)?
Other (describe)
E.3. Toxicity Reduction Evaluation. Is the treatment works involved in a Toxicity Reduction Evaluation?
____Yes ____No
If yes, describe:
____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
E.4. Summary of Submitted Biomonitoring Test Information. If you have submitted biomonitoring test information, or information regarding the
cause of toxicity, within the past four and one-half years, provide the dates the information was submitted to the permitting authority and a
summary of the results.
Date submitted:
________________ (MM/DD/YYYY)
Summary of results: (see instructions)
____________________________________________________________________________________
____________________________________________________________________________________
END OF PART E.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE.
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 17 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
SUPPLEMENTAL APPLICATION INFORMATION
PART F.
INDUSTRIAL USER DISCHARGES AND RCRA/CERCLA WASTES
All treatment works receiving discharges from significant industrial users or which receive RCRA, CERCLA, or other remedial wastes must
complete Part F.
GENERAL INFORMATION:
F.1. Pretreatment Program. Does the treatment works have, or is it subject to, an approved pretreatment program?
____Yes ____No
F.2.
Number of Significant Industrial Users (SIUs) and Categorical Industrial Users (CIUs). Provide the number of each of the following types
of industrial users that discharge to the treatment works.
a. Number of non-categorical SIUs.
____________
b. Number of CIUs.
____________
SIGNIFICANT INDUSTRIAL USER INFORMATION:
Supply the following information for each SIU. If more than one SIU discharges to the treatment works, copy questions F.3 through F.8
and provide the information requested for each SIU.
F.3. Significant Industrial User Information. Provide the name and address of each SIU discharging to the treatment works. Submit additional
pages as necessary.
Name:
____________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________
____________________________________________________________________________________
F.4.
Industrial Processes. Describe all of the industrial processes that affect or contribute to the SIU's discharge.
_______________________________________________________________________________________________________
F.5.
F.6.
Principal Product(s) and Raw Material(s). Describe all of the principal processes and raw materials that affect or contribute to the SIU's
discharge.
Principal product(s):
________________________________________________________________________________
Raw material(s):
________________________________________________________________________________
Flow Rate.
a. Process wastewater flow rate. Indicate the average daily volume of process wastewater discharged into the collection system in gallons
per day (gpd) and whether the discharge is continuous or intermittent.
_____________ gpd
(_____continuous or ______intermittent)
b. Non-process wastewater flow rate. Indicate the average daily volume of non-process wastewater flow discharged into the collection
system in gallons per day (gpd) and whether the discharge is continuous or intermittent.
_____________ gpd
(_____continuous or ______intermittent)
F.7. Pretreatment Standards. Indicate whether the SIU is subject to the following:
a. Local limits
____Yes
____No
b. Categorical pretreatment standards ____Yes
____No
If subject to categorical pretreatment standards, which category and subcategory?
_______________________________________________________________________________________________________
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 18 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
F.8. Problems at the Treatment Works Attributed to Waste Discharged by the SIU. Has the SIU caused or contributed to any problems (e.g.,
upsets, interference) at the treatment works in the past three years?
____Yes ____No
If yes, describe each episode.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
RCRA HAZARDOUS WASTE RECEIVED BY TRUCK, RAIL, OR DEDICATED PIPELINE:
F.9. RCRA Waste. Does the treatment works receive or has it in the past three years received RCRA hazardous waste by truck, rail, or dedicated
pipe?
____Yes ___No (go to F.12.)
F.10. Waste Transport. Method by which RCRA waste is received (check all that apply):
______Truck
______Rail
______Dedicated Pipe
F.11. Waste Description. Give EPA hazardous waste number and amount (volume or mass, specify units).
EPA Hazardous Waste Number
Amount
Units
_________________________
_______________
_______________
_________________________
_______________
_______________
_________________________
_______________
_______________
CERCLA (SUPERFUND) WASTEWATER, RCRA REMEDIATION/CORRECTIVE
ACTION WASTEWATER, AND OTHER REMEDIAL ACTIVITY WASTEWATER:
F.12. Remediation Waste. Does the treatment works currently (or has it been notified that it will) receive waste from remedial activities?
____Yes (complete F.13 through F.15.)
____No
Provide a list of sites and the requested information (F.13 - F.15.) for each current and future site.
F.13. Waste Origin. Describe the site and type of facility at which the CERCLA/RCRA/or other remedial waste originates (or is expected to originate
in the next five years).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
F.14. Pollutants. List the hazardous constituents that are received (or are expected to be received). Include data on volume and concentration, if
known. (Attach additional sheets if necessary).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
F.15. Waste Treatment.
a. Is this waste treated (or will it be treated) prior to entering the treatment works?
____Yes ____No
If yes, describe the treatment (provide information about the removal efficiency):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
b. Is the discharge (or will the discharge be) continuous or intermittent?
____Continuous
____Intermittent
If intermittent, describe discharge schedule.
____________________________________________________________________________________________________
END OF PART F.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 19 of 21
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
SUPPLEMENTAL APPLICATION INFORMATION
PART G. COMBINED SEWER SYSTEMS
If the treatment works has a combined sewer system, complete Part G.
G.1. System Map. Provide a map indicating the following: (may be included with Basic Application Information)
a. All CSO discharge points.
b. Sensitive use areas potentially affected by CSOs (e.g., beaches, drinking water supplies, shellfish beds, sensitive aquatic ecosystems, and
outstanding natural resource waters).
c.
Waters that support threatened and endangered species potentially affected by CSOs.
G.2. System Diagram. Provide a diagram, either in the map provided in G.1. or on a separate drawing, of the combined sewer collection system
that includes the following information:
a. Locations of major sewer trunk lines, both combined and separate sanitary.
b. Locations of points where separate sanitary sewers feed into the combined sewer system.
c.
Locations of in-line and off-line storage structures.
d. Locations of flow-regulating devices.
e. Locations of pump stations.
CSO OUTFALLS:
Complete questions G.3 through G.6 once for each CSO discharge point.
G.3. Description of Outfall.
a. Outfall number
________________________________
b. Location
________________________________________________________________
(City or town, if applicable)
(Zip Code)
________________________________________________________________
(County)
(State)
________________________________________________________________
(Latitude)
c.
(Longitude)
Distance from shore (if applicable)
____________ft.
d. Depth below surface (if applicable)
____________ft.
e. Which of the following were monitored during the last year for this CSO?
f.
____Rainfall
____CSO pollutant concentrations
____CSO flow volume
____Receiving water quality
How many storm events were monitored during the last year?
____CSO frequency
_____________
G.4. CSO Events.
a. Give the number of CSO events in the last year.
__________ events (___ actual or ___ approx.)
b. Give the average duration per CSO event.
__________ hours (____ actual or ____ approx.)
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 20 of 21
FACILITY NAME AND PERMIT NUMBER:
c.
Form Approved 1/14/99
OMB Number 2040-0086
Give the average volume per CSO event.
__________ million gallons (_____ actual or _____ approx.)
d. Give the minimum rainfall that caused a CSO event in the last year.
__________ inches of rainfall
G.5. Description of Receiving Waters.
a. Name of receiving water: ______________________________________________________________________________
b. Name of watershed/river/stream system: _______________________________________________________________
United States Soil Conservation Service 14-digit watershed code (if known): _______________________________________
c.
Name of State Management/River Basin:
_______________________________________________________________
United States Geological Survey 8-digit hydrologic cataloging unit code (if known):
______________________________
G.6. CSO Operations.
Describe any known water quality impacts on the receiving water caused by this CSO (e.g., permanent or intermittent beach closings,
permanent or intermittent shell fish bed closings, fish kills, fish advisories, other recreational loss, or violation of any applicable State water
quality standard).
______________________________________________________________________________________________
______________________________________________________________________________________________
END OF PART G.
REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM
2A YOU MUST COMPLETE.
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22.
Page 21 of 21
Additional information, if provided, will appear on the following pages.
NPDES FORM 2A Additional Information
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
Form Approved
OMB No. 2040-0250
Approval expires 12-15-05
EPA I.D. NUMBER (copy from Item 1 of Form 1)
FORM
2B
U.S. ENVIRONMENTAL PROTECTION AGENCY
APPLICATIONS FOR PERMIT TO DISCHARGE WASTEWATER
CONCENTRATED ANIMAL FEEDING OPERATIONS AND AQUATIC ANIMAL PRODUCTION
FACILITIES
EPA
NPDES
I. GENERAL INFORMATION
Applying for:
A. TYPE OF BUSINESS
Individual Permit
G
Coverage Under General Permit
B. CONTACT INFORMATION
G
C. FACILITY OPERATION
STATUS
“ 1. Concentrated Animal Feeding
Operation (complete items B, C, D,
and Section II)
Owner/or
Operator Name: __________________________________
“ 1. Existing Facility
Telephone: ( _____ ) ______________________________
“ 2. Proposed Facility
“ 2. Concentrated Aquatic Animal
Production Facility (complete items
B, C, and section III)
Address: ________________________________________
Facsimile: ( _____ ) _______________________________
City: ______________ State:_____ Zip Code: _________
D. FACILITY INFORMATION
Name: ___________________________________________________________ Telephone: ( _____ ) _____________________________
Address: _________________________________________________________ Facsimile: ( _____ ) _____________________________
City: __________________________________ State: ___________________ Zip Code: _____________________________________
County: _________________________ Latitude: _________________________ Longitude: _______________________________
If contract operation: Name of Integrator: _________________________________________________
Address of Integrator: _______________________________________________
II. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS
A. TYPE AND NUMBER OF ANIMALS
B. Manure, Litter and/or Wastewater Production and Use
2. ANIMALS
1. TYPE
“ Mature Dairy Cows
“ Dairy Heifers
“ Veal Calves
“ Cattle (not dairy or veal)
“ Swine (55 lbs. or over)
“ Swine (under 55 lbs.)
“ Horses
“ Sheep or Lambs
“ Turkeys
EPA Form 3510-2B (12-02)
NO. IN OPEN
CONFINEMENT
NO. HOUSED
UNDER ROOF
a) How much manure, litter and wastewater is generated
annually by the facility? _____ tons _______ gallons
b) If land applied how many acres of land under the control of
the applicant are available for applying the CAFOs
manure/litter/wastewater? ____________________ acres
c) How many tons of manure or litter, or gallons of waste
water produced by the CAFO will be transferred annually
tons
to other persons? tons/gallons (circle one)
Form Approved
OMB No. 2040-0250
Approval expires 12-15-05
“ Chickens (Broilers)
“ Chickens (Layers)
“ Ducks
“ Other
Specify ___________
3. TOTAL ANIMALS
C. “ TOPOGRAPHIC MAP
D. TYPE OF CONTAINMENT, STORAGE AND CAPACITY
1. Type of Containment
“
Lagoon
“
Holding Pond
“
Evaporation Pond
“
Other: Specify _______________
Total Capacity (in gallons)
2. Report the total number of acres contributing drainage: __________________________ acres
3. Type of Storage
“
Anaerobic Lagoon
“
Storage Lagoon
“
Evaporation Pond
“
Aboveground Storage Tanks
“
Belowground Storage Tanks
“
Roofed Storage Shed
“
Concrete Pad
“
Impervious Soil Pad
“
Other: Specify _______________
Total Number of
Days
Total Capacity
(gallons/tons)
E. NUTRIENT MANAGEMENT PLAN
A. Has a nutrient management plan been developed?
G Yes
G No
B. Is a nutrient management plan being implemented for the facility?
G Yes
G No
C. If no, when will the nutrient management plan be developed? Date: ____________
D. The date of the last review or revision of the nutrient management plan. Date: ____________
E. If not land applying, describe alternative use(s) of manure, litter and or wastewater:
EPA Form 3510-2B (12-02)
Form Approved
OMB No. 2040-0250
Approval expires 12-15-05
F. LAND APPLICATION BEST MANAGEMENT PRACTICES
Please check any of the following best management practices that are being implemented at the facility to control runoff and protect water
quality:
“ Buffers
“ Setbacks
“ Conservation tillage
“ Constructed wetlands
“ Infiltration field
“ Grass filter
“ Terrace
III. CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY CHARACTERISTICS
A. For each outfall give the maximum daily flow, maximum 30-day
flow, and the long-term average flow.
B. Indicate the total number of ponds, raceways, and similar
structures in your facility.
1. Outfall No.
1. Ponds
2. Flow (gallons per day)
a. Maximum
Daily
b. Maximum
30 Day
c. Long Term
Average
2. Raceways
3. Other
C. Provide the name of the receiving water and the source of water
used by your facility.
1. Receiving Water
2. Water Source
D. List the species of fish or aquatic animals held and fed at your facility. For each species, give the total weight produced by your facility
per year in pounds of harvestable weight, and also give the maximum weight present at any one time.
1. Cold Water Species
a. Species
2. Warm Water Species
b. Harvestable Weight (pounds)
(1) Total Yearly
a. Species
(2) Maximum
E. Report the total pounds of food during the calendar month of
maximum feeding.
b. Harvestable Weight (pounds)
(1) Total Yearly
1. Month
(2) Maximum
2. Pounds of Food
IV. CERTIFICATION
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all
attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the
information is true accurate and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment.
A. Name and Official Title (print or type)
B. Phone No. (
C. Signature
D. Date Signed
EPA Form 3510-2B (12-02)
)
Form Approved
OMB No. 2040-0250
Approval expires 12-15-05
INSTRUCTIONS
GENERAL
This form must be completed by all applicants who check “yes” to
Item II-B in Form 1. Not all animal feeding operations or fish farms are
required to obtain NPDES permits. Exclusions are based on size. See the
description of these statutory and regulatory exclusions in the General
Instructions that accompany Form 1.
For aquatic animal production facilities, the size cutoffs are based on
whether the species are warm water or cold water, on the production
weight per year in harvestable pounds, and on the amount of feeding in
pounds of food (for cold water species). Also, facilities which discharge
less than 30 days per year, or only during periods of excess runoff (for
warm water fish) are not required to have a permit.
Refer to the Form 1 instructions to determine where to file this form.
Item I-A
See the note above and the General Instructions which accompany Form
1 to be sure that your facility is a “concentrated animal feeding
operation” (CAFO).
Item I-B
Use this space to give owner/operator contact information.
Item I-C
Check “proposed” if your facility is not now in operation or is expanding
to meet the definition of a CAFO in accordance with the information
found in the General Instructions that accompany Form 1.
Item I-D
Use this space to give a complete legal description of your facility’s
location including name, address, and latitude/longitude. Also, the if a
contract grower, the name and address of the integrator.
Item II
Supply all information in item II if you checked (1) in item I-A.
Item II-A
Give the maximum number of each type of animal in open confinement
or housed under roof (either partially or totally) which are held at your
facility for a total of 45 days or more in any 12 month period. Provide the
total number of animals confined at the facility.
Item II-B
Provide the total amount of manure, litter and wastewater generated
annually by the facility. Identify if manure, litter and wastewater
generated by the facility is to be land applied and the number of acres,
under the control of the CAFO operator, suitable for land application. If
the answer to question 3 is yes, provide the estimated annual quantity of
manure, litter and wastewater that the applicant plans to transfer off-site.
Item II-C
Check this box if you have submitted a topographic map of the
geographic area in which the CAFO is located showing the specific
location of the production area.
Item II-D
1. Provide information on the type of containment and the capacity of the
containment structure (s).
2. The number of acres that are drained and collected in the containment
structure (s).
3. Identify the type of storage for the manure, litter and/or wastewater.
Give the capacity of this storage in days and gallons or tons.
Item II-E
Provide information concerning the status of the development and
implementation of a nutrient management plan for the facility. In those
cases where the nutrient management plan has not been completed,
provide an estimated date of development and implementation. If not
land applying, describe the alternative uses of the manure, litter and
wastewater (e.g., composting, pelletizing, energy generation, etc.).
Item II-F
Check any of the identified conservation practices that are being
implemented at the facility to control runoff and protect water quality.
Item III
Supply all information in Item III if you checked (2) in Item I-A.
Item III-A
Outfalls should be numbered to correspond with the map submitted in
Item XI of Form 1. Values given for flow should be representative of
your normal operation. The maximum daily flow is the maximum
measured flow occurring over a calendar day. The maximum 30-day
flow is the average of measured daily flow over the calendar month of
highest flow. The long-term average flow is the average of measure daily
flows over a calendar year.
Item III-B
Give the total number of discrete ponds or raceways in your facility.
Under “other,” give a descriptive name of any structure which is not a
pond or a raceway but which results in discharge to waters of the United
States.
Item III-C
Use names for receiving water and source of water which correspond to
the map submitted in Item XI of Form 1.
Item III-D
The names of fish species should be proper, common, or scientific names
as given in special Publication No. 6 of the American Fisheries Society.
“A List of Common and Scientific Names of Fishes from the United
States and Canada.” The values given for total weight produced by your
facility per year and the maximum weight present at any one time should
be representative of your normal operation.
Item III-E
The value given for maximum monthly pounds of food should be
representative of your normal operation.
Item IV
The Clean Water Act provides for severe penalties for submitting false
information on this application form.
Section 309(C)(2) of the Clean Water Act provides that “Any person
who knowingly makes any false statement, representation, or
certification in any application...shall upon conviction, be punished by a
fine of no more than $10,000 or by imprisonment for not more than six
months, or both.”
Federal regulations require the certification to be signed as follows:
A. For corporation, by a principal executive officer of at least the level
of vice president.
B. For a partnership or sole proprietorship, by a general partner or the
proprietor, respectively; or
C. For a municipality, State, Federal, or other public facility, by either
a principal executive officer or ranking elected official.
Paper Reduction Act Notice
The Public reporting burden for this collection of information
estimated to average 4 hours per response. The estimate includes
time for reviewing instructions, searching existing data sources,
gathering and maintaining the needed data, and completing and
reviewing the collection of information. Send comments regarding
the burden estimate or any other aspect of this collection of
information to the chief, Information Policy Branch (PM-223),
U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue,
N.W., Washington, D.C. 20460, and the Office of Information and
Regulatory Afairs, Office of Management and Budget, Washington,
D.C. 20503, marked Attention: Desk Officer for EPA.
EPA Form 3510-2B (12-02)
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
United States
Environmental Protection
Agency
Office of
Enforcement
Washington, DC 20460
EPA Form 3510-2C
Revised August 1990
Previous editions
are obsolete
Permits Division
Application Form 2C –
Wastewater Discharge
Information
Consolidated Permits Program
This form must be completed by all persons applying
for an EPA permit to discharge wastewater (existing
manufacturing, commercial, mining, and silvicultural
operations).
Paperwork Reduction Act Notice
The public reporting burden for this collection of information is
estimated to average 33 hours per response. This estimate
includes time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and
completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect
of this collection of information to the Chief, Information Policy
Branch (PM-223), US Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and
to the Office of Information and Regulatory Affairs, Office of
Management and Budget, Washington, DC 20503, marked
Attention: Desk Officer for EPA.
INSTRUCTIONS – FORM 2c
Application for Permit to Discharge Wastewater
EXISTING MANUFACTURING, COMMERCIAL, MINING. AND SILVICULTURAL OPERATIONS
“Maximum Daily” columns (columns 4-a-2 and 4-b-2). Report the
average of all daily values measured during days when discharge
occurred within the last year in the “Long Term Average” columns
(columns 4-a-1 and 4-b-1).
This form must be completed by all applicants who check “yes” to
item II-C in Form 1.
Public Availability of Submitted Information.
Your application will not be considered complete unless you answer
every question on this form and on Form 1. If an item does not apply
to you, enter “NA” (for not applicable) to show that you considered
the question.
Item III-A
All effluent guidelines promulgated by EPA appear in the Federal
Register and are published annually in 40 CFR Subchapter N. A
guideline applies to you if you have any operations contributing
process wastewater in any subcategory covered by a BPT, BCT, or
BAT guideline. If you are unsure whether you are covered by a
promulgated effluent guideline, check with your EPA Regional office
(Table 1 in the Form 1 instructions). You must check “yes” if an
applicable effluent guideline has been promulgated, even if the
guideline limitations are being contested in court. If you believe that a
promulgated effluent guideline has been remanded for
reconsideration by a court and does not apply to your operations,
you may check “no.”
You may not claim as confidential any information required by this
form or Form 1, whether the information is reported on the forms or
in an attachment. This information will be made available to the
public upon request.
Any information you submit to EPA which goes beyond that required
by this form or Form 1 you may claim as confidential, but claims for
information which is effluent data will be denied. If you do not assert
a claim of confidentiality at the time of submitting the information,
EPA may make the information public without further notice to you.
Claims of confidentiality will be handled in accordance with EPA’s
business confidentiality regulations at 40 CFR Part 2.
Item III-B
An effluent guideline is expressed in terms of production (or other
measure of operation) if the limitation is expressed as mass of
pollutant per operational parameter; for example, “pounds of BOD
per cubic foot of logs from which bark is removed,” or “pounds of
TSS per megawatt hour of electrical energy consumed by smelting
furnace.” An example of a guideline not expressed in terms of a
measure of operation is one which limits the concentration of
pollutants.
Definitions
All significant terms used in these instructions and in the form are
defined in the glossary found in the General Instructions which
accompany Form 1.
EPA ID Number
Fill in your EPA Identification Number at the top of each page of
Form 2c. You may copy this number directly from item I of Form 1.
Item III-C
This item must be completed only if you checked “yes” to item III-B.
The production information requested here is necessary to apply
effluent guidelines to your facility and you cannot claim it as
confidential. However, you do not have to indicate how the reported
information was calculated. Report quantities in the units of
measurement used in the applicable effluent guideline. The
production figures provided must be based on actual daily production
and not on design capacity or on predictions of future operations. To
obtain alternate limits under 40 CFR 122.45(b)(2)(ii), you must define
your maximum production capability and demonstrate to the Director
that your actual production is substantially below maximum
production capability and that there is a reasonable potential for an
increase above actual production during the duration of the permit.
Item I
You may use the map you provided for item XI of Form 1 to
determine the latitude and longitude of each of your outfalls and the
name of the receiving water.
Item II-A
The line drawing should show generally the route taken by water in
your facility from intake to discharge. Show all operations
contributing wastewater, including process and production areas,
sanitary flows, cooling water, and stormwater runoff. You may group
similar operations into a single unit, labeled to correspond to the
more detailed listing in item II-B. The water balance should show
average flows. Show all significant losses of water to products,
atmosphere, and discharge. You should use actual measurements
whenever available; otherwise use your best estimate. An example
of an acceptable line drawing appears in Figure 2c-1 to these
instructions.
Item IV-A
If you check “yes” to this question, complete all parts of the chart, or
attach a copy of any previous submission you have made to EPA
containing same information.
Item II-B
List all sources of wastewater to each outfall. Operations may be
described in general terms (for example, “dye-making reactor” or
“distillation tower”). You may estimate the flow contributed by each
source if no date are available. For stormwater discharges you may
estimate the average flow, but you must indicate the rainfall event
upon which the estimate is based and the method of estimation. For
each treatment unit, indicate its size, flow rate, and retention time,
and describe the ultimate disposal of any solid or liquid wastes not
discharged. Treatment units should be listed in order and you should
select the proper code from Table 2c-1 to fill in column 3-b for each
treatment unit. Insert “XX” into column 3-b if no code corresponds to
a treatment unit you list. If you are applying for a permit for a
privately owned treatment works, you must also identify all of your
contributors in an attached listing.
Item IV-B
You are not required to submit a description of future pollution
control projects if you do not wish to or if none is planned.
Item V-A, B, C, and D
The items require you to collect and report data on the pollutants
discharged for each of your outfalls. Each part of this item addresses
a different set of pollutants and must be completed in accordance
with the specific instructions for that part. The following general
instructions apply to the entire item.
General Instructions
Part A requires you to report at least one analysis for each pollutant
listed. Parts B and C require you to report analytical data in two
ways. For some pollutants, you may be required to mark “X” in the
“Testing Required” column (column 2-a, Part C), and test (sample
and analyze) and report the levels of the pollutants in your discharge
whether or not you expect them to be present in your discharge. For
all others, you must mark “X” in either the “Believe Present” column
or the “Believe Absent” column (columns 2-a or 2-b, Part B, and
columns 2-b or 2-c, Part C) based on your best estimate, and test for
those which you believe to be present. (See specific instructions on
the form and below for Parts A through D.) Base your determination
that a pollutant is present in or absent from your discharge on your
Item II-C
A discharge is intermittent unless it occurs without interruption during
the operating hours of the facility, except for infrequent shutdowns
for maintenance, process changes, or other similar activities. A
discharge is seasonal if it occurs only during certain parts of the
year. Fill in every applicable column in this item for each source of
intermittent or seasonal discharges. Base your answers on actual
data whenever available; otherwise, provide your best estimate.
Report the highest daily value for flow rate and total volume in the
2C-1
FORM 2c – INSTRUCTIONS (continued)
Item V-A, B, C, and D (continued)
times, the collection of duplicate samples, etc. The time when you
sample should be representative of your normal operation, to the
extent feasible, with all processes which contribute wastewater in
normal operation, and with your treatment system operating properly
with no system upsets. Samples should be collected from the center
of the flow channel, where turbulence is at a maximum, at a site
specified in your present permit, or at any site adequate for the
collection of a representative sample.
knowledge of your raw materials, maintenance chemicals,
intermediate and final products and byproducts, and any previous
analyses known to you of your effluent or similar effluent. (For
example, if you manufacture pesticides, you should expect those
pesticides to be present in contaminated stormwater runoff.) If you
would expect a pollutant to be present solely as a result of its
presence in your intake water, you must mark “Believe Present” but
you are not required to analyze for that pollutant. Instead, mark an
‘X’ In the “Intake” column.
A.
For pH, temperature, cyanide, total phenols, residual chlorine, oil and
grease, and fecal coliform, grab samples must be used. For all other
pollutants 24-hour composite samples must be used. However, a
minimum of one grab sample may be taken for effluents from holding
ponds or other impoundments with a retention period of greater than
24 hours. For stormwater discharges a minimum of one to four grab
samples may be taken, depending on the duration of the discharge.
One grab must be taken in the first hour (or less) of discharge, with
one additional grab (up to a minimum of four) taken in each
succeeding hour of discharge for discharges lasting four or more
hours. The Director may waive composite sampling for any outfall for
which you demonstrate that use of an automatic sampler is infeasible
and that a minimum of four grab samples will be representative of
your discharge.
Reporting. All levels must be reported as concentration
and as total mass. You may report some or all of the
required data by attaching separate sheets of paper
instead of filling out pages V-I to V-9 if the separate sheets
contain all the required information in a format which is
consistent with pages V-I to V-9 in spacing and in
identification of pollutants and columns. (For example, the
data system used in your GC/MS analysis may be able to
print data in the proper format.) Use the following
abbreviations in the columns headed “Units” (column 3,
Part A, and column 4, Parts B and C).
Concentration
Mass
ppm…….parts per million
mg/l ...milligrams per liter
ppb.…......parts per billion
ug/l ...micrograms per liter
lbs……………...…….pounds
ton….........tons (English tons)
mg………..............milligrams
g……………….............grams
kg……………..…..kilograms
Grab and composite samples are defined as follows:
Grab sample: An individual sample of at least 100 milliliters
collected at a randomly-selected time over a period not exceeding
15 minutes.
T………..tonnes (metric tons)
Composite sample: A combination of at least 8 sample aliquots
of at least 100 milliliters, collected at periodic intervals during the
operating hours of a facility over a 24 hour period. The composite
must be flow proportional; either the time interval between each
aliquot or the volume of each aliquot must be proportional to either
the stream flow at the time of sampling or the total stream flow
since the collection of the previous aliquot. Aliquots may be
collected manually or automatically. For GC/MS Volatile Organic
Analysis (VOA), aliquots must be combined in the laboratory
immediately before analysis. Four (4) (rather than eight ) aliquots
or grab samples should be collected for VOA. These four samples
should be collected during actual hours of discharge over a 24hour period and need not be flow proportioned. Only one analysis
is required.
All reporting of values for metals must be in terms of “total
recoverable metal,” unless:
(1)
An applicable, promulgated effluent limitation or standard
specifies the limitation for the metal in dissolved, valent, or total
form; or
(2)
All approved analytical methods for the metal inherently
measure only its dissolved form (e.g., hexavalent chromium); or
(3)
The permitting authority has determined that in establishing
case-by-case limitations it is necessary to express the
limitations on the metal in dissolved, valent, or total form to
carry out the provisions of the CWA.
The Agency is currently reviewing sampling requirements in light of
recent research on testing methods. Upon completion of its review,
the Agency plans to propose changes to the sampling requirements.
If you measure only one daily value, complete only the “Maximum
Daily Values” columns and insert ‘1’ into the “Number of Analyses”
column (columns 2-a and 2-d, Part A, and column 3-a, 3-d, Parts B
and C). The permitting authority may require you to conduct
additional analyses to further characterize your discharges. For
composite samples, the daily value is the total mass or average
concentration found in a composite sample taken over the operating
hours of the facility during a 24-hour period; for grab samples, the
daily value is the arithmetic or flow-weighted total mass or average
concentration found in a series of at least four grab samples taken
over the operating hours of the facility during a 24-hour period.
Data from samples taken in the past may be used, provided that:
All data requirements are met;
Sampling was done no more than three years before submission;
and
All data are representative of the present discharge.
Among the factors which would cause the data to be
unrepresentative are significant changes in production level,
changes in raw materials, processes, or final products, and changes
in wastewater treatment. When the Agency promulgates new
analytical methods in 40 CFR Part 136, EPA will provide information
as to when you should use the new methods to generate data on
your discharges. Of course, the Director may request additional
information, including current quantitative data, if she or he
determines it to be necessary to assess your discharges.
If you measure more than one daily value for a pollutant and those
values are representative of your wastestream, you must report
them. You must describe your method of testing and data analysis.
You also must determine the average of all values within the last
year and report the concentration and mass under the “Long Term
Average Values” columns (column 2-c, Part A, and column 3-c, Parts
B and C), and the total number of daily values under the “Number of
Analyses” columns (column 2-d, Part A, and columns 3-d, Parts B
and C). Also, determine the average of all daily values taken during
each calendar month, and report the highest average under the
“Maximum 30-day Values” columns (column 2-c, Part A, and column
3-b, Parts B and C).
C. Analysis: You must use test methods promulgated in 40 CFR
Part 136; however, if none has been promulgated for a particular
pollutant, you may use any suitable method for measuring the level
of the pollutant in your discharge provided that you submit a
description of the method or a reference to a published method. Your
description should include the sample holding time, preservation
techniques, and the quality control measures which you used. If you
have two or more substantially identical outfalls, you may request
permission from your permitting authority to sample and analyse only
one outfall and submit the results of the analysis for other
substantially identical outfalls. If your request is granted by the
B. Sampling: The collection of the samples for the reported
analyses should be supervised by a person experienced in
performing sampling of industrial wastewater. You may contact your
EPA or State permitting authority for detailed guidance on sampling
techniques and for answers to specific questions. Any specific
requirements contained in the applicable analytical methods should
be followed for sample containers, sample preservation, holding
2C-1
FORM 2c – INSTRUCTIONS (continued)
Item V-A, B, C, and D (continued)
treatment works, determine your testing requirements on the basis of
the industry categories of your contributors. When you determine
which industry category you are in to find your testing requirements,
you are not determining your category for any other purpose and you
are not giving up your right to challenge your inclusion in that
category (for example, for deciding whether an effluent guideline is
applicable) before your permit is issued. For all other cases
(secondary industries, nonprocess wastewater outfalls, and
nonrequired GC/MS fractions), you must mark “X” in either the
“Believed Present” column (column 2-b) or the “Believed Absent”
column (column 2-c) for each pollutant. For every pollutant you know
or have reason to believe is present in your discharge in
concentrations of 10 ppb or greater, you must report quantitative
data. For acrolein, acrylonitrile, 2, 4 dinitrophenol, and 2-methyl-4, 6
dinitrophenol, where you expect these four pollutants to be
discharged in concentrations of 100 ppb or greater, you must report
quantitative data. For every pollutant expected to be discharged in
concentrations less than the thresholds specified above, you must
either submit quantitative data or briefly describe the reasons the
pollutant is expected to be discharged. At your request the Director,
Office of Water Enforcement and Permits, may waive the
requirement to test for pollutants for an industrial category or
subcategory. Your request must be supported by data
representatives of the industrial category or subcategory in question.
The data must demonstrate that individual testing for each applicant
is unnecessary, because the facilities in question discharge
substantially identical levels of the pollutant, or discharge the
pollutant uniformly at sufficiently low levels. If you qualify as a small
business (see below) you are exempt from testing for the organic
toxic pollutants, listed on pages V-4 to V-9 in Part C. For pollutants in
intake water, see discussion in General Instructions to this item. The
“Long Term Average Values” column (column 3-c) and “Maximum
30-day Values” column (column 3-b) are not compulsory but should
be filled out if data are available. You are required to mark “Testing
Required” for dioxin if you use or manufacture one of the following
compounds:
permitting authority, on a separate sheet attached to the application
form, identify which outfall you did test, and describe why the outfalls
which you did not test are substantially identical to the outfall which
you did test.
D. Reporting of Intake Data: You are not required to report data
under the “Intake” columns unless you wish to demonstrate your
eligibility for a “net” effluent limitation for one or more pollutants, that
is, an effluent limitation adjusted by subtracting the average level of
the pollutant(s) present in your intake water, NPDES regulations
allow net limitations only in certain circumstances. To demonstrate
your eligibility, under the “Intake” columns report the average of the
results of analyses on your intake water (if your water is treated
before use, test the water after it is treated), and discuss the
requirements for a net limitation with your permitting authority.
Part V-A
Part V-A must be completed by all applicants for all outfalls, including
outfalls containing only noncontact cooling water or storm runoff.
However, at your request, the Director may waive the requirement to
test for one or more of these pollutants, upon a determination that
available information is adequate to support issuance of the permit
with less stringent reporting requirements for these pollutants. You
also may request a waiver for one or more of these pollutants for
your category or subcategory from the Director, Office of Water
Enforcement and Permits. See discussion in General Instructions to
item V for definitions of the columns in Part A. The “Long Term
Average Values” column (column 2-c) and “Maximum 30-day
Values” column (column 2-b) are not compulsory but should be filled
out if data are available.
Use composite samples for all pollutants in this Part, except use grab
samples for pH and temperature. See discussion in General
Instructions to Item V for definitions of the columns in Part A. The
“Long Term Average Values” column (column 2-c) and “Maximum
30-Day Values” column (column 2-b) are not compulsory but should
be filled out if data are available.
Part V-B
Part V-B must be completed by all applicants for all outfalls, including
outfalls containing only noncontact cooling water or storm runoff. You
must report quantitative data if the pollutant(s) in question is limited
in an effluent limitations guideline either directly, or indirectly but
expressly through limitation on an indicator (e.g., use of TSS as an
indicator to control the discharge of iron and aluminum). For other
discharged pollutants you must provide quantitative data or explain
their presence in your discharge. EPA will consider requests to the
Director of the Office of Water Enforcement and Permits to eliminate
the requirement to test for pollutants for an industrial category or
subcategory. Your request must be supported by data representative
of the industrial category or subcategory in question. The data must
demonstrate that individual testing for each applicant is unnecessary,
because the facilities in the category or subcategory discharge
substantially identical levels of the pollutant or discharge the
pollutant uniformly at sufficiently low levels. Use composite samples
for all pollutants you analyze for in this part, except use grab
samples for residual chlorine, oil and grease, and fecal coliform. The
“Long Term Average Values” column (column 3-c) and “Maximum
30-day Values” column (column 3-b) are not compulsory but should
be filled out if data are available.
(a)
2,4,5-trichlorophenoxy acetic acid, (2,4,5-T);
(b)
2-(2,4,5-trichlorophenoxy) propanoic acid, (Silvex, 2,4,5-TP)
(c)
2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate, (Erbon);
(d)
0,0-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate, (Ronnel);
(e)
2,4,5,-trichlorophenol, (TCP); or
(f)
hexachlorophene, (HCP).
If you mark “Testing Required” or “Believed Present,” you must
perform a screening analysis for dioxins, using gas chromotography
with an electron capture detector. A TCDD standard for quantitation
is not required. Describe the results of this analysis in the space
provided; for example, “no measurable baseline deflection at the
retention time of TCDD” or “a measurable peak within the tolerances
of the retention time of TCDD.” The permitting authority may require
you to perform a quantitative analysis if you report a positive result.
The Effluent Guidelines Division of EPA has collected and analyzed
samples from some plants for the pollutants listed in Part C in the
course of its BAT guidelines development program. If your effluents
are sampled and analyzed as part of this program in the last three
years, you may use these data to answer Part C provided that the
permitting authority approves, and provided that no process change
or change in raw materials or operating practices has occurred since
the samples were taken that would make the analyses
unrepresentative of your current discharge.
Part V-C
Table 2c-2 lists the 34 “primary” industry categories in the lefthand
column. For each outfall, if any of your processes which contribute
wastewater falls into one of those categories, you must mark “X” in
“Testing Required” column (column 2-a) and test for (l) all of the toxic
metals, cyanide, and total phenols, and (2) the organic toxic
pollutants contained in Table 2c-2 as applicable to your category,
unless you qualify as a small business (see below). The organic toxic
pollutants are listed by GC/MS fractions on pages V-4 to V-9 in Part
V-C. For example, the Organic Chemicals Industry has an asterisk in
all four fractions; therefore, applicants in this category must test for
all organic toxic pollutants in Part V-C. The inclusion of total phenols
in Part V-C is not intended to classify total phenols as a toxic
pollutant. If you are applying for a permit for a privately owned
Small Business Exemption: If you qualify as a “small business”,
you are exempt from the reporting requirements for the organic toxic
pollutants, listed on pages V-4 to V-9 in Part C. There are two ways
in which you can qualify as a “small business.” If your facility is a coal
mine, and if your probable total annual production is less than
100,000 tons per year, you may submit past production data or
estimated future production (such as a schedule of estimated total
production under 30 CFR § 795.14(c)) instead of conducting
analyses for the organic toxic pollutants. If your facility is not a coal
mine, and if your gross total annual sales for the most recent three
years average less than $100,000 per year (in second quarter 1980
2C-1
FORM 2c – INSTRUCTIONS (continued)
Item V-A, B, C, and D (continued)
40 CFR Part 122.22 requires the certification to be signed as follows:
dollars), you may submit sales data for those years instead of
conducting analyses for the organic toxic pollutants. The production
or sales data must be for the facility which is the source of the
discharge. The data should not be limited to production or sales for
the process or processes which contribute to the discharge, unless
those are the only processes at your facility. For sales data, in
situations involving intracorporate transfer of goods and services, the
transfer price per unit should approximate market prices for those
goods and services as closely as possible. Sales figures for years
after 1980 should be indexed to the second quarter of 1980 by using
the gross national product price deflator (second quarter of
1980=100). This index is available in National Income and Product
Accounts of the United States (Department of Commerce, Bureau of
Economic Analysis).
(A) For a corporation: by a responsible corporate official. For
purposes of this section, a responsible corporate official means (i) a
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 employing more than 250 persons
or having gross annual sales or expenditures exceeding $25,000,000
(in second-quarter 1980 dollars), if authority to sign documents has
been assigned or delegated to the manager in accordance with
corporate procedures.
Note: EPA does not require specific assignments or delegation of
authority to responsible corporate officers identified in
§122.22(a)(1)(i). The Agency will presume that these responsible
corporate officers have the requisite authority to sign permit
applications unless the corporation has notified the director to the
contrary. Corporate procedures governing authority to sign permit
applications may provide for assignment or delegation to applicable
corporate position under §122.22(a)(1)(ii) rather than to specific
individuals.
Part V-D
List any pollutants in Table 2c-3 that you believe to be present and
explain why you believe them to be present. No analysis is required,
but if you have analytical data, you must report it.
Note: Under 40 CFR 117.12(a)(2), certain discharges of hazardous
substances (listed in Table 2c-4 of these instructions) may be
exempted from the requirements of section 311 of CWA, which
establishes reporting requirements, civil penalties and liability for
cleanup costs for spills of oil and hazardous substances. A discharge
of a particular substance may be exempted if the origin, source, and
amount of the discharged substances are identified in the NDPES
permit application or in the permit, if the permit contains a
requirement for treatment of the discharge, and if the treatment is in
place. To apply for an exclusion of the discharge of any hazardous
substance from the requirements of section 311, attach additional
sheets of paper to your form, setting forth the following information:
1.
The substance and the amount of each substance which may
be discharged.
2.
The origin and source of the discharge of the substance.
3.
(B) For a partnership or sole proprietorship: by a general partner or
the proprietor, respectively; or
(C) For a municipality, State, Federal, or other public agency: by
either a principal executive officer or ranking elected official. For
purposes of this section, a principal executive officer of a Federal
Agency includes (i) the chief executive officer of the Agency, or (ii) a
senior executive officer having responsibility for the overall
operations of a principal geographic unit of the Agency (e.g.,
Regional Administrators of EPA). Applications for Group II
stormwater dischargers may be signed by a duly authorized
representative (as defined in 40 CFR 122.22(b)) of the individuals
identified above.
The treatment which is to be provided for the discharge by:
a.
An onsite treatment system separate from any treatment
system treating your normal discharge;
b.
A treatment system designed to treat your normal
discharge and which is additionally capable of treating the
amount of the substance identified under paragraph 1
above; or
c.
Any combination of the above.
See 40 CFR §117.12(a)(2) and (c) published on August 29, 1979, in
44 FR 50766, or contact your Regional Office (Table 1 on Form 1,
Instructions), for further information on exclusions from section 311.
Item VI
This requirement applies to current use or manufacture of a toxic
pollutant as an intermediate or final product or byproduct. The
Director may waive or modify the requirement if you demonstrate
that it would be unduly burdensome to identify each toxic pollutant
and the Director has adequate information to issue your permit. You
may not claim this information as confidential; however, you do not
have to distinguish between use or production of the pollutants or list
the amounts.
Item VII
Self explanatory. The permitting authority may ask you to provide
additional details after your application is received.
Item IX
The Clean Water Act provides for severe penalties for submitting
false information on this application form.
Section 309(c)(2) of the Clean Water Act provides that “Any person
who knowingly makes any false statement, representation, or
certification in any application,... shall upon conviction, be punished
by a fine of not more than $10,000 or by imprisonment for not more
than six months, or by both.”
2C-2
CODES FOR TREATMENT UNITS
PHYSICAL TREATMENT PROCESSES
1–A. . . . . . . . . .
1–B . . . . . . . . . .
1–C . . . . . . . . . .
1–D . . . . . . . . . .
1–E . . . . . . . . .
1–F . . . . . . . . .
1–G . . . . . . . . . .
1–H . . . . . . . . . .
1–I . . . . . . . . . .
1–J . . . . . . . . . .
1–K . . . . . . . . . .
1–L . . . . . . . . . .
Ammonia Stripping
Dialysis
Diatomaceous Earth Filtration
Distillation
Electrodialysis
Evaporation
Flocculation
Flotation
Foam Fractionation
Freezing
Gas–Phase Separation
Grinding (Comminutors)
1–M . . . . . . . . . .
1–N . . . . . . . . . .
1–O . . . . . . . . . .
1–P . . . . . . . . . . .
1–Q. . . . . . . . . . .
1–R . . . . . . . . . .
1–S . . . . . . . . . . .
1–T . . . . . . . . . . .
1–U . . . . . . . . . .
1–V . . . . . . . . . . .
1–W . . . . . . . . . .
1–X . . . . . . . . . . .
Grit Removal
Microstraining
Mixing
Moving Bed Filters
Multimedia Filtration
Rapid Sand Filtration
Reverse Osmosis (Hyperfiltration)
Screening
Sedimentation (Settling)
Slow Sand Filtration
Solvent Extraction
Sorption
CHEMICAL TREATMENT PROCESSES
2–A . . . . . . . . . .
2–B . . . . . . . . . .
2–C . . . . . . . . . .
2–D . . . . . . . . . .
2–E . . . . . . . . . .
2–F . . . . . . . . . .
Carbon Adsorption
Chemical Oxidation
Chemical Precipitation
Coagulation
Dechlorination
Disinfection (Chlor i ne)
3–A . . . . . . . . . .
3–B . . . . . . . . . .
3–C . . . . . . . . . .
3–D . . . . . . . . . .
Activated Sludge
Aerated Lagoons
Anaerobic Treatment
Nitrification–Denitrification
2–G . . . . . . . . . .
2–H . . . . . . . . . .
2–I . . . . . . . . . . .
2–J . . . . . . . . . . .
2–K . . . . . . . . . . .
2–L . . . . . . . . . . .
Disinfection (Ozone)
Disinfection (Other)
Electrochemical Treatment
Ion Exchange
Neutralization
Reduction
BIOLOGICAL TREATMENT PROCESSES
3–E . . . . . . . . . . .
3–F . . . . . . . . . . .
3–G . . . . . . . . . .
3–H . . . . . . . . . .
Pre-Aeration
Spray Irrigation/Land Application
Stabilization Ponds
Trickling Filtration
OTHER PROCESSES
4–A . . . . . . . . . . Discharge to Surface Water
4–B . . . . . . . . . . Ocean Discharge Through Outfall
4–C . . . . . . . . . . Reuse/Recycle of Treated Effluent
4-D . . . . . . . . . . . Underground Injection
SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–A . . . . . . . . . .
5–B . . . . . . . . . .
5–C. . . . . . . . . .
5–D. . . . . . . . . .
5–E . . . . . . . . . .
5–F . . . . . . . . . .
5–G . . . . . . . . . .
5–H . . . . . . . . . .
5–I. . . . . . . . . . .
5–J . . . . . . . . . .
5–K . . . . . . . . . .
5–L . . . . . . . . . .
Aerobic Digestion
Anaerobic Digestion
Belt Filtration
Centrifugation
Chemical Conditioning
Chlorine Treatment
Composting
Drying Beds
Elutriation
Flotation Thickening
Freezing
Gravity Thickening
5–M . . . . . . . . . .
5–N . . . . . . . . . .
5–O . . . . . . . . . .
5–P . . . . . . . . . . .
5–Q . . . . . . . . . .
5–R . . . . . . . . . .
5–S . . . . . . . . . .
5–T . . . . . . . . . .
5–U . . . . . . . . . .
5–V . . . . . . . . . .
5–W . . . . . . . . . .
Table 2C-1
Heat Drying
Heat Treatment
Incineration
Land Application
Landfill
Pressure Filtration
Pyrolysis
Sludge Lagoons
Vacuum Filtration
Vibration
Wet Oxidation
TESTING REQUIREMENTS FOR ORGANIC TOXIC POLLUTANTS INDUSTRY CATEGORY*
GC/MS FRACTION
INDUSTRY CATEGORY
Adhesives and sealants ............................................................
Aluminum forming .....................................................................
Auto and other laundries...........................................................
Battery manufacturing...............................................................
Coal mining ...............................................................................
Coil coating ...............................................................................
Copper forming .........................................................................
Electric and electronic compounds ...........................................
Electroplating ............................................................................
Explosives manufacturing .........................................................
Foundries ..................................................................................
Gum and wood chemicals.........................................................
Inorganic chemicals manufacturing ..........................................
Iron and steel manufacturing ....................................................
Leather tanning and finishing....................................................
Mechanical products manufacturing .........................................
Nonferrous metals manufacturing.............................................
Ore mining ................................................................................
Organic chemicals manufacturing.............................................
Paint and ink formulation ..........................................................
Pesticides..................................................................................
Petroleum refining.....................................................................
Pharmaceutical preparations ....................................................
Photographic equipment and supplies......................................
Plastic and synthetic materials manufacturing..........................
Plastic processing .....................................................................
Porcelain enameling .................................................................
Printing and publishing..............................................................
Pulp and paperboard mills ........................................................
Rubber processing....................................................................
Soap and detergent manufacturing...........................................
Steam electric power plants......................................................
Textile mills ...............................................................................
Timber products processing......................................................
1
Volatile
Acid
Base/Neutral
Pesticide
X
X
X
X
X
X
X
X
X
–
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
–
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
–
–
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
–
X
X
X
X
X
X
X
X
–
–
X
–
X
–
–
X
–
–
–
X
–
–
X
–
X
X
X
X
X
X
–
X
X
–
X
X
X
–
–
–
X
X
*See note at conclusion of 40 CFR Part 122, Appendix D (1983) for explanation of effect of suspensions on testing requirements for primary
industry categories.
1
The pollutants in each fraction are listed in Item V-C.
X = Testing required.
– = Testing not required.
Tabe 2C-2
TOXIC POLLUTANTS AND HAZARDOUS SUBSTANCES
REQUIRED TO BE IDENTIFIED BY APPLICANTS IF EXPECTED TO BE PRESENT
TOXIC POLLUTANT
HAZARDOUS SUBSTANCES
HAZARDOUS SUBSTANCES
Asbestos
Dichlorvos
Diethyl amine
Dimethyl amine
Dintrobenzene
Diquat
Disulfoton
Diuron
Epichlorohydrin
Ethion
Ethylene diamine
Ethylene dibromide
Formaldehyde
Furfural
Guthion
Isoprene
Isopropanolamine
Kelthane
Kepone
Malathion
Mercaptodimethur
Methoxychlor
Methyl mercaptan
Methyl methacrylate
Methyl parathion
Mevinphos
Mexacarbate
Monoethyl amine
Monomethyl amine
Naled
Napthenic acid
Nitrotoluene
Parathion
Phenolsulfonate
Phosgene
Propargite
Propylene oxide
Pyrethrins
Quinoline
Resorcinol
Strontium
Strychnine
Styrene
2,4,5-T (2,4,5-Trichlorophenoxyacetic acid)
TDE (Tetrachlorodiphenyl ethane)
2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanoic acid]
Trichlorofon
Triethanolamine
Triethylamine
Trimethylamine
Uranium
Vanadium
Vinyl acetate
Xylene
Xylenol
Zirconium
HAZARDOUS SUBSTANCES
Acetaldehyde
Allyl alcohol
Allyl chloride
Amyl acetate
Aniline
Benzonitrile
Benzyl chloride
Butyl acetate
Butylamine
Captan
Carbaryl
Carbofuran
Carbon disulfide
Chlorpyrifos
Coumaphos
Cresol
Crotonaldehyde
Cyclohexane
2,4-D (2,4-Dichlorophenoxyacetic acid)
Diazinon
Dicamba
Dichlobenil
Dichlone
2,2-Dichloropropionic acid
Table 2C-3
HAZARDOUS SUBSTANCES
1. Acetaldehyde
2. Acetic acid
3. Acetic anhydride
4. Acetone cyanohydrin
5. Acetyl bromide
6. Acetyl chloride
7. Acrolein
8. Acrylonitrile
9. Adipic acid
10. Aldrin
11. Allyl alcohol
12. Allyl chloride
13. Aluminum sulfate
14. Ammonia
15. Ammonium acetate
16. Ammonium benzoate
17. Ammonium bicarbonate
18. Ammonium bichromate
19. Ammonium bifluoride
20. Ammonium bisulfite
21. Ammonium carbamate
22. Ammonium carbonate
23. Ammonium chloride
24. Ammonium chromate
25. Ammonium citrate
26. Ammonium fluoroborate
27. Ammonium fluoride
28. Ammonium hydroxide
29. Ammonium oxalate
30. Ammonium silicofluoride
31. Ammonium sulfamate
32. Ammonium sulfide
33. Ammonium sulfite
34. Ammonium tartrate
35. Ammonium thiocyanate
36. Ammonium thiosulfate
37. Amyl acetate
38. Aniline
39. Antimony pentachloricle
40. Antimony potassium tartrate
41. Antimony tribromide
42. Antimony trichloride
43. Antimony trifluoride
44. Antimony trioxide
45. Arsenic disulfide
46. Arsenic pentoxide
47. Arsenic trichloride
48. Arsenic trioxide
49. Arsenic trisulfide
50. Barium cyanide
51. Benzene
52. Benzoic acid
53. Benzonitrile
54. Benzoyl chloride
55. Benzyl chloride
56. Beryllium chloride
57. Beryllium fluoride
58. Beryllium nitrate
59. Butylacetate
60. n-Butylphthalate
61. Butylamine
62. Butyric acid
63. Cadmium acetate
64. Cadmium bromide
65. Cadmium chloride
66. Calcium arsenate
67. Calcium arsenite
69. Calcium carbide
69. Calcium chromate
70. Calcium cyanide
71. Calcium dodecylbenzenesulfonate
72. Calcium hypochlorite
73. Captan
74. Carbaryl
75. Carbofuran
76. Carbon disulfide
77. Carbon tetrachloride
78. Chlordane
79. Chlorine
80. Chlorobenzene
81. Chloroform
82. Chloropyrifos
83. Chlorosulfonic acid
84. Chromic acetate
85. Chromic acid
86. Chromic sulfate
87. Chromous chloride
88. Cobaltous bromide
89. Cobaltous formate
90. Cobaltous sulfamate
91. Coumaphos
92. Cresol
93. Crotonaldehyde
94. Cupric acetate
95. Cupric acetoarsenite
96. Cupric chloride
97. Cupric nitrate
98. Cupric oxalate
99. Cupric sulfate
100. Cupric sulfate ammoniated
101. Cupric tartrate
102. Cyanogen chloride
103. Cyclohexane
104. 2,4-D acid (2,4- Dichlorophenoxyacetic
acid)
105. 2,4-D esters (2,4- Dichlorophenoxyacetic
acid esters)
106. DDT
107. Diazinon
108. Dicamba
109. Dichlobenil
110. Dichlone
111. Dichlorobenzene
112. Dichloropropane
113. Dichloropropene
114. Dichloropropene-dichloproropane mix
115. 2,2-Dichloropropionic acid
116. Dichlorvos
117. Dieldrin
118. Diethylamine
119. Dimethylamine
120. Dinitrobenzene
121. Dinitrophenol
122. Dinitrotoluene
123. Diquat
124. Disulfoton
125. Diuron
126. Dodecylbenzesulfonic acid
127. Endosulfan
128. Endrin
129. Epichlorohydrin
130. Ethion
131. Ethylbenzene
132. Ethylenediamine
133. Ethylene dibromide
134. Ethylene dichloride
135. Ethylene diaminetetracetic acid (EDTA)
136. Ferric ammonium citrate
137. Ferric ammonium oxalate
138. Ferric chloride
139. Ferric fluoride
140. Ferric nitrate
141. Ferric sulfate
142. Ferrous ammonium sulfate
143. Ferrous chloride
144. Ferrous sulfate
Table 2C-4
145. Formaldehyde
146. Formic acid
147. Fumaric acid
148. Furfural
149. Guthion
150. Heptachlor
151. Hexachlorocyclopentadiene
152. Hydrochloric acid
153. Hydrofluoric acid
154. Hydrogen cyanide
155. Hydrogen sulfide
156. Isoprene
157. Isopropanolamine
dodecylbenzenesulfonate
158. Kelthane
159. Kepone
160. Lead acetate
161. Lead arsenate
162. Lead chloride
163. Lead fluoborate
164. Lead flourite
165. Lead iodide
166. Lead nitrate
167. Lead stearate
168. Lead sulfate
169. Lead sulfide
170. Lead thiocyanate
171. Lindane
172. Lithium chromate
173. Malathion
174. Maleic acid
175. Maleic anhydride
176. Mercaptodimethur
177. Mercuric cyanide
178. Mercuric nitrate
179. Mercuric sulfate
180. Mercuric thiocyanate
181. Mercurous nitrate
182. Methoxychlor
183. Methyl mercaptan
184. Methyl methacrylate
185. Methyl parathion
186. Mevinphos
187. Mexacarbate
188. Monoethylamine
189. Monomethylamine
190. Naled
191. Naphthalene
192. Naphthenic acid
193. Nickel ammonium sulfate
194. Nickel chloride
195. Nickel hydroxide
196. Nickel nitrate
197. Nickel sulfate
198. Nitric acid
199. Nitrobenzene
200. Nitrogen dioxide
201. Nitrophenol
202. Nitrotoluene
203. Paraformaldehyde
204. Parathion
205. Pentachlorophenol
206. Phenol
207. Phosgene
208. Phosphoric acid
209. Phosphorus
210. Phosphorus oxychloride
211. Phosphorus pentasulfide
212. Phosphorus trichloride
213. Polychlorinated biphenyls (PCB)
214. Potassium arsenate
215. Potassium arsenite
216. Potassium bichromate
HAZARDOUS SUBSTANCES
217. Potassium chromate
218. Potassium cyanide
219. Potassium hydroxide
220. Potassium permanganate
221. Propargite
222. Propionic acid
223. Propionic anhydride
224. Propylene oxide
225. Pyrethrins
226. Quinoline
227. Resorcinol
228. Selenium oxide
229. Silver nitrate
230. Sodium
231. Sodium arsenate
232. Sodium arsenite
233. Sodium bichromate
234. Sodium bifluoride
235. Sodium bisulfite
236. Sodium chromate
237. Sodium cyanide
238. Sodium dodecylbenzenesulfonate
239. Sodium fluoride
240. Sodium hydrosulfide
241. Sodium hydroxide
242. Sodium hypochlorite
243. Sodium methylate
244. Sodium nitrite
245. Sodium phosphate (dibasic)
246. Sodium phosphate (tribasic)
247. Sodium selenite
248. Strontium chromate
249. Strychnine
250. Styrene
251. Sulfuric acid
252. Sulfur monochloride
253. 2,4,5-T acid (2,4,5Trichlorophenoxyacetic acid)
254. 2,4,5-T amines (2,4,5-Trichlorophenoxy
acetic acid amines)
255. 2,4,5-T esters (2,4,5 Trichlorophenoxy
acetic acid esters)
256. 2,4,5-T salts (2,4,5-Trichlorophenoxy
acetic acid salts)
257. 2,4,5-TP acid (2,4,5-Trichlorophenoxy
propanoic acid)
258. 2,4,5-TP acid esters (2,4,5Trichlorophenoxy propanoic acid esters)
259. TDE (Tetrachlorodiphenyl ethane)
260. Tetraethyl lead
261. Tetraethyl pyrophosphate
262. Thallium sulfate
263. Toluene
264. Toxaphene
265. Trichlorofon
266. Trichloroethylene
267. Trichlorophenol
268. Triethanolamine
dodecylbenzenesulfonate
269. Triethylamine
Table 2C-4 (continued)
270. Trimethylamine
271. Uranyl acetate
272. Uranyl nitrate
273. Vanadium penoxide
274. Vanadyl sulfate
275. Vinyl acetate
276. Vinylidene chloride
277. Xylene
278. Xylenol
279. Zinc acetate
280. Zinc ammonium chloride
281. Zinc borate
282. Zinc bromide
283. Zinc carbonate
284. Zinc chloride
285. Zinc cyanide
286. Zinc fluoride
287. Zinc formate
288. Zinc hydrosulfite
289. Zinc nitrate
290. Zinc phenolsulfonate
291. Zinc phosphide
292. Zinc silicofluoride
293. Zinc sulfate
294. Zirconium nitrate
295. Zirconium potassium flouride
296. Zirconium sulfate
297. Zirconium tetrachloride
LINE DRAWING
Blue River
Municipal
Water Supply
90,000 GPD
45,000 GPD
Raw Materials
10,000 GPD
Fiber
Preparation
15,000
GPD
40,000 GPD
Solid Waste
4,000 GPD
Grit
Separator
36,000 GPD
Stormwater
Max: 20,000 GPD
45,000 GPD
Dyeing
20,000
GPD
40,000 GPD
Neutralization
Tank
10,000 GPD
Cooling Water
30,000 GPD
10,000
GPD
Washing
Drying
10,000
GPD
40,000
GPD
Waste
Treatment
Plant #2
Loss
6,000 GPD
34,000 GPD
Waste
Treatment
Plant #1
Blue River
Outfall 002
50,000 GPD
Outfall 001
70,000 GPD + Stormwater
Schematic of Water Flow
Brown Mills, Inc.
City, County, State
Figure 2C-1
5,000 GPD
To Atmosphere
To Product
5,000 GPD
EPA I.D. NUMBER (copy from Item 1 of Form 1)
Form Approved.
OMB No. 2040-0086.
Approval expires 3-31-98.
Please print or type in the unshaded areas only.
FORM
U.S. ENVIRONMENTAL PROTECTION AGENCY
APPLICATION FOR PERMIT TO DISCHARGE WASTEWATER
2C
EXISTING MANUFACTURING, COMMERCIAL, MINING AND SILVICULTURE OPERATIONS
Consolidated Permits Program
NPDES
I. OUTFALL LOCATION
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
A. OUTFALL NUMBER
(list)
B. LATITUDE
1. DEG.
2. MIN.
C. LONGITUDE
3. SEC.
1. DEG.
2. MIN.
3. SEC.
D. RECEIVING WATER (name)
II. FLOWS, SOURCES OF POLLUTION, AND TREATMENT TECHNOLOGIES
A. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the effluent, and treatment units
labeled to correspond to the more detailed descriptions in Item B. Construct a water balance on the line drawing by showing average flows between intakes, operations,
treatment units, and outfalls. If a water balance cannot be determined (e.g., for certain mining activities), provide a pictorial description of the nature and amount of any
sources of water and any collection or treatment measures.
B. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary wastewater, cooling water,
and storm water runoff; (2) The average flow contributed by each operation; and (3) The treatment received by the wastewater. Continue on additional sheets if
necessary.
1. OUTFALL
NO. (list)
2. OPERATION(S) CONTRIBUTING FLOW
a. OPERATION (list)
3. TREATMENT
b. AVERAGE FLOW
(include units)
a. DESCRIPTION
b. LIST CODES FROM
TABLE 2C-1
OFFICIAL USE ONLY (effluent guidelines sub-categories)
EPA Form 3510-2C (8-90)
PAGE 1 of 4
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
C. Except for storm runoff, leaks, or spills, are any of the discharges described in Items II-A or B intermittent or seasonal?
YES (complete the following table)
NO (go to Section III)
4. FLOW
3. FREQUENCY
a. DAYS PER
WEEK
(specify
average)
2. OPERATION(s)
CONTRIBUTING FLOW
(list)
1. OUTFALL
NUMBER (list)
b. MONTHS
PER YEAR
(specify average)
a. FLOW RATE (in mgd)
1. LONG TERM
AVERAGE
2. MAXIMUM
DAILY
B. TOTAL VOLUME
(specify with units)
1. LONG TERM
AVERAGE
2. MAXIMUM
DAILY
C. DURATION
(in days)
III. PRODUCTION
A. Does an effluent guideline limitation promulgated by EPA under Section 304 of the Clean Water Act apply to your facility?
YES (complete Item III-B)
NO (go to Section IV)
B. Are the limitations in the applicable effluent guideline expressed in terms of production (or other measure of operation)?
YES (complete Item III-C)
NO (go to Section IV)
C. If you answered “yes” to Item III-B, list the quantity which represents an actual measurement of your level of production, expressed in the terms and units used in the
applicable effluent guideline, and indicate the affected outfalls.
1. AVERAGE DAILY PRODUCTION
a. QUANTITY PER DAY
b. UNITS OF MEASURE
c. OPERATION, PRODUCT, MATERIAL, ETC.
(specify)
2. AFFECTED OUTFALLS
(list outfall numbers)
IV. IMPROVEMENTS
A. Are you now required by any Federal, State or local authority to meet any implementation schedule for the construction, upgrading or operations of wastewater
treatment equipment or practices or any other environmental programs which may affect the discharges described in this application? This includes, but is not limited to,
permit conditions, administrative or enforcement orders, enforcement compliance schedule letters, stipulations, court orders, and grant or loan conditions.
YES (complete the following table)
1. IDENTIFICATION OF CONDITION,
AGREEMENT, ETC.
NO (go to Item IV-B)
2. AFFECTED OUTFALLS
a. NO.
3. BRIEF DESCRIPTION OF PROJECT
b. SOURCE OF DISCHARGE
4. FINAL COMPLIANCE DATE
a. REQUIRED
b. PROJECTED
B. OPTIONAL: You may attach additional sheets describing any additional water pollution control programs (or other environmental projects which may affect your
discharges) you now have underway or which you plan. Indicate whether each program is now underway or planned, and indicate your actual or planned schedules for
construction.
MARK “X” IF DESCRIPTION OF ADDITIONAL CONTROL PROGRAMS IS ATTACHED
EPA Form 3510-2C (8-90)
PAGE 2 of 4
CONTINUE ON PAGE 3
EPA I.D. NUMBER (copy from Item 1 of Form 1)
CONTINUED FROM PAGE 2
V. INTAKE AND EFFLUENT CHARACTERISTICS
A, B, & C: See instructions before proceeding – Complete one set of tables for each outfall – Annotate the outfall number in the space provided.
NOTE: Tables V-A, V-B, and V-C are included on separate sheets numbered V-1 through V-9.
D. Use the space below to list any of the pollutants listed in Table 2c-3 of the instructions, which you know or have reason to believe is discharged or may be discharged
from any outfall. For every pollutant you list, briefly describe the reasons you believe it to be present and report any analytical data in your possession.
1. POLLUTANT
2. SOURCE
1. POLLUTANT
2. SOURCE
VI. POTENTIAL DISCHARGES NOT COVERED BY ANALYSIS
Is any pollutant listed in Item V-C a substance or a component of a substance which you currently use or manufacture as an intermediate or final product or byproduct?
YES (list all such pollutants below )
EPA Form 3510-2C (8-90)
NO (go to Item VI-B)
PAGE 3 of 4
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
VII. BIOLOGICAL TOXICITY TESTING DATA
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges or on a receiving water in
relation to your discharge within the last 3 years?
YES (identify the test(s) and describe their purposes below)
NO (go to Section VIII)
VIII. CONTRACT ANALYSIS INFORMATION
Were any of the analyses reported in Item V performed by a contract laboratory or consulting firm?
YES (list the name, address, and telephone number of, and pollutants analyzed by,
each such laboratory or firm below)
A. NAME
B. ADDRESS
NO (go to Section IX)
C. TELEPHONE
(area code & no.)
D. POLLUTANTS ANALYZED
(list)
IX. 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 gather and evaluate 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.
A. NAME & OFFICIAL TITLE (type or print)
B. PHONE NO. (area code & no.)
C. SIGNATURE
D. DATE SIGNED
EPA Form 3510-2C (8-90)
PAGE 4 of 4
PLEASE PRINT OR TYPE IN THE UNSHADED AREAS ONLY. You may report some or all of this information
on separate sheets (use the same format) instead of completing these pages.
SEE INSTRUCTIONS.
EPA I.D. NUMBER (copy from Item 1 of Form 1)
OUTFALL NO.
V. INTAKE AND EFFLUENT CHARACTERISTICS (continued from page 3 of Form 2-C)
PART A –You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details.
a. MAXIMUM DAILY VALUE
1. POLLUTANT
(1)
CONCENTRATION
(2) MASS
2. EFFLUENT
b. MAXIMUM 30 DAY VALUE
(if available)
(1)
CONCENTRATION
(2) MASS
3. UNITS
(specify if blank)
c. LONG TERM AVRG. VALUE
(if available)
(1) CONCENTRATION
(2) MASS
d. NO. OF
ANALYSES
a. CONCENTRATION
b. MASS
4. INTAKE
(optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
a. Biochemical Oxygen
Demand (BOD)
b. Chemical Oxygen
Demand (COD)
c. Total Organic Carbon
(TOC)
d. Total Suspended
Solids (TSS)
e. Ammonia (as N)
VALUE
VALUE
VALUE
g. Temperature
(winter)
VALUE
VALUE
VALUE
h. Temperature
(summer)
VALUE
VALUE
VALUE
f. Flow
i. pH
MINIMUM
MAXIMUM
MINIMUM
VALUE
°C
°C
MAXIMUM
VALUE
VALUE
STANDARD UNITS
PART B – Mark “X” in column 2-a for each pollutant you know or have reason to believe is present. Mark “X” in column 2-b for each pollutant you believe to be absent. If you mark column 2a for any pollutant which is limited either
directly, or indirectly but expressly, in an effluent limitations guideline, you must provide the results of at least one analysis for that pollutant. For other pollutants for which you mark column 2a, you must provide
quantitative data or an explanation of their presence in your discharge. Complete one table for each outfall. See the instructions for additional details and requirements.
5. INTAKE (optional)
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG. VALUE
a. LONG TERM AVERAGE
AND
(if available)
(if available)
VALUE
a. MAXIMUM DAILY VALUE
a.
b.
CAS NO.
d. NO. OF
a. CONCENb. NO. OF
BELIEVED BELIEVED
(1)
(1)
(1)
(1)
(if available)
ANALYSES
TRATION
b. MASS CONCENTRATION (2) MASS ANALYSES
PRESENT
ABSENT
CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
a. Bromide
(24959-67-9)
b. Chlorine, Total
Residual
c. Color
d. Fecal Coliform
e. Fluoride
(16984-48-8)
f. Nitrate-Nitrite
(as N)
EPA Form 3510-2C (8-90)
PAGE V-1
CONTINUE ON REVERSE
ITEM V-B CONTINUED FROM FRONT
2. MARK “X”
1. POLLUTANT
AND
a. MAXIMUM DAILY VALUE
a.
b.
CAS NO.
BELIEVED BELIEVED
(1)
(if available)
PRESENT
ABSENT
CONCENTRATION
(2) MASS
3. EFFLUENT
b. MAXIMUM 30 DAY VALUE
(if available)
(1)
CONCENTRATION
(2) MASS
4. UNITS
c. LONG TERM AVRG. VALUE
(if available)
(1)
CONCENTRATION
(2) MASS
d. NO. OF
ANALYSES
a. CONCENTRATION
b. MASS
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
g. Nitrogen,
Total Organic (as
N)
h. Oil and
Grease
i. Phosphorus
(as P), Total
(7723-14-0)
j. Radioactivity
(1) Alpha, Total
(2) Beta, Total
(3) Radium,
Total
(4) Radium 226,
Total
k. Sulfate
(as SO4)
(14808-79-8)
l. Sulfide
(as S)
m. Sulfite
(as SO3)
(14265-45-3)
n. Surfactants
o. Aluminum,
Total
(7429-90-5)
p. Barium, Total
(7440-39-3)
q. Boron, Total
(7440-42-8)
r. Cobalt, Total
(7440-48-4)
s. Iron, Total
(7439-89-6)
t. Magnesium,
Total
(7439-95-4)
u. Molybdenum,
Total
(7439-98-7)
v. Manganese,
Total
(7439-96-5)
w. Tin, Total
(7440-31-5)
x. Titanium,
Total
(7440-32-6)
EPA Form 3510-2C (8-90)
PAGE V-2
CONTINUE ON PAGE V-3
EPA I.D. NUMBER (copy from Item 1 of Form 1)
OUTFALL NUMBER
CONTINUED FROM PAGE 3 OF FORM 2-C
PART C - If you are a primary industry and this outfall contains process wastewater, refer to Table 2c-2 in the instructions to determine which of the GC/MS fractions you must test for. Mark “X” in column 2-a for all such GC/MS
fractions that apply to your industry and for ALL toxic metals, cyanides, and total phenols. If you are not required to mark column 2-a (secondary industries, nonprocess wastewater outfalls, and nonrequired GC/MS
fractions), mark “X” in column 2-b for each pollutant you know or have reason to believe is present. Mark “X” in column 2-c for each pollutant you believe is absent. If you mark column 2a for any pollutant, you must
provide the results of at least one analysis for that pollutant. If you mark column 2b for any pollutant, you must provide the results of at least one analysis for that pollutant if you know or have reason to believe it will be
discharged in concentrations of 10 ppb or greater. If you mark column 2b for acrolein, acrylonitrile, 2,4 dinitrophenol, or 2-methyl-4, 6 dinitrophenol, you must provide the results of at least one analysis for each of these
pollutants which you know or have reason to believe that you discharge in concentrations of 100 ppb or greater. Otherwise, for pollutants for which you mark column 2b, you must either submit at least one analysis or
briefly describe the reasons the pollutant is expected to be discharged. Note that there are 7 pages to this part; please review each carefully. Complete one table (all 7 pages) for each outfall. See instructions for
additional details and requirements.
5. INTAKE (optional)
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
a. LONG TERM
AND
(if available)
VALUE (if available)
AVERAGE VALUE
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENb. NO. OF
CAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
(1)
TRATION
b. MASS CONCENTRATION (2) MASS ANALYSES
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
METALS, CYANIDE, AND TOTAL PHENOLS
1M. Antimony, Total
(7440-36-0)
2M. Arsenic, Total
(7440-38-2)
3M. Beryllium, Total
(7440-41-7)
4M. Cadmium, Total
(7440-43-9)
5M. Chromium,
Total (7440-47-3)
6M. Copper, Total
(7440-50-8)
7M. Lead, Total
(7439-92-1)
8M. Mercury, Total
(7439-97-6)
9M. Nickel, Total
(7440-02-0)
10M. Selenium,
Total (7782-49-2)
11M. Silver, Total
(7440-22-4)
12M. Thallium,
Total (7440-28-0)
13M. Zinc, Total
(7440-66-6)
14M. Cyanide,
Total (57-12-5)
15M. Phenols,
Total
DIOXIN
2,3,7,8-Tetrachlorodibenzo-PDioxin (1764-01-6)
EPA Form 3510-2C (8-90)
DESCRIBE RESULTS
PAGE V-3
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
GC/MS FRACTION – VOLATILE COMPOUNDS
1V. Accrolein
(107-02-8)
2V. Acrylonitrile
(107-13-1)
3V. Benzene
(71-43-2)
4V. Bis (Chloromethyl) Ether
(542-88-1)
5V. Bromoform
(75-25-2)
6V. Carbon
Tetrachloride
(56-23-5)
7V. Chlorobenzene
(108-90-7)
8V. Chlorodibromomethane
(124-48-1)
9V. Chloroethane
(75-00-3)
10V. 2-Chloroethylvinyl Ether
(110-75-8)
11V. Chloroform
(67-66-3)
12V. Dichlorobromomethane
(75-27-4)
13V. Dichlorodifluoromethane
(75-71-8)
14V. 1,1-Dichloroethane (75-34-3)
15V. 1,2-Dichloroethane (107-06-2)
16V. 1,1-Dichloroethylene (75-35-4)
17V. 1,2-Dichloropropane (78-87-5)
18V. 1,3-Dichloropropylene
(542-75-6)
19V. Ethylbenzene
(100-41-4)
20V. Methyl
Bromide (74-83-9)
21V. Methyl
Chloride (74-87-3)
EPA Form 3510-2C (8-90)
PAGE V-4
CONTINUE ON PAGE V-5
CONTINUED FROM PAGE V-4
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
GC/MS FRACTION – VOLATILE COMPOUNDS (continued)
22V. Methylene
Chloride (75-09-2)
23V. 1,1,2,2Tetrachloroethane
(79-34-5)
24V. Tetrachloroethylene (127-18-4)
25V. Toluene
(108-88-3)
26V. 1,2-TransDichloroethylene
(156-60-5)
27V. 1,1,1-Trichloroethane (71-55-6)
28V. 1,1,2-Trichloroethane (79-00-5)
29V Trichloroethylene (79-01-6)
30V. Trichlorofluoromethane
(75-69-4)
31V. Vinyl Chloride
(75-01-4)
GC/MS FRACTION – ACID COMPOUNDS
1A. 2-Chlorophenol
(95-57-8)
2A. 2,4-Dichlorophenol (120-83-2)
3A. 2,4-Dimethylphenol (105-67-9)
4A. 4,6-Dinitro-OCresol (534-52-1)
5A. 2,4-Dinitrophenol (51-28-5)
6A. 2-Nitrophenol
(88-75-5)
7A. 4-Nitrophenol
(100-02-7)
8A. P-Chloro-MCresol (59-50-7)
9A. Pentachlorophenol (87-86-5)
10A. Phenol
(108-95-2)
11A. 2,4,6-Trichlorophenol (88-05-2)
EPA Form 3510-2C (8-90)
PAGE V-5
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS
1B. Acenaphthene
(83-32-9)
2B. Acenaphtylene
(208-96-8)
3B. Anthracene
(120-12-7)
4B. Benzidine
(92-87-5)
5B. Benzo (a)
Anthracene
(56-55-3)
6B. Benzo (a)
Pyrene (50-32-8)
7B. 3,4-Benzofluoranthene
(205-99-2)
8B. Benzo (ghi)
Perylene (191-24-2)
9B. Benzo (k)
Fluoranthene
(207-08-9)
10B. Bis (2-Chloroethoxy) Methane
(111-91-1)
11B. Bis (2-Chloroethyl) Ether
(111-44-4)
12B. Bis (2Chloroisopropyl)
Ether (102-80-1)
13B. Bis (2-Ethylhexyl) Phthalate
(117-81-7)
14B. 4-Bromophenyl
Phenyl Ether
(101-55-3)
15B. Butyl Benzyl
Phthalate (85-68-7)
16B. 2-Chloronaphthalene
(91-58-7)
17B. 4-Chlorophenyl Phenyl Ether
(7005-72-3)
18B. Chrysene
(218-01-9)
19B. Dibenzo (a,h)
Anthracene
(53-70-3)
20B. 1,2-Dichlorobenzene (95-50-1)
21B. 1,3-Di-chlorobenzene (541-73-1)
EPA Form 3510-2C (8-90)
PAGE V-6
CONTINUE ON PAGE V-7
CONTINUED FROM PAGE V-6
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS (continued)
22B. 1,4-Dichlorobenzene (106-46-7)
23B. 3,3-Dichlorobenzidine (91-94-1)
24B. Diethyl
Phthalate (84-66-2)
25B. Dimethyl
Phthalate
(131 -11-3)
26B. Di-N-Butyl
Phthalate (84-74-2)
27B. 2,4-Dinitrotoluene (121-14-2)
28B. 2,6-Dinitrotoluene (606-20-2)
29B. Di-N-Octyl
Phthalate (117-84-0)
30B. 1,2-Diphenylhydrazine (as Azobenzene) (122-66-7)
31B. Fluoranthene
(206-44-0)
32B. Fluorene
(86-73-7)
33B. Hexachlorobenzene (118-74-1)
34B. Hexachlorobutadiene (87-68-3)
35B. Hexachlorocyclopentadiene
(77-47-4)
36B Hexachloroethane (67-72-1)
37B. Indeno
(1,2,3-cd) Pyrene
(193-39-5)
38B. Isophorone
(78-59-1)
39B. Naphthalene
(91-20-3)
40B. Nitrobenzene
(98-95-3)
41B. N-Nitrosodimethylamine
(62-75-9)
42B. N-NitrosodiN-Propylamine
(621-64-7)
EPA Form 3510-2C (8-90)
PAGE V-7
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS (continued)
43B. N-Nitrosodiphenylamine
(86-30-6)
44B. Phenanthrene
(85-01-8)
45B. Pyrene
(129-00-0)
46B. 1,2,4-Trichlorobenzene
(120-82-1)
GC/MS FRACTION – PESTICIDES
1P. Aldrin
(309-00-2)
2P. α-BHC
(319-84-6)
3P. β-BHC
(319-85-7)
4P. γ-BHC
(58-89-9)
5P. δ-BHC
(319-86-8)
6P. Chlordane
(57-74-9)
7P. 4,4’-DDT
(50-29-3)
8P. 4,4’-DDE
(72-55-9)
9P. 4,4’-DDD
(72-54-8)
10P. Dieldrin
(60-57-1)
11P. α-Enosulfan
(115-29-7)
12P. β-Endosulfan
(115-29-7)
13P. Endosulfan
Sulfate
(1031-07-8)
14P. Endrin
(72-20-8)
15P. Endrin
Aldehyde
(7421-93-4)
16P. Heptachlor
(76-44-8)
EPA Form 3510-2C (8-90)
PAGE V-8
CONTINUE ON PAGE V-9
EPA I.D. NUMBER (copy from Item 1 of Form 1)
OUTFALL NUMBER
CONTINUED FROM PAGE V-8
2. MARK “X”
3. EFFLUENT
4. UNITS
1. POLLUTANT
b. MAXIMUM 30 DAY VALUE
c. LONG TERM AVRG.
AND
(if available)
VALUE (if available)
a. MAXIMUM DAILY VALUE
a.
b.
c.
d. NO. OF a. CONCENCAS NUMBER
TESTING BELIEVED BELIEVED
(1)
(1)
(1)
TRATION
b. MASS
(if available)
REQUIRED PRESENT ABSENT CONCENTRATION
(2) MASS
CONCENTRATION
(2) MASS
CONCENTRATION (2) MASS ANALYSES
GC/MS FRACTION – PESTICIDES (continued)
17P. Heptachlor
Epoxide
(1024-57-3)
18P. PCB-1242
(53469-21-9)
19P. PCB-1254
(11097-69-1)
20P. PCB-1221
(11104-28-2)
21P. PCB-1232
(11141-16-5)
22P. PCB-1248
(12672-29-6)
23P. PCB-1260
(11096-82-5)
24P. PCB-1016
(12674-11-2)
25P. Toxaphene
(8001-35-2)
EPA Form 3510-2C (8-90)
PAGE V-9
5. INTAKE (optional)
a. LONG TERM
AVERAGE VALUE
(1)
CONCENTRATION
(2) MASS
b. NO. OF
ANALYSES
Disclaimer
This is an updated PDF document that allows you to type your information
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5. Mail it to the directed contact.
United States
Environmental Protection
Agency
Office of Water
Enforcement and Permits
Washington, DC 20460
EPA Form 3510-2D
August 1990
Permits Division
Application Form 2D —
New Sources and
New Dischargers:
Application for Permit to
Discharge Process
Wastewater
PAPERWORK REDUCTION ACT NOTICE: The public reporting and
recordkeeping burden for this collection of information is estimated to average
32 hours as an average response for some minor facilities, to 46 hours as an
average per response for some major facilities, with a weighted average for
major and minor of 33.2 hours per response. This estimate includes the time
needed to review instructions; develop, acquire, install, and utilize validating,
and verifying information, processing and maintaining information, and
disclosing and providing information; adjust the existing ways to comply with
any previously applicable instructions and requirements; train personnel to
respond to a collection of information; search existing data sources; complete
and review the collection of information; and transmit or otherwise disclose the
information. As specified in 5 CFR 1320.5(b) (2), an Agency may not conduct
or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number.
Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing the burden, to
Chief, OPPE Regulatory Information Division, U.S. Environmental Protection
Agency 1200 Pennsylvania Ave., NW, Washington, DC 20460; and to the
Office of Information and Regulatory Affairs, Office of Management and
Budget, 725 17th St., NW, Washington, DC 20503, Attention: Desk Officer for
EPA. Include the OMB control number in any correspondence. Do not send
the completed application form to these addresses.
EPA Form 3510-2D (Rev. 8-90)
Form 2D Instructions
Item III-B
An example of an acceptable line drawing appears in Figure 2D-1 to
these instructions. The line drawing should show the route taken by
water in your proposed facility form intake to discharge. Show all
sources of wastewater, including process and production areas,
sanitary flows, cooling water, and storm water runoff. You may group
similar operations into a single unit, labeled to correspond to the
more detailed listing in Item III-A. The water balance should show
estimates of anticipated average flows. Show all significant losses of
water to production, atmosphere, and discharge. You should use
your best estimates.
Form 2D must be completed in conjunction with EPA form 3510-1
(Form 1).
This form must be completed by applicants who checked “yes” to
Item II-D in Application Form 1. However, facilities which discharge
only nonprocess wastewater that is not regulated by an effluent
limitations guideline or new source performance standard may use
EPA Form 3510-2E (Form 2E). Educational, medical, and
commercial chemical laboratories should use this form or EPA Form
3510-2C (Form 2C). To further determine if you are a new source or
a new discharger, see §122.2 and §122.29. This form should not be
used for discharges of stormwater runoff.
Item III-C
Fill in every applicable column in this item for each source of
intermittent or seasonal discharge. Base your answers on your best
estimate. A discharge is intermittent if it occurs with interruptions
during the operating hours of the facility. Discharges caused by
routine maintenance shutdowns, process changes, or other similar
activities are not considered to be intermittent. A discharge is
seasonal if it occurs only during certain parts of the year. The
reported flow rate is the highest daily value and should be measured
in gallons per day. Maximum total volume means the total volume of
any one discharge within 24 hours and is measured in units such as
gallons.
Public Availability of Submitted Information.
You may not claim as confidential any information required by this
form or Form 1, whether the information is reported on the forms or
in an attachment, Section 402(j) of the CWA requires that all permit
applications shall be available to the public. This information will
therefore be made available to the public upon request.
You may not claim as confidential any information you submit to EPA
which goes beyond that required by this form and Form 1.
Confidentiality claims for effluent data must be denied. If you do not
assert a claim of confidentiality at the time of submitting the
information, EPA may make the information public without further
notice. Claims of confidentiality will be handled in accordance with
EPA’s business confidentiality regulations in 40 CFR Part 2.
Item IV
“Production” in this question refers to those goods which the
proposed facility will produce, not to “wastewater” production. This
information is only necessary where production-based new source
performance standards (NSPS) or effluent guidelines apply to your
facility. Your estimated production figures should be based on a
realistic projection of actual daily production level (not design
capacity) for each of the first three operating years of the facility. This
estimate must be a long-term-average estimate (e.g., average
production on an annual basis). If production will vary depending on
long-term shifts in operating schedule or capacity, the applicant may
report alternative production estimates and the basis for the alternate
estimates.
Completeness
Your application will not be considered complete unless you answer
every question on this form and on Form 1 (except as instructed
below). If an items does not apply to you, enter “NA” (for “not
applicable”) to show that you considered the question.
Followup Requirements
Although you are now required to submit estimated data on this form
(Form 2D), please note that no later than two years after you begin
discharging from the proposed facility, you must complete and
submit Items V and VI of NPDES application Form 2C (EPA Form
3510-2C). However, you need not complete those portions of Item V
requiring tests which you have already performed under the
discharge monitoring requirements of your NPDES permit. In
addition, the permitting authority may waive requirements of Items VA and VI if the permittee makes the demonstrations required under
40 CFR §122.22(g)(7)(i)(B) and 122.21(g)(9).
If known, report quantities in the units of measurement used in the
applicable NSPS or effluent guideline. For example, if the applicable
NSPS is expressed as “grams of pollutant discharged per kilogram of
unit production,” then report maximum “Quantity Per Day” in
kilograms. If you do not know whether any NPSP or effluent
guideline applies to your facility, report quantities in any unit of
measurement known to you. If an effluent guideline or NSPS
specifies a method for estimating production, that method must be
followed.
Definitions
All significant terms used in these instructions and in the form are
defined in the glossary found in the General Instructions which
accompany Form 1.
There is no need to conduct new studies to obtain these figures; only
data already on hand are required. You are not required to indicate
how the reported information was calculated.
Item I
You may use the map you provided for Item XI of Form 1 to
determine the latitude and longitude (to the nearest 15 seconds) of
each of your outfalls and the name of the receiving water. You
should name all waters to which discharge is made and which flow
into significant receiving waters. For example, if the discharge is
made to a ditch which flows into an unnamed tributary which in turn
flows into a named river, you should provide the name or description
(if no name is available) of the ditch, the tributary, and the river.
Item V-A, B, and C
These items require you to estimate and report data on the pollutants
expected to be discharged from each of your outfalls. Where there is
more than one outfall, you should submit a separate Item V for each
outfall. For Part C only a list is required. Sampling and analysis are
not required at this time. If, however, data from such analyses are
available, then those data should be reported. Each part of this item
addresses a different set of pollutants or parameters and must be
completed in accordance with the specific instructions for that part.
The following are the general and specific instructions for Items V-A
through V-C.
Item II
This item requires your best estimate of the date on which your
facility or new outfall will begin to discharge.
Item V – General Instructions
Each part of this item requires you to provide an estimated maximum
daily and average daily value for each pollutant or parameter listed
(see Table 2D-2), according to the specific instructions below. The
source of the data is also required.
Item III-A
List all outfalls, their source (operations contributing to the flow), and
estimate an average flow from each source. Briefly describe the
planned treatment for these wastewaters prior to discharge. Also
describe the ultimate disposal of any solid or liquid wastes not
discharged. You should describe the treatment in either a narrative
form or list the proper code for the treatment unit from a list provided
in Table 2D-1.
EPA Form 3510-2D (Rev. 8-90)
For Parts A through C, base your determination of whether a
pollutant will be present in your discharge on your knowledge of the
proposed facility’s raw materials, maintenance chemicals,
I-1
through promulgated limitations on an indicator pollutant. The priority
pollutants in Group B are divided into the following three sections:
intermediate and final products, byproducts, and any analyses of
your effluent or of any similar effluent. You may also provide the
determination and the estimates based on available in-house or
contractor’s engineering reports or any other studies performed on
the proposed facility (see Item VI of the form). If you expect a
pollutant to be present solely as a result of its presence in your
intake water, please state this information on the form.
1) Metal toxic pollutants, total cyanide, and total phenols
2) 2,3,7,8-Tetrachlorodibenzo-P-Dioxin (TCDD) (CAS # 1764-016)
3) Organic Toxic Pollutants (Gas Chromatography/Mass Spectrometry Fractions)
Please note that no later than 2 years after you begin discharging
from the proposed facility, you must complete and submit Items V
and VI of NPDES application Form 2C (followup data).
a)
b)
c)
d)
Reporting Intake Data. You are not required to report pollutants or
parameters present in intake water unless you wish to demonstrate
your eligibility for a “net” effluent limitation for these pollutants or
parameters, that is, an effluent limitation adjusted to provide
allowance for the pollutants or parameters present in your intake
water. If you wish to obtain credits for pollutants or parameters
present in your intake water, please insert a separate sheet, with a
short statement of why you believe you are eligible (see §122.45(g)),
under Item VII (Other Information). You will then be contacted by the
permitting authority for further instructions.
Volatile compounds
Acid compounds
Base/neutral compounds
Pesticides
For pollutants listed in Sections 1 and 3, you must report estimates
as instructed above:
For Section 2, you are required to report that TCDD may be
discharged if you will use or manufacture one of the following
compounds, or if you know or have reason to believe that TCDD is or
may be present in an effluent:
A. 2,4,5-trichlorophenoxy acetic acid (2,4,5-T) (CAS # 93-765);
All estimated pollutant or parameter levels must be reported as
concentration and as total mass, except for discharge flow,
temperature, and pH. Total mass is the total weight of pollutants or
parameters discharged over a day.
B. 2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4, 5TP) (CAS
# 93-72-1);
Use the following abbreviations for units:
D. 0, O-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate
(Ronnel) (CAS # 299-84-3);
Concentration
Mass
E. 2,4,5-trichlorophenol (TCP) (CAS # 95-95-4); or
ppm................. parts per million
mg/l .............milligrams per liter
ppb................... parts per billion
ug/l ............ micrograms per liter
kg .............................. kilograms
lbs................................. pounds
ton .............. tons (English tons)
mg ............................milligrams
g .....................................grams
T ............... tonnes (metric tons)
F. Hexachlorophene (HCP) (CAS # 70-30-4).
C. 2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate (Erbon)
(CAS # 136-25-4);
Small Business Exemption
If you are a “small business,” you are exempt from the reporting
requirement for Item V-B (section 3). You may qualify as a “small
business” if you it one of the following definitions:
Source
In providing the estimates, use the codes in the following table to
indicate the source of such information in column 4 of Parts V – A
and – B.
1) Your expected gross sales will total less than $100,000 per year
for the next three years, or
2) In the case of coal mines, you average production will be less
than 100,000 tons of coal per year.
Code
Engineering study ..................................................................... 1
Actual data from pilot plants...................................................... 1
Estimates from other engineering studies................................. 2
Data from other similar plants ................................................... 3
Best professional estimates ...................................................... 4
Others ........................................................... specify on the form
If you are a “small business,” you may submit projected sales or
production figures to qualify for this exemption. The sales or
production figures you submit must be for the facility which is the
source of the discharge. The data should not be limited only to
production or sales for the process or processes which contribute to
the discharge, unless those are the only processes at your facility.
For sales data, where intracorporate transfers of goods and services
are involved, the transfer price per unit should approximate market
prices for those goods and services as closely as possible. If
necessary, you may index your sales figures to the second quarter of
1980 to demonstrate your eligibility for a small business exemption.
This may be done by using the gross national product price deflator
(second quarter of 1980 = 100), an index available in “National
Income and Product Accounts of the United States” (Department of
Commerce, Bureau of Economic Analysis).
Item V-A
Estimates of data on pollutants or parameters in Group A must be
reported by all applicants for all outfalls: including outfalls containing
only noncontact cooling water or nonprocess wastewater.
To request a waiver from reporting any of these pollutants or
parameters, the applicant must submit to the permitting authority a
written request specifying which pollutants or parameters should be
waived and the reasons for requesting such a waiver. This request
should be submitted to the permitting authority before or with the
permit application. The permitting authority may waive the
requirements for information about these pollutants or parameters if
he or she determines that less stringent reporting requirements are
adequate to support issuance of the permit. No extensive
documentation will normally be needed, but the applicant should
contact the permitting authority if she or he wishes to receive
instructions on what his or her particular request should contain.
The small business exemption applies to the GC/MS fractions
(Section 3) of Item V-B only. Even if you are eligible for a small
business exemption, you are still required to provide information on
metals, cyanide, total phenols, and dioxin in Item V-B, as well as all
of Items V-A and C.
Item V-C
List any pollutants in Table 2D-3 that you believe to be present in
any outfalls and briefly explain why you believe they will be present.
No estimate of the pollutant’s quantity is required, unless you already
have quantitative data.
Item V-B
Estimates of data on pollutants in Group B must be reported by all
applicants for all outfalls, including outfalls containing only
noncontact cooling water or nonprocess wastewater. You are merely
required to report estimates for those pollutants which you know or
have reason to believe will be discharged or which are limited
directly by an effluent limitations guideline (or NSPS) or indirectly
EPA Form 3510-2D (Rev. 8-90)
Note: The discharge of pollutants listed in Table 2D-4 may subject
you to the additional requirements of section 311 of the CWA (Oil
and Hazardous Substance Liability). These requirements are not
administered through the NPDES program. However, if you wish an
exemption under 40 CFR 117.12(a)(2) from these requirements,
attach additional sheets of paper to this form providing the following
information:
I-2
A. The substance and the amount of each substance which may be
discharged;
Item VII
A space is provided for additional information which you believe
would be useful in setting permit limits, such as additional sampling.
Any response is optional.
B. The origin and source of the discharge of the substance;
C. The treatment which is to be provided for the discharge by:
1. An onsite treatment system separate from any treatment
system which will treat your normal discharge;
2. A treatment system designed to treat your normal discharge
and which is additionally capable of treating the amount of the
substance identified under paragraph 1 above; or
3. Any combination of the above.
Item VIII
The Clean Water Act provides for severe penalties for submitting
false information on this application form.
Section 309(c)(2) of the Clean Water Act provides that “Any person
who knowingly makes any false statement, representation, or
certification in any application,… shall upon conviction, be punished
by a fine of no more than $10,000 or by imprisonment for not more
than six months, or both.”
An exemption from the section 311 reporting requirements pursuant
to 40 CFR Part 117 for pollutants on Table 2D does not exempt you
from the section 402 reporting requirements pursuant to 40 CFR Part
122 (Item V-C) for pollutants listed on Table 2D-3.
40 CFR Part 122.22 Requires the Certification to be Signed as
Follows:
A. For a corporation: by a responsible corporate officer.
For further information on exclusions from Section 311, see 40 CFR
Section 117.12(a)(2) and (c), or contact your EPA Regional office
(Table 1 in Form 1 instructions).
A responsible corporate officer means (i) a 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 employing more than 250 persons or having
gross annual sales or expenditures exceeding $25,000,000 (in
second-quarter 1980 dollars), if authority to sign documents has
been assigned or delegated to the manager in accordance with
corporate procedures.
Item VI-A
If an engineering study was conducted, check the box labeled “report
available.” If no study was done, check the box labeled “no report.”
Item VI-B
Report the name and location of any existing plant(s) which (to the
best of your knowledge) resembles your planned operation with
respect to items produced, production process, wastewater
constituents, or wastewater treatment. No studies need be
conducted to respond to this item. Only data which are already
available need be submitted.
B. For a partnership or sole proprietorship: by a general partner or
the proprietor, respectively; or
This information will be used to inform the permit writer of
appropriate treatment methods and their associated permit
conditions and limits.
EPA Form 3510-2D (Rev. 8-90)
C. For a municipality, State, Federal, or other public agency: by
either a principal executive officer or ranking elected official. For
purposes of this section, a principal executive officer of a Federal
agency includes (i) the chief executive officer of the agency, or
(ii) a senior executive office having responsibility for the overall
operations of the principal geographic unit of the agency (e.g.,
Regional Administrators of EPA).
I-3
PHYSICAL TREATMENT PROCESSES
1–A. . . . . . . . . .
1–B . . . . . . . . . .
1–C . . . . . . . . . .
1–D . . . . . . . . . .
1–E . . . . . . . . .
1–F . . . . . . . . .
1–G . . . . . . . . . .
1–H . . . . . . . . . .
1–I . . . . . . . . . .
1–J . . . . . . . . . .
1–K . . . . . . . . . .
1–L . . . . . . . . . .
Ammonia Stripping
Dialysis
Diatomaceous Earth Filtration
Distillation
Electrodialysis
Evaporation
Flocculation
Flotation
Foam Fractionation
Freezing
Gas–Phase Separation
Grinding (Comminutors)
1–M . . . . . . . . . .
1–N . . . . . . . . . .
1–O . . . . . . . . . .
1–P . . . . . . . . . . .
1–Q. . . . . . . . . . .
1–R . . . . . . . . . .
1–S . . . . . . . . . . .
1–T . . . . . . . . . . .
1–U . . . . . . . . . .
1–V . . . . . . . . . . .
1–W . . . . . . . . . .
1–X . . . . . . . . . . .
Grit Removal
Microstraining
Mixing
Moving Bed Filters
Multimedia Filtration
Rapid Sand Filtration
Reverse Osmosis (Hyperfiltration)
Screening
Sedimentation (Settling)
Slow Sand Filtration
Solvent Extraction
Sorption
CHEMICAL TREATMENT PROCESSES
2–A . . . . . . . . . .
2–B . . . . . . . . . .
2–C . . . . . . . . . .
2–D . . . . . . . . . .
2–E . . . . . . . . . .
2–F . . . . . . . . . .
Carbon Adsorption
Chemical Oxidation
Chemical Precipitation
Coagulation
Dechlorination
Disinfection (Chlor i ne)
2–G . . . . . . . . . .
2–H . . . . . . . . . .
2–I . . . . . . . . . . .
2–J . . . . . . . . . . .
2–K . . . . . . . . . . .
2–L . . . . . . . . . . .
Disinfection (Ozone)
Disinfection (Other)
Electrochemical Treatment
Ion Exchange
Neutralization
Reduction
BIOLOGICAL TREATMENT PROCESSES
3–A . . . . . . . . . .
3–B . . . . . . . . . .
3–C . . . . . . . . . .
3–D . . . . . . . . . .
Activated Sludge
Aerated Lagoons
Anaerobic Treatment
Nitrification–Denitrification
3–E . . . . . . . . . . .
3–F . . . . . . . . . . .
3–G . . . . . . . . . .
3–H . . . . . . . . . .
Pre-Aeration
Spray Irrigation/Land Application
Stabilization Ponds
Trickling Filtration
OTHER PROCESSES
4–A . . . . . . . . . . Discharge to Surface Water
4–B . . . . . . . . . . Ocean Discharge Through Outfall
4–C . . . . . . . . . . Reuse/Recycle of Treated Effluent
4-D . . . . . . . . . . . Underground Injection
SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–A . . . . . . . . . .
5–B . . . . . . . . . .
5–C. . . . . . . . . .
5–D. . . . . . . . . .
5–E . . . . . . . . . .
5–F . . . . . . . . . .
5–G . . . . . . . . . .
5–H . . . . . . . . . .
5–I. . . . . . . . . . .
5–J . . . . . . . . . .
5–K . . . . . . . . . .
5–L . . . . . . . . . .
Aerobic Digestion
Anaerobic Digestion
Belt Filtration
Centrifugation
Chemical Conditioning
Chlorine Treatment
Composting
Drying Beds
Elutriation
Flotation Thickening
Freezing
Gravity Thickening
5–M . . . . . . . . . .
5–N . . . . . . . . . .
5–O . . . . . . . . . .
5–P . . . . . . . . . . .
5–Q . . . . . . . . . .
5–R . . . . . . . . . .
5–S . . . . . . . . . .
5–T . . . . . . . . . .
5–U . . . . . . . . . .
5–V . . . . . . . . . .
5–W . . . . . . . . . .
Table 2D-1
EPA Form 3510-2D (Rev. 8-90)
Heat Drying
Heat Treatment
Incineration
Land Application
Landfill
Pressure Filtration
Pyrolysis
Sludge Lagoons
Vacuum Filtration
Vibration
Wet Oxidation
GROUP A
Biochemical Oxygen Demand (BOD)
Chemical Oxygen Demand (COD)
Total Organic Carbon (TOC)
Total Suspended Solids (TSS)
Flow
Ammonia (as N)
Temperature (winter)
Temperature (summer)
pH
GROUP B
Bromide
Total Residual Chlorine
Color
Fecal Coliform
Fluoride
Nitrate-Nitrite (as N)
Oil and Grease
Phosphorus (as P) Total
Radioactivity
(1) Alpha, Total
(2) Beta, Total
(3) Radium, Total
(4) Radium 226, Total
Sulfate (as S04)
Sulfide (as S)
Sulfite (as S03)
Surfactants
Aluminum, Total
Barium, Total
Boron, Total
Cobalt, Total
Iron, Total
Magnesium, Total
Molybdenum, Total
Manganese, Total
Tin, Total
Titanium, Total
Section 1
Antimony, Total
Beryllium, Total
Chromium, Total
Lead, Total
Nickel, Total
Silver, Total
Zinc, Total
Phenols, Total
Arsenic, Total
Cadmium, Total
Copper, Total
Mercury, Total
Selenium, Total
Thallium, Total
Cyanide, Total
Section 2
2,3,7,8,Tetrachlorodibenzo-P-Dioxin
Section 3
GC/MS FRACTION* — VOLATILE COMPOUNDS
Acrolein
Benzene
Carbon Tetrachloride
Chlorodibramomethane
2-Chloroethylvinyl Ether
Dichlorobomomethane
1,2-Dichloroethane
1,2-Dichloropropane
Ethylbenzene
Methyl Chloride
1,1,2,2-Tetrachloroethane
Toluene
1,1,1-Trichloroethane
Trichloroethylene
Vinyl Chloride
Acrylonitirle
Bromoform
Chlorobenzene
Chloroethane
Chloroform
1,1-Dichloroethane
1,3-Dichloropropylene
Methyl Bromide
Methylene chloroethane
Tetrachloroethylene
1,2-Trans-Dichloroethylene
1,1,2-Trichloroethane
GS/MS FRACTION — ACID COMPOUNDS
2-Chlorophenol
2,4-Dimethylphenol
2,4-Dinitro-phenol
4-Nitrophenol
Pentachlorophenol
2,4,6-Trichlorophenol
2,4-Dichlorophenol
4,6-Dinitro-O-Cresol
2-Nitrophenol
P-Chloro-M-Cresol
Phenol
Table 2D-2
EPA Form 3510-2D (Rev. 8-90)
GC/MS FRACTION — BASE/NEUTRAL COMPOUNDS
Acenaphthene
Anthracene
Benzo (a) Anthracene
3,5-Benzofluoranthene
Benzo (k) Fluoranthene
Bis (2-Chloroethyl) Ether Bis
Bis (2-Ethylhexyl) Phthalate
Butyl Benzyl Phthalate
4-Chlorophenyl Phenyl Ether
Dibenzo (a, h) Anthracene
1,3-Dichlorobenzene
3,3-Dichlorobenzidine
Dimethyl Phthalate
2,4-Dinitrotoluene
Di-N-Octyl Phthalate
Fluoranthene
Hexachlorobenzene
Hexachlorocyclopentadiene
Indeno (1,2,3-cd) Pyrene
Naphthalene
N-Nitro-sodimethylamine
N-Nitro-sodiphenylamine
Pyrene
Acenaphtylene
Benzidine
Benzo (a) Pyrene
Benzo (ghi) Perylene
Bis (2 Chloroethoxy) Methane
(2-Chloroisopropyl) Ether
4-Bromophenyl Phenyl Ether
2-Chloronaphthalene
Chrysene
1,2-Dichlorobenzene
1,4-Dichlorobenzene
Diethyl Phthalate
Di-N-Butyl Phthalate
2,6-Dinitrotoluene
1,2, Diphenylhydrazine (as Azobenzen)
Fluorene
Hexachlorobutadiene
Hexachloroethane
lsophorone
Nitrobenzene
N-Nitrosodi-N-Propylamine
Phenanthrene
1,2,4-Trichlorobenzene
GC/MS FRACTION — PESTICIDES
Aldrin
Alpha-BHC
Beta-BHC
4,4' DDT
4,4'-DDD
Alpha-Endosulfan
Endosulfan Sulfate
Endrin Aldehyde
Heptachlor Epoxide
PCB-1254
PCB-1232
PCB-1260
Toxaphene
*fractions defined in 40 CFR Part 136
Gamma-BHC
Delta-BHC
Chlordane
4,4' DDE
Dieldrin
Beta-Endosulfan
Endrin
Heptachlor
PCB-1242
PCB-1221
PCB-1248
PCB-1016
Table 2D-2
EPA Form 3510-2D (Rev. 8-90)
TOXIC POLLUTANTS AND HAZARDOUS SUBSTANCES
REQUIRED TO BE IDENTIFIED BY APPLICANTS IF EXPECTED TO BE PRESENT
TOXIC POLLUTANT
HAZARDOUS SUBSTANCES
Asbestos
Isoprene
Isopropanolamine dodecylbenzenesulfonate
Kelthane
Kepone
Malathion
Mercaptodimethur
Methoxychlor
Methyl mercaptan
Methyl methacrylate
Methyl parathion
Mevinphos
Mexacarbate
Monoethyl amine
Monomethyl amine
Naled
Napthenic acid
Nitrotoluene
Parathion
Phenolsulfonate
Phosgene
Propargite
Propylene oxide
Pyrethrins
Quinoline
Resorcinol
Strontium
Strychnine
2,4,5-T (2,4,5-Trichlorophenoxyacetic acid)
TDE (Tetrochlorodiphenyl ethane)
2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanic acid]
Trichlorofon
Triethanolamine dodecylbenzenesulfonate
Triethylamine
Uranium
Vanadium
Vinyl acetate
Xylene
Xylenol
Zirconium
HAZARDOUS SUBSTANCES
Acetaldehyde
Allyl alcohol
Allyl chloride
Amyl acetate
Aniline
Benzonitrile
Benzyl chloride
Butyl acetate
Butylamine
Captan
Carbaryl
Carbofuran
Carbon disulfide
Chlorpyrifos
Coumaphos
Cresol
Crotonaldehyde
Cyclohexane
2,4-D (2,4-Dichlorophenoxyacetic acid)
Diazinon
Dicamba
Dichlobenil
Dichlone
2,2-Dichloropropionic acid
Dichlorvos
Diethyl amine
Dimethyl amine
Dintrobenzene
Diquat
Disulfoton
Diuron
Epichlorohydrin
Ethion
Ethylene diamine
Formaldehyde
Furfural
Guthion
Table 2D-3
EPA Form 3510-2D (Rev. 8-90)
HAZARDOUS SUBSTANCES
1. Acetaldehyde
2. Acetic acid
3. Acetic anhydride
4. Acetone cyanohydrin
5. Acetyl bromide
6. Acetyl chloride
7. Acrolein
8. Acrylonitrile
9. Adipic acid
10. Aldrin
11. Allyl alcohol
12. Allyl chloride
13. Aluminum sulfate
14. Ammonia
15. Ammonium acetate
16. Ammonium benzoate
17. Ammonium bicarbonate
18. Ammonium bichromate
19. Ammonium bifluoride
20. Ammonium bisulfite
21. Ammonium carbamate
22. Ammonium carbonate
23. Ammonium chloride
24. Ammonium chromate
25. Ammonium citrate
26. Ammonium fluoroborate
27. Ammonium fluoride
28. Ammonium hydroxide
29. Ammonium oxalate
30. Ammonium silicofluoride
31. Ammonium sulfamate
32. Ammonium sulfide
33. Ammonium sulfite
34. Ammonium tartrate
35. Ammonium thiocyanate
36. Ammonium thiosulfate
37. Amyl acetate
38. Aniline
39. Antimony pentachloride
40. Antimony potassium tartrate
41. Antimony tribromide
42. Antimony trichloride
43. Antimony trifluoride
44. Antimony trioxide
45. Arsenic disulfide
46. Arsenic pentoxide
47. Arsenic trichloride
48. Arsenic trioxide
49. Arsenic trisulfide
50. Barium cyanide
51. Benzene
52. Benzoic acid
53. Benzonitrile
54. Benzoyl chloride
55. Benzyl chloride
56. Beryllium chloride
57. Beryllium fluoride
58. Beryllium nitrate
59. Butylacetate
60. n-Butylphthalate
61. Butylamine
62. Butyric acid
63. Cadmium acetate
64. Cadmium bromide
65. Cadmium chloride
66. Calcium arsenate
67. Calcium arsenite
69. Calcium carbide
69. Calcium chromate
70. Calcium cyanide
71. Calcium dodecylbenzenesulfonate
72. Calcium hypochlorite
73. Captan
74. Carbaryl
75. Carbofuran
76. Carbon disulfide
77. Carbon tetrachloride
78. Chlordane
79. Chlorine
80. Chlorobenzene
81. Chloroform
82. Chloropyrifos
83. Chlorosulfonic acid
84. Chromic acetate
85. Chromic acid
86. Chromic sulfate
87. Chromous chloride
88. Cobaltous bromide
89. Cobaltous formate
90. Cobaltous sulfamate
91. Coumaphos
92. Cresol
93. Crotonaldehyde
94. Cupric acetate
95. Cupric acetoarsenite
96. Cupric chloride
97. Cupric nitrate
98. Cupric oxalate
99. Cupric sulfate
100. Cupric sulfate ammoniated
101. Cupric tartrate
102. Cyanogen chloride
103. Cyclohexane
104. 2,4-D acid (2,4- Dichlorophenoxyacetic
acid)
105. 2,4-D esters (2,4Dichlorophenoxyacetic acid esters)
106. DDT
107. Diazinon
108. Dicamba
109. Dichlobenil
110. Dichlone
111. Dichlorobenzene
112. Dichloropropane
113. Dichloropropene
114. Dichloropropene-Dichloproropane mix
115. 2,2-Dichloropropionic acid
116. Dichlorvos
117. Dieldrin
118. Diethylamine
119. Dimethylamine
120. Dinitrobenzene
121. Dinitrophenol
122. Dinitrotoluene
123. Diquat
124. Disulfoton
125. Diuron
126. Dodecylbenzesulfonic acid
127. Endosulfan
128. Endrin
129. Epichlorohydrin
130. Ethion
Table 2D-4
EPA Form 3510-2D (8-90)
131. Ethylbenzene
132. Ethylenediamine
133. Ethylene dibromide
134. Ethylene dichloride
135. Ethylene diaminetetracetic acid (EDTA)
136. Ferric ammonium citrate
137. Ferric ammonium oxalate
138. Ferric chloride
139. Ferric fluoride
140. Ferric nitrate
141. Ferric sulfate
142. Ferrous ammonium sulfate
143. Ferrous chloride
144. Ferrous sulfate
145. Formaldehyde
146. Formic acid
147. Fumaric acid
148. Furfural
149. Guthion
150. Heptachlor
151. Hexachlorocyclopentadiene
152. Hydrochloric acid
153. Hydrofluoric acid
154. Hydrogen cyanide
155. Hydrogen sulfide
156. Isoprene
157. Isopropanolamine
dodecylbenzenesulfonate
158. Kelthane
159. Kepone
160. Lead acetate
161. Lead arsenate
162. Lead chloride
163. Lead fluoborate
164. Lead flourite
165. Lead iodide
166. Lead nitrate
167. Lead stearate
168. Lead sulfate
169. Lead sulfide
170. Lead thiocyanate
171. Lindane
172. Lithium chromate
173. Malathion
174. Maleic acid
175. Maleic anhydride
176. Mercaptodimethur
177. Mercuric cyanide
178. Mercuric nitrate
179. Mercuric sulfate
180. Mercuric thiocyanate
181. Mercurous nitrate
182. Methoxychlor
183. Methyl mercaptan
184. Methyl methacrylate
185. Methyl parathion
186. Mevinphos
187. Mexacarbate
188. Monoethylamine
189. Monomethylamine
190. Naled
191. Naphthalene
192. Naphthenic acid
193. Nickel ammonium sulfate
194. Nickel chloride
195. Nickel hydroxide
HAZARDOUS SUBSTANCES (Continued)
196. Nickel nitrate
197. Nickel sulfate
198. Nitric acid
199. Nitrobenzene
200. Nitrogen dioxide
201. Nitrophenol
202. Nitrotoluene
203. Paraformaldehyde
204. Parathion
205. Pentachlorophenol
206. Phenol
207. Phosgene
208. Phosphoric acid
209. Phosphorus
210. Phosphorus oxychloride
211. Phosphorus pentasulfide
212. Phosphorus trichloride
213. Polychlorinated biphenyls (PCB)
214. Potassium arsenate
215. Potassium arsenite
216. Potassium bichromate
217. Potassium chromate
218. Potassium cyanide
219. Potassium hydroxide
220. Potassium permanganate
221. Propargite
222. Propionic acid
223. Propionic anhydride
224. Propylene oxide
225. Pyrethrins
226. Quinoline
227. Resorcinol
228. Selenium oxide
229. Silver nitrate
230. Sodium
231. Sodium arsenate
232. Sodium arsenite
233. Sodium bichromate
234. Sodium bifluoride
235. Sodium bisulfite
236. Sodium chromate
237. Sodium cyanide
238. Sodium dodecylbenzenesulfonate
239. Sodium fluoride
240. Sodium hydrosulfide
241. Sodium hydroxide
242. Sodium hypochlorite
243. Sodium methylate
244. Sodium nitrite
245. Sodium phosphate (dibasic)
246. Sodium phosphate (tribasic)
247. Sodium selenite
248. Strontium chromate
249. Strychnine
250. Styrene
251. Sulfuric acid
252. Sulfur monochloride
253. 2,4,5-T acid (2,4,5Trichlorophenoxyacetic acid)
254. 2,4,5-T amines (2,4,5-Trichlorophenoxy
acetic acid amines)
255. 2,4,5-T esters (2,4,5 Trichlorophenoxy
acetic acid esters)
256. 2,4,5-T salts (2,4,5-Trichlorophenoxy
acetic acid salts)
257. 2,4,5-TP acid (2,4,5-Trichlorophenoxy
propanoic acid)
258. 2,4,5-TP acid esters (2,4,5Trichlorophenoxy propanoic acid esters)
259. TDE (Tetrachlorodiphenyl ethane)
260. Tetraethyl lead
261. Tetraethyl pyrophosphate
262. Thallium sulfate
263. Toluene
264. Toxaphene
265. Trichlorofon
266. Trichloroethylene
267. Trichlorophenol
268. Triethanolamine
dodecylbenzenesulfonate
269. Triethylamine
270. Trimethylamine
271. Uranyl acetate
272. Uranyl nitrate
273. Vanadium pentoxide
274. Vanadyl sulfate
275. Vinyl acetate
276. Vinylidene chloride
277. Xylene
278. Xylenol
279. Zinc acetate
280. Zinc ammonium chloride
281. Zinc borate
282. Zinc bromide
283. Zinc carbonate
284. Zinc chloride
285. Zinc cyanide
286. Zinc fluoride
287. Zinc formate
288. Zinc hydrosulfite
289. Zinc nitrate
290. Zinc phenolsulfonate
291. Zinc phosphide
292. Zinc silicofluoride
293. Zinc sulfate
294. Zirconium nitrate
295. Zirconium potassium flouride
296. Zirconium sulfate
297. Zirconium tetrachloride
Table 2D-4
EPA Form 3510-2D (Rev. 8-90)
LINE DRAWING
Blue River
Municipal
Water Supply
90,000 GPD
45,000 GPD
Raw Materials
10,000 GPD
Fiber
Preparation
15,000
GPD
40,000 GPD
Solid Waste
4,000 GPD
Grit
Separator
36,000 GPD
Stormwater
Max: 20,000 GPD
45,000 GPD
Dyeing
20,000
GPD
40,000 GPD
Neutralization
Tank
10,000 GPD
Cooling Water
30,000 GPD
10,000
GPD
Washing
Drying
10,000
GPD
40,000
GPD
Waste
Treatment
Plant #2
Loss
6,000 GPD
34,000 GPD
Waste
Treatment
Plant #1
Blue River
Outfall 002
50,000 GPD
Outfall 001
70,000 GPD + Stormwater
Schematic of Water Flow
Brown Mills, Inc.
City, County, State
Figure 2D-1
EPA Form 3510-2D (Rev. 8-90)
5,000 GPD
To Atmosphere
To Product
5,000 GPD
Form Approved. OMB No. 2040-0086. Approval expires 8-31-98.
EPA I.D. NUMBER (copy from Item 1 of Form 1)
Please print or type in the unshaded areas only
Form
New Sources and New Dischargers
Application for Permit to Discharge Process Wastewater
2D
NPDES
I. Outfall Location
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
Outfall Number
(list)
Latitude
Deg.
Min.
Receiving Water (name)
Longitude
Sec.
Deg.
Min.
Sec.
II. Discharge Date (When do you expect to begin discharging?)
III. Flows, Sources of Pollution, and Treatment Technologies
A. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary
wastewater, cooling water, and storm water runoff; (2) The average flow contributed by each operation; and (3) The treatment received by the
wastewater. Continue on additional sheets if necessary.
Outfall
Number
1. Operations Contributing Flow
(List)
EPA Form 3510-2D (Rev. 8-90)
2. Average Flow
(Include Units)
3. Treatment
(Description or List codes from Table 2D-1)
PAGE 1 of 5
B. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the
effluent, and treatment units labeled to correspond to the more detailed descriptions in Item III-A. Construct a water balance on the line drawing
by showing average flows between intakes, operations, treatment units, and outfalls. If a water balance cannot be determined (e.g., for certain
mining activities), provide a pictorial description of the nature and amount of any sources of water and any collection or treatment measures.
C. Except for storm runoff, leaks, or spills, will any of the discharges described in Items III-A be intermittent or seasonal?
YES (complete the following table)
NO (go to Section IV)
1. Frequency
Outfall
Number
a. Days
Per Week
(specify average)
2. Flow
b. Months
Per Year
(specify average)
a. Maximum Daily
b. Maximum
Flow Rate
Total Volume
(in mgd)
(specify with units)
c. Duration
(in days)
IV. Production
If there is an applicable production-based effluent guideline or NSPS, for each outfall list the estimated level of production (projection of actual
production level, not design), expressed in the terms and units used in the applicable effluent guideline or NSPS, for each of the first 3 years of
operation. If production is likely to vary, you may also submit alternative estimates (attach a separate sheet).
Year
A. Quantity Per Day
EPA Form 3510-2D (Rev. 8-90)
B. Units Of Measure
c. Operation, Product, Material, etc. (specify)
Page 2 of 5
CONTINUE ON NEXT PAGE
CONTINUED FROM THE FRONT
EPA I.D. NUMBER (copy from Item 1 of Form 1)
Outfall Number
V. Effluent Characteristics
A and B: These items require you to report estimated amounts (both concentration and mass) of the pollutants to be discharged from each of your
outfalls. Each part of this item addresses a different set of pollutants and should be completed in accordance with the specific instructions for that
part. Data for each outfall should be on a separate page. Attach additional sheets of paper if necessary.
General Instructions (See table 2D-2 for Pollutants)
Each part of this item requests you to provide an estimated daily maximum and average for certain pollutants and the source of information. Data
for all pollutants in Group A, for all outfalls, must be submitted unless waived by the permitting authority. For all outfalls, data for pollutants in Group
B should be reported only for pollutants which you believe will be present or are limited directly by an effluent limitations guideline or NSPS or
indirectly through limitations on an indicator pollutant.
1. Pollutant
EPA Form 3510-2D (Rev. 8-90)
2. Maximum Daily
Value
(include units)
3. Average Daily
Value
(include units)
Page 3 of 5
4. Source (see instructions)
CONTINUE ON REVERSE
CONTINUED FROM THE FRONT
EPA I.D. NUMBER (copy from Item 1 of Form 1)
C. Use the space below to list any of the pollutants listed in Table 2D-3 of the instructions which you know or have reason to believe will be
discharged from any outfall. For every pollutant you list, briefly describe the reasons you believe it will be present.
1. Pollutant
2. Reason for Discharge
VI. Engineering Report on Wastewater Treatment
A. If there is any technical evaluation concerning your wastewater treatment, including engineering reports or pilot plant studies, check the
appropriate box below.
Report Available
No Report
B. Provide the name and location of any existing plant(s) which, to the best of your knowledge resembles this production facility with respect to
production processes, wastewater constituents, or wastewater treatments.
Name
EPA Form 3510-2D (Rev. 8-90)
Location
Page 4 of 5
CONTINUE ON NEXT PAGE
EPA I.D. NUMBER (copy from Item 1 of Form 1)
VII. Other Information (Optional)
Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information you feel should be
considered in establishing permit limitations for the proposed facility. Attach additional sheets if necessary.
VIII. 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 gather and evaluate 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.
A. Name and Official Title (type or print)
B. Phone No.
C. Signature
D. Date Signed
EPA Form 3510-2D (Rev. 8-90)
PAGE 5 of 5
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
United States
Environmental Protection
Agency
Office of Water
Enforcement and Permits
Washington, DC 20460
EPA Form 3510-2E
Revised August 1990
Permits Division
Application Form 2E —
Facilities Which Do Not
Discharge Process
Wastewater
Paperwork Reduction Act Notice
The public reporting burden for this collection of information is
estimated to average 33 hours per response. This estimate
includes time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and
completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect
of this collection of information to the Chief, Information Policy
Branch (PM-223), US Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and
to the Office of Information and Regulatory Affairs, Office of
Management and Budget, Washington, DC 20503, marked
Attention: Desk Officer for EPA.
EPA Form 3510-2E (8-90)
Form 2E Instructions
you, enter “NA” (for “not applicable”) to show that you
considered the question.
Who Must File Form 2E
EPA Form 3510-2E must be completed in conjunction with
EPA Form 3510-1 (Form 1). This short form may be used
only by operators of facilities which discharge only
nonprocess wastewater (process wastewater is water that
comes into direct contact with or results from the production
or use of any raw material, intermediate product, finished
product, byproduct, waste product, or wastewater) which is
not regulated by effluent limitations guidelines or new source
performance standards. The form is intended primarily for
use by dischargers (new or existing) of sanitary wastes and
noncontact cooling water. It may not be used for discharges
of stormwater runoff or by educational, medical, or
commercial chemical laboratories or by publicly owned
treatment works (POTW’s).
Followup Requirements for New Dischargers and
New Sources
Please note that no later than 2 years after commencement
of discharge from the proposed facility, you must complete
and submit Item IV of this form (NPDES Form 2E). At that
time you must test and report actual rather than estimated
data for the pollutants or parameters in Item IV, unless
waived by the permitting authority.
Definitions
Significant terms used in these instructions and in the
form are defined in the Glossary found in the General
Instructions accompanying Form 1.
Where to File Applications
Item I
The application forms should be sent to the EPA
Regional Office which covers the State in which the
facility is located. Form 2E (the short form) must be used
only when applying for permits in States where the
NPDES permits program is administered by EPA. For
facilities located in States which are approved to
administer the NPDES permits program, the State
environmental agency should be contacted for proper
permit application forms and instructions. Information on
whether a particular program is administered by EPA or
by a State agency can be obtained from your EPA
Regional Office. Form 1, Table 1 of the “General
Instructions” lists the addresses of EPA Regional Offices
and the States within the jurisdiction of each Office.
Under Part A, list an outfall number. Under Part B, list the
latitude and longitude to the nearest 15 seconds for this
outfall. Under Part C, list the name of the outfall’s receiving
water. When there is more than one outfall, you must submit
a separate Form 2E (Items I, III, and IV only) for each outfall.
Item II (New Dischargers Only)
This item requires your best estimate of the date on
which your facility will begin to discharge.
Item III
In Part A, indicate the general type(s) of wastes to be
discharged by placing an “x” in the appropriate box(es).
If “other nonprocess wastewater” is marked, it should be
identified. If cooling water additives are to be used, they
must be listed by name under Part B.
Public Availability of Submitted Information
You may not claim as confidential any information
required by this form or Form1, whether the information
is reported on the forms or in an attachment. Section
402(j) of the CWA requires that all permit applications
shall be available to the public. This information will
therefore be made public upon request.
In addition, the composition of the cooling water
additives should be listed if this information is available.
The composition of cooling water additives may be found
on product labels or from manufacturer’s data sheets.
Item IV — Reporting
You may claim as confidential any information you submit to
EPA which goes beyond that required by this form or Form
1. However, confidentiality claims for effluent data must be
denied. If you do not assert a claim of confidentiality at the
time of submitting the information, EPA may make the
information public without further notice. Claims of
confidentiality will be handled in accordance with EPA’s
business confidentiality regulations in 40 CFR Part 2.
All pollutant levels must be reported as concentration and as
total mass (except for discharge flow, pH, and temperature).
Total mass is the total weight of pollutants discharged over a
day. Use the following abbreviations for units:
Completeness
Your application will not be considered complete unless
you answer every question on this form and Form 1
(except as instructed below). If an item does not apply to
EPA Form 3510-2E (8-90)
I-1
Concentration
Mass
ppm
parts per million
lbs
pounds
mg/1
milligrams per liter
ton
tons (English tons)
ppb
parts per billion
mg
milligrams
Ug/1
micrograms per liter
g
grams
kg
kilograms
T
Tonnes (metric tons)
Engineering Study
Code
Actual data from pilot plants .....................................1
Estimates from other engineering studies ................2
Data from other similar plants...................................3
Best professional estimates......................................4
Others .......................................... specify on the form
A. Existing Sources
You are required to provide at least one analysis for
each pollutant or parameter listed by filling in the
requested information under the applicable column. Data
reported must be representative of the facility’s current
operation (average daily value over the previous 365
days should be reported). Most facilities routinely
monitor these pollutants or parameters as part of
existing permit requirements.
C. Testing Waivers
To request a waiver from reporting any of these
pollutants or parameters, the applicant (whether a new
or existing discharger) must submit to the permitting
authority a written request specifying which pollutants or
parameters should be waived and the reasons for
requesting a waiver. This request should be submitted to
the permitting authority before or with the permit
application. The permitting authority may waive the
requirements for information about any pollutant or
parameter if he determines that less stringent reporting
requirements are adequate to support issuance of the
permit. No extensive documentation of the request will
normally be needed, but the applicant should contact the
permitting authority if her or she wishes to receive
instructions on what his or her particular request should
contain.
The pollutants or parameters listed are: average flow,
biochemical oxygen demand (BOD), total suspended
solids (TSS), fecal coliform (if believed present or if
sanitary waste is discharged), pH, total residual chlorine
(if chlorine is used), temperature (winter and summer),
oil and grease, chemical oxygen demand (COD), total
organic carbon (TOC) (COD and TOC are only required
if noncontact cooling water is discharged), and ammonia
(as N). The analysis of these pollutants or parameters
must be done in accordance with procedures
promulgated in 40 CFR Part 136. Grab samples must be
used for pH, temperature, residual chlorine, oil and
grease, and fecal coliform. For all other pollutants, 24hour composite samples must be used. Any further
questions on sampling or analysis should be directed to
your EPA or State permitting authority. The authority
may request that you do additional testing, if appropriate,
on a case-by-case basis under Section 308 of the Clean
Water Act (CWA).
Item V
Describe the average frequency of flow and duration of
any intermittent or seasonal discharge (except for
stormwater runoff, leaks, or spills). The frequency of flow
means the number of days or months per year there is
intermittent discharge. Duration means the number of
days or hours per discharge. For new dischargers, base
your answers on your best estimate.
If you expect a pollutant to be present solely as a result
of its presence in you intake water, state this information
on Item VII of the form.
B. New dischargers
Item VI
Your are required to provide an estimated maximum
daily and average daily value for each pollutant or
parameter (exceptions noted on the form). Please note
that followup testing and reporting are required no later
than 2 years after the facility starts to discharge.
Sampling and analysis are not required at this time. If,
however, data from such analyses are available, then
such data should be reported. The source of the
estimates is also required. Base your determination of
whether a pollutant will be present in your discharge on
your knowledge of the proposed facility’s use of
maintenance chemicals, and any analyses of your
effluent or of any similar effluent. You may also provide
the estimates based on available inhouse or contractor’s
engineering reports or any other studies performed on
the proposed facility. If you expect a pollutant or
parameter to be present solely as a result of its presence
in your intake water, state this information on Item VII of
the form.
Describe briefly any treatment system(s) used (or to be
used for new dischargers), indicating whether the
treatment system is physical, chemical, biological,
sludge and disposal, or other. Also give the particular
type(s) of process(es) used (or to be used). For
example, if a physical treatment system is used (or will
be used), specify the processes applied, such as grit
removal, ammonia stripping, dialysis, etc.
Item VII
This item is intended for you to provide any additional
information (such as sampling results) that you feel
should be considered by the reviewer in establishing
permit limitations. Any response here is optional. If you
wish to demonstrate your eligibility for a “net” effluent
limitation, i.e., an effluent limitation adjusted to provide
credit for the pollutant(s) present in your intake water,
please add a short statement of why you believe you are
eligible (see §122.45(g)). You will then be contacted by
the permitting authority for further instructions.
In providing the estimates, use the codes in the following
table to indicate the source of such information.
EPA Form 3510-2E (8-90)
I-2
Item VIII
The Clean Water Act provides severe penalties for
submitting false information on this application form.
Section 309(c)(2) of the Clean Water Act provides that
“Any person who knowingly makes any false statement,
representation, or certification in any application, ...shall
upon conviction, be punished by a fine of no more than
$10,000 or by imprisonment for not more than six
months or both.”
40 CFR Part 122.22 requires the certification to be
signed as follows:
a. For a corporation: by a responsible corporate officer.
A responsible corporate officer means (i) a
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
employing more than 250 persons or having gross
annual
sales
or
expenditures
exceeding
$25,000,000 (in second quarter 1980 dollars), if
authority to sign documents has been assigned or
delegated to the manager in accordance with
corporate pocedures.
b. For a partnership or sole proprietorship: by a general
partner or the proprietor, respectively; or
c.
For a municipality, State, Federal, or other public
agency: by either a principal executive officer or
ranking elected official. For purposes of this section,
a principal executive officer of a Federal agency
includes (i) the chief executive officer of the agency,
or (ii) a senior executive officer having responsibility
for the overall operations of a principal geographic
unit of the agency (e.g., Regional Administrators of
EPA).
EPA Form 3510-2E (8-90)
I-3
Form Approved. OMB No. 2040-0086.
Approval expires 5-31-92.
EPA ID Number (copy from Item 1 of Form 1)
Please print or type in the unshaded areas only.
FORM
Facilities Which Do Not Discharge Process Wastewater
2E
NPDES
I. RECEIVING WATERS
For this outfall, list the latitude and longitude, and name of the receiving water(s).
Outfall
Number (list)
Latitude
Deg
Min
Receiving Water (name)
Longitude
Sec
Deg
Min
Sec
II. DISCHARGE DATE (If a new discharger, the date you expect to begin discharging)
III. TYPE OF WASTE
A. Check the box(es) indicating the general type(s) of wastes discharged.
Sanitary Wastes
Restaurant or Cafeteria Wastes
Noncontact Cooling Water
Other Nonprocess
Wastewater (Identify)
B. If any cooling water additives are used, list them here. Briefly describe their composition if this information is available.
IV. EFFLUENT CHARACTERISTICS
A. Existing Sources — Provide measurements for the parameters listed in the left-hand column below, unless waived by the permitting
authority (see instructions).
B. New Dischargers — Provide estimates for the parameters listed in the left-hand column below, unless waived by the permitting
authority. Instead of the number of measurements taken, provide the source of estimated values (see instructions).
(1)
Maximum
Daily Value
(include units)
Pollutant or
Parameter
Mass
(2)
Average Daily
Value (last year)
(include units)
Concentration
Mass
(3)
Number of
Measurements
Taken
(last year)
Concentration
(or)
(4)
Source of Estimate
(if new discharger)
Biochemical Oxygen
Demand (BOD)
Total Suspended Solids (TSS)
Fecal Coliform (if believed present
or if sanitary waste is discharged)
Total Residual Chlorine (if
chlorine is used)
Oil and Grease
*Chemical oxygen demand (COD)
*Total organic carbon (TOC)
Ammonia (as N)
Discharge Flow
pH (give range)
Value
Value
Temperature (Winter)
Temperature (Summer)
°C
°C
°C
°C
*If noncontact cooling water is discharged
EPA Form 3510-2E (8-90)
Page 1 of 2
V.
Except for leaks or spills, will the discharge described in this form be intermittent or seasonal?
If yes, briefly describe the frequency of flow and duration.
VI.
TREATMENT SYSTEM (Describe briefly any treatment system(s) used or to be used)
Yes
No
VII. OTHER INFORMATION (Optional)
Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information you feel
should be considered in establishing permit limitations. Attach additional sheets, if necessary.
VIII. 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 gather and evaluate 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.
A. Name & Official Title
B. Phone No. (area code
& no.)
C. Signature
D. Date Signed
EPA Form 3510-2E (8-90)
Page 2 of 2
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
EPA ID Number (copy from Item 1 of Form 1)
Please print or type in the unshaded areas only.
Form Approved. OMB No. 2040-0086
Approval expires 5-31-92
U.S. Environmental Protection Agency
Washington, DC 20460
FORM
2F
Application for Permit to Discharge Storm Water
Discharges Associated with Industrial Activity
NPDES
Paperwork Reduction Act Notice
Public reporting burden for this application is estimated to average 28.6 hours per application, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate, any other aspect
of this collection of information, or suggestions for improving this form, including suggestions which may increase or reduce this burden to: Chief, Information Policy
Branch, PM-223, U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, or Director, Office of Information and Regulatory
Affairs, Office of Management and Budget, Washington, DC 20503.
I. Outfall Location
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
A. Outfall Number
(list)
B. Latitude
C. Longitude
D. Receiving Water
(name)
II. Improvements
A. Are you now required by any Federal, State, or local authority to meet any implementation schedule for the construction, upgrading or operation of wastewater
treatment equipment or practices or any other environmental programs which may affect the discharges described in this application? This includes, but is not limited
to, permit conditions, administrative or enforcement orders, enforcement compliance schedule letters, stipulations, court orders, and grant or loan conditions.
1. Identification of Conditions,
Agreements, Etc.
2. Affected Outfalls
number
source of discharge
3. Brief Description of Project
4. Final
Compliance Date
a. req.
b. proj.
B: You may attach additional sheets describing any additional water pollution (or other environmental projects which may affect your discharges) you now have under
way or which you plan. Indicate whether each program is now under way or planned, and indicate your actual or planned schedules for construction.
III. Site Drainage Map
Attach a site map showing topography (or indicating the outline of drainage areas served by the outfalls(s) covered in the application if a topographic map is unavailable)
depicting the facility including: each of its intake and discharge structures; the drainage area of each storm water outfall; paved areas and buildings within the drainage
area of each storm water outfall, each known past or present areas used for outdoor storage of disposal of significant materials, each existing structural control measure
to reduce pollutants in storm water runoff, materials loading and access areas, areas where pesticides, herbicides, soil conditioners and fertilizers are applied; each of
its hazardous waste treatment, storage or disposal units (including each area not required to have a RCRA permit which is used for accumulating hazardous waste
under 40 CFR 262.34); each well where fluids from the facility are injected underground; springs, and other surface water bodies which received storm water discharges
from the facility.
EPA Form 3510-2F (1-92)
Page 1 of 3
Continue on Page 2
Continued from the Front
IV. Narrative Description of Pollutant Sources
A. For each outfall, provide an estimate of the area (include units) of imperious surfaces (including paved areas and building roofs) drained to the outfall, and an estimate of the total surface area
drained by the outfall.
Outfall
Number
Area of Impervious Surface
(provide units)
Total Area Drained
(provide units)
Outfall
Number
Area of Impervious Surface
(provide units)
Total Area Drained
(provide units)
B. Provide a narrative description of significant materials that are currently or in the past three years have been treated, stored or disposed in a manner to allow exposure
to storm water; method of treatment, storage, or disposal; past and present materials management practices employed to minimize contact by these materials with
storm water runoff; materials loading and access areas, and the location, manner, and frequency in which pesticides, herbicides, soil conditioners, and fertilizers are
applied.
C. For each outfall, provide the location and a description of existing structural and nonstructural control measures to reduce pollutants in storm water runoff; and a
description of the treatment the storm water receives, including the schedule and type of maintenance for control and treatment measures and the ultimate disposal
of any solid or fluid wastes other than by discharge.
Outfall
Number
List Codes from
Table 2F-1
Treatment
V. Nonstormwater Discharges
A. I certify under penalty of law hat the outfall(s) covered by this application have been tested or evaluated for the presence of nonstormwater discharges, and that all
nonstormwater discharged from these outfall(s) are identified in either an accompanying Form 2C or From 2E application for the outfall.
Name and Official Title (type or print)
Signature
Date Signed
B. Provide a description of the method used, the date of any testing, and the onsite drainage points that were directly observed during a test.
VI. Significant Leaks or Spills
Provide existing information regarding the history of significant leaks or spills of toxic or hazardous pollutants at the facility in the last three years, including the
approximate date and location of the spill or leak, and the type and amount of material released.
EPA Form 3510-2F (1-92)
Page 2 of 3
Continue on Page 3
Continued from Page 2
EPA ID Number (copy from Item 1 of Form 1)
VII. Discharge Information
A, B, C, & D:
See instructions before proceeding. Complete one set of tables for each outfall. Annotate the outfall number in the space provided.
Table VII-A, VII-B, VII-C are included on separate sheets numbers VII-1 and VII-2.
E. Potential discharges not covered by analysis – is any toxic pollutant listed in table 2F-2, 2F-3, or 2F-4, a substance or a component of a substance which you
currently use or manufacture as an intermediate or final product or byproduct?
Yes (list all such pollutants below)
No (go to Section IX)
VIII. Biological Toxicity Testing Data
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges or on a receiving water in
relation to your discharge within the last 3 years?
Yes (list all such pollutants below)
No (go to Section IX)
IX. Contract Analysis Information
Were any of the analyses reported in Item VII performed by a contract laboratory or consulting firm?
Yes (list the name, address, and telephone number of, and pollutants
analyzed by, each such laboratory or firm below)
A. Name
B. Address
No (go to Section X)
C. Area Code & Phone No.
D. Pollutants Analyzed
X. 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 gather and evaluate 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.
A. Name & Official Title (Type Or Print)
B. Area Code and Phone No.
C. Signature
D. Date Signed
EPA Form 3510-2F (1-92)
Page 3 of 3
EPA ID Number (copy from Item 1 of Form 1)
Form Approved. OMB No. 2040-0086
Approval expires 5-31-92
VII. Discharge information (Continued from page 3 of Form 2F)
Part A – You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details.
Pollutant
and
CAS Number
(if available)
Maximum Values
(include units)
Grab Sample
Taken During
Flow-Weighted
First 20
Composite
Minutes
Oil and Grease
Average Values
(include units)
Grab Sample
Taken During
Flow-Weighted
First 20
Composite
Minutes
Number
of
Storm
Events
Sampled
Sources of Pollutants
N/A
Biological Oxygen
Demand (BOD5)
Chemical Oxygen
Demand (COD)
Total Suspended
Solids (TSS)
Total Nitrogen
Total Phosphorus
Minimum
pH
Part B –
Maximum
Minimum
Maximum
List each pollutant that is limited in an effluent guideline which the facility is subject to or any pollutant listed in the facility’s NPDES permit for its process
wastewater (if the facility is operating under an existing NPDES permit). Complete one table for each outfall. See the instructions for additional details and
requirements.
Pollutant
and
CAS Number
(if available)
Maximum Values
(include units)
Grab Sample
Taken During
First 20
Flow-Weighted
Minutes
Composite
EPA Form 3510-2F (1-92)
Average Values
(include units)
Grab Sample
Taken During
First 20
Flow-Weighted
Minutes
Composite
Page VII-1
Number
of
Storm
Events
Sampled
Sources of Pollutants
Continue on Reverse
Continued from the Front
Part C - List each pollutant shown in Table 2F-2, 2F-3, and 2F-4 that you know or have reason to believe is present. See the instructions for additional details and
requirements. Complete one table for each outfall.
Pollutant
and
CAS Number
(if available)
Maximum Values
(include units)
Grab Sample
Taken During
First 20
Flow-Weighted
Minutes
Composite
Average Values
(include units)
Grab Sample
Taken During
First 20
Flow-Weighted
Minutes
Composite
Number
of
Storm
Events
Sampled
Sources of Pollutants
Part D –
Provide data for the storm event(s) which resulted in the maximum values for the flow weighted composite sample.
4.
5.
1.
2.
3.
Number of hours between
Maximum flow rate during
beginning of storm measured
rain event
Date of
Duration
Total rainfall
and end of previous
Storm
of Storm Event
during storm event
(gallons/minute or
measurable rain event
Event
specify units)
(in minutes)
(in inches)
7. Provide a description of the method of flow measurement or estimate.
EPA Form 3510-2F (1-92)
Page VII-2
6.
Total flow from
rain event
(gallons or specify units)
Instructions – Form 2F
Application for Permit to Discharge Storm Water
Associated with Industrial Activity
Who Must File Form 2F
Form 2F must be completed by operators of facilities which discharge storm water associated with industrial
activity or by operators of storm water discharges that EPA is evaluating for designation as a significant
contributor of pollutants to waters of the United States, or as contributing to a violation of a water quality
standard.
Operators of discharges which are composed entirely of storm water must complete Form 2F (EPA Form
3510-2F) in conjunction with Form 1 (EPA Form 3510-1).
Operators of discharges of storm water which are combined with process wastewater (process wastewater is
water that comes into direct contact with or results from the production or use of any raw material,
intermediate product, finished product, byproduct, waste product, or wastewater) must complete and submit
Form 2F, Form 1, and Form 2C (EPA Form 3510-2C).
Operators of discharges of storm water which are combined with nonprocess wastewater (nonprocess
wastewater includes noncontact cooling water and sanitary wastes which are not regulated by effluent
guidelines or a new source performance standard, except discharges by educational, medical, or commercial
chemical laboratories) must complete Form 1, Form 2F, and Form 2E (EPA Form 3510 2E).
Operators of new sources or new discharges of storm water associated with industrial activity which will be
combined with other nonstormwater new sources or new discharges must submit Form 1, Form 2F, and Form
2D (EPA Form 3510-2D).
Where to File Applications
The application forms should be sent to the EPA Regional Office which covers the State in which the facility is
located. Form 2F must be used only when applying for permits in States where the NPDES permits program
is administered by EPA. For facilities located in States which are approved to administer the NPDES permits
program, the State environmental agency should be contacted for proper permit application forms and
instructions.
Information on whether a particular program is administered by EPA or by a State agency can be obtained
from your EPA Regional Office. Form 1, Table 1 of the “General Instructions” lists the addresses of EPA
Regional Offices and the States within the jurisdiction of each Office.
Completeness
Your application will not be considered complete unless you answer every question on this form and on Form
1. If an item does not apply to you, enter “NA” (for not applicable) to show that you considered the question.
Public Availability of Submitted Information
You may not claim as confidential any information required by this form or Form 1, whether the information is
reported on the forms or in an attachment. Section 402(j) of the Clean Water Act requires that all permit
applications will be available to the public. This information will be made available to the public upon request.
Any information you submit to EPA which goes beyond that required by this form, Form 1, or Form 2C you
may claim as confidential, but claims for information which are effluent data will be denied.
If you do not assert a claim of confidentiality at the time of submitting the information, EPA may make the
information public without further notice to you. Claims of confidentiality will be handled in accordance with
EPA's business confidentiality regulations at 40 CFR Part 2.
Definitions
All significant terms used in these instructions and in the form are defined in the glossary found in the General
Instructions which accompany Form 1.
EPA ID Number
Fill in your EPA Identification Number at the top of each odd numbered page of Form 2F. You may copy this
number directly from item I of Form 1.
EPA Form 3510-2F (Rev. 1-92)
I-1
Item I
You may use the map you provided for item XI of Form 1 to determine the latitude and longitude of each of
your outfalls and the name of the receiving water.
Item 11-A
If you check “yes” to this question, complete all parts of the chart, or attach a copy of any previous submission
you have made to EPA containing the same information.
Item 11-B
You are not required to submit a description of future pollution control projects if you do not wish to or if none
is planned.
Item III
Attach a site map showing topography (or indicating the outline of drainage areas served by the outfall(s)
covered in the application if a topographic map is unavailable) depicting the facility including:
each of its drainage and discharge structures;
the drainage area of each storm water outfall;
paved areas and building within the drainage area of each storm water outfall, each known past or
present areas used for outdoor storage or disposal of significant materials, each existing structural
control measure to reduce pollutants in storm water runoff, materials loading and access areas, areas
where pesticides, herbicides, soil conditioners and fertilizers are applied;
each of its hazardous waste treatment, storage or disposal facilities (including each area not required
to have a RCRA permit which is used for accumulating hazardous waste for less than 90 days under
40 CFR 262.34);
each well where fluids from the facility are injected underground; and
springs, and other surface water bodies which receive storm water discharges from the facility;
Item IV-A
For each outfall, provide an estimate of the area drained by the outfall which is covered by impervious
surfaces. For the purpose of this application, impervious surfaces are surfaces where storm water runs off at
rates that are significantly higher than background rates (e.g., predevelopment levels) and include paved
areas, building roofs, parking lots, and roadways. Include an estimate of the total area (including all
impervious and pervious areas) drained by each outfall. The site map required under item III can be used to
estimate the total area drained by each outfall.
Item IV-B
Provide a narrative description of significant materials that are currently or in the past three years have been
treated, stored, or disposed in a manner to allow exposure to storm water; method of treatment, storage or
disposal of these materials; past and present materials management practices employed, in the last three
years, to minimize contact by these materials with storm water runoff; materials loading and access areas;
and the location, manner, and frequency in which pesticides, herbicides, soil conditioners, and fertilizers are
applied. Significant materials should be identified by chemical name, form (e.g., powder, liquid, etc.), and type
of container or treatment unit. Indicate any materials treated, stored, or disposed of together. “Significant
materials” includes, but is not limited to: raw materials; fuels; materials such as solvents, detergents, and
plastic pellets; finished materials such as metallic products; raw materials used in food processing or
production; hazardous substances designated under Section 101 (14) of CERCLA; any chemical the facility is
required to report pursuant to Section 313 of Title III of SARA; fertilizers; pesticides; and waste products such
as ashes, slag and sludge that have the potential to be released with storm water discharges.
Item IV-C
For each outfall, structural controls Include structures which enclose material handling or storage areas,
covering materials, berms, dikes, or diversion ditches around manufacturing, production, storage or treatment
units, retention ponds, etc. Nonstructural controls include practices such as spill prevention plans, employee
training, visual inspections, preventive maintenance, and housekeeping measures that are used to prevent or
minimize the potential for releases of pollutants.
EPA Form 3510-2F (Rev. 1-92)
I-2
Item V
Provide a certification that all outfalls that should contain storm water discharges associated with industrial
activity have been tested or evaluated for the presence of non-storm water discharges which are not covered
by an NPDES permit. Tests for such non-storm water discharges may include smoke tests, fluorometric dye
tests, analysis of accurate schematics, as well as other appropriate tests. Part B must include a description of
the method used, the date of any testing, and the onsite drainage points that were directly observed during a
test. All non-storm water discharges must be identified in a Form 2C or Form 2E which must accompany this
application (see beginning of instructions under section titled “Who Must File Form 2F” for a description of
when Form 2C and Form 2E must be submitted).
Item VI
Provide a description of existing information regarding the history of significant leaks or spills of toxic or
hazardous pollutants at the facility in the last three years.
Item VII-A, B, and C
These items require you to collect and report data on the pollutants discharged for each of your outfalls. Each
part of this item addresses a different set of pollutants and must be completed in accordance with the specific
instructions for that part. The following general instructions apply to the entire item.
General Instructions
Part A requires you to report at least one analysis for each pollutant listed. Parts B and C require you to report
analytical data in two ways. For some pollutants addressed in Parts B and C, if you know or have reason to
know that the pollutant is present in your discharge, you may be required to list the pollutant and test (sample
and analyze) and report the levels of the pollutants in your discharge. For all other pollutants addressed in
Parts B and C, you must list the pollutant if you know or have reason to know that the pollutant is present in
the discharge, and either report quantitative data for the pollutant or briefly describe the reasons the pollutant
is expected to be discharged. (See specific instructions on the form and below for Parts A through C.) Base
your determination that a pollutant is present in or absent from your discharge on your knowledge of your raw
materials, material management practices, maintenance chemicals, history of spills and releases,
intermediate and final products and byproducts, and any previous analyses known to you of your effluent or
similar effluent.
A. Sampling: The collection of the samples for the reported analyses should be supervised by a person
experienced in performing sampling of industrial wastewater or storm water discharges. You may contact
EPA or your State permitting authority for detailed guidance on sampling techniques and for answers to
specific questions. Any specific requirements contained in the applicable analytical methods should be
followed for sample containers, sample preservation, holding times, the collection of duplicate samples,
etc. The time when you sample should be representative, to the extent feasible, of your treatment system
operating properly with no system upsets. Samples should be collected from the center of the flow
channel, where turbulence is at a maximum, at a site specified in your present permit, or at any site
adequate for the collection of a representative sample.
For pH, temperature, cyanide, total phenols, residual chlorine, oil and grease, and fecal coliform, grab
samples taken during the first 30 minutes (or as soon thereafter as practicable) of the discharge must be
used (you are not required to analyze a flow-weighted composite for these parameters). For all other
pollutants both a grab sample collected during the first 30 minutes (or as soon thereafter as practicable)
of the discharge and a flow-weighted composite sample must be analyzed. However, a minimum of one
grab sample may be taken for effluents from holding ponds or other impoundments with a retention period
of greater than 24 hours.
All samples shall be collected from the discharge resulting from a storm event that is greater than 0.1
inches and at least 72 hours from the previously measurable (greater than 0.1 inch rainfall) storm event.
Where feasible, the variance in the duration of the event and the total rainfall of the event should not
exceed 50 percent from the average or median rainfall event in that area.
A grab sample shall be taken during the first thirty minutes of the discharge (or as soon thereafter as
practicable), and a flow-weighted composite shall be taken for the entire event or for the first three hours
of the event.
EPA Form 3510-2F (Rev. 1-92)
I-3
Grab and composite samples are defined as follows:
Grab sample: An individual sample of at least 100 milliliters collected during the first thirty minutes
(or as soon thereafter as practicable) of the discharge. This sample is to be analyzed separately from
the composite sample.
Flow-weighted Composite sample: A flow-weighted composite sample may be taken with a
continuous sampler that proportions the amount of sample collected with the flow rate or as a
combination of a minimum of three sample aliquots taken in each hour of discharge for the entire
event or for the first three hours of the event, with each aliquot being at least 100 milliliters and
collected with a minimum period of fifteen minutes between aliquot collections. The composite must
be flow proportional; either the time interval between each aliquot or the volume of each aliquot must
be proportional to either the stream flow at the time of sampling or the total stream flow since the
collection of the previous aliquot. Aliquots may be collected manually or automatically. Where GC/MS
Volatile Organic Analysis (VOA) is required, aliquots must be combined in the laboratory immediately
before analysis. Only one analysis for the composite sample is required.
Data from samples taken in the past may be used, provided that:
All data requirements are met;
Sampling was done no more than three years before submission; and
All data are representative of the present discharge.
Among the factors which would cause the data to be unrepresentative are significant changes in
production level, changes in raw materials, processes, or final products, and changes in storm water
treatment. When the Agency promulgates new analytical methods in 40 CFR Part 136, EPA will provide
information as to when you should use the new methods to generate data on your discharges. Of course,
the Director may request additional information, including current quantitative data, if they determine it to
be necessary to assess your discharges. The Director may allow or establish appropriate site-specific
sampling procedures or requirements including sampling locations, the season in which the sampling
takes place, the minimum duration between the previous measurable storm event and the storm event
sampled, the minimum or maximum level of precipitation required for an appropriate storm event, the form
of precipitation sampled (snow melt or rainfall), protocols for collecting samples under 40 CFR Part 136,
and additional time for submitting data on a case-by-case basis.
B. Reporting: All levels must be reported as concentration and mass (note: grab samples are reported in
terms of concentration). You may report some or all of the required data by attaching separate sheets of
paper instead of filling out pages VII-1 and VII-2 if the separate sheets contain all the required information
in a format which is constant with pages VII-1 and VII-2 in spacing and identification of pollutants and
columns. Use the following abbreviations in the columns headed “Units.”
Concentration
ppm
mg/1
ppb
ug/1
kg
parts per million
milligrams per liter
parts per billion
micrograms per liter
kilograms
Mass
lbs
ton
mg
g
T
pounds
tons (English tons)
milligrams
grams
tonnes (metric tons)
All reporting of values for metals must be in terms of “total recoverable metal,” unless:
(1) An applicable, promulgated effluent limitation or standard specifies the limitation for the metal in
dissolved, valent, or total form; or
(2) All approved analytical methods for the metal inherently measure only its dissolved form (e.g.,
hexavalent chromium); or
(3) The permitting authority has determined that in establishing case-by-case limitations it is
necessary to express the limitations on the metal in dissolved, valent, or total form to carry out the
provisions of the CWA. If you measure only one grab sample and one flow-weighted composite
EPA Form 3510-2F (Rev. 1-92)
I-4
sample for a given outfall, complete only the “Maximum Values” columns and insert “1” into the
“Number of Storm Events Sampled” column. The permitting authority may require you to conduct
additional analyses to further characterize your discharges.
If you measure more than one value for a grab sample or a flow-weighted composite sample for a given
outfall and those values are representative of your discharge, you must report them. You must describe
your method of testing and data analysis. You also must determine the average of all values within the
last year and report the concentration and mass under the “Average Values” columns, and the total
number of storm events sampled under the “Number of Storm Events Sampled” columns.
C. Analysis: You must use test methods promulgated in 40 CFR Part 136; however, if none has been
promulgated for a particular pollutant, you may use any suitable method for measuring the level of the
pollutant in your discharge provided that you submit a description of the method or a reference to a
published method. Your description should include the sample holding time, preservation techniques, and
the quality control measures which you used. If you have two or more substantially identical outfalls, you
may request permission from your permitting authority to sample and analyze only one outfall and submit
the results of the analysis for other substantially identical outfalls. If your request is granted by the
permitting authority, on a separate sheet attached to the application form, identify which outfall you did
test, and describe why the outfalls which you did not test are substantially identical to the outfall which
you did test.
Part VII-A
Part VII-A must be completed by all applicants for all outfalls who must complete Form 2F.
Analyze a grab sample collected during the first thirty minutes (or as soon thereafter as practicable) of the
discharge and flow-weighted composite samples for all pollutants in this Part, and report the results except
use only grab samples for pH and oil and grease. See discussion in General Instructions to Item VII for
definitions of grab sample collected during the first thirty minutes of discharge and flow-weighted composite
sample. The “Average Values” column is not compulsory but should be filled out if data are available.
Part VII B
List all pollutants that are limited in an effluent guideline which the facility is subject to (see 40 CFR
Subchapter N to determine which pollutants are limited in effluent guidelines) or any pollutant listed in the
facility's NPDES permit for its process wastewater (if the facility is operating under an existing NPIDES
permit). Complete one table for each outfall. See discussion in General instructions to item VII for definitions
of grab sample collected during the first thirty minutes (or as soon thereafter as practicable) of discharge and
flow-weighted composite sample. The “Average Values” column is not compulsory but should be filled out if
data are available.
Analyze a grab sample collected during the first thirty minutes of the discharge and flow-weighted composite
samples for all pollutants in this Part, and report the results, except as provided in the General Instructions.
Part VII-C
Part V11-C must be completed by all applicants for all outfalls which discharge storm water associated with
industrial activity, or that EPA is evaluating for designation as a significant contributor of pollutants to waters
of the United States, or as contributing to a violation of a water quality standard. Use both a grab sample and
a composite sample for all pollutants you analyze for in this part except use grab samples for residual chlorine
and fecal coliform. The “Average Values” column is not compulsory but should be filled out if data are
available. Part C requires you to address the pollutants in Table 2F-2, 2F-3, and 2F-4 for each outfall.
Pollutants in each of these Tables are addressed differently.
Table 2F-2: For each outfall, list all pollutants in Table 2F-2 that you know or have reason to believe are
discharged (except pollutants previously listed in Part VII-B). If a pollutant is limited in an effluent guideline
limitation which the facility is subject to, the pollutant must be analyzed and reported in Part VII-B. If a
pollutant in Table 2F-2 is indirectly limited by an effluent guideline limitation through an indicator (e.g., use of
TSS as an indicator to control the discharge of iron and aluminum), you must analyze for it and report the
data in Part VII-B. For other pollutants listed in Table 2F-2 (those not limited directly or indirectly by an effluent
limitation guideline), that you know or have reason to believe are discharged, you must either report
quantitative data or briefly describe the reasons the pollutant is expected to be discharged.
EPA Form 3510-2F (Rev. 1-92)
I-5
Table 2F-3: For each outfall, list all pollutants in Table 2F-3 that you know or have reason to believe are
discharged. For every pollutant in Table 2F-3 expected to be discharged in concentrations of 10 ppb or
greater, you must submit quantitative data. For acrolein, acrylonitrile, 2,4 dinitrophenol, and 2-methyl-4,6
dinitrophenol, you must submit quantitative data if any of these four pollutants is expected to be discharged in
concentrations of 100 ppb or greater. For every pollutant expected to be discharged in concentrations less
than 10 ppb (or 100 ppb for the four pollutants listed above), then you must either submit quantitative data or
briefly describe the reasons the pollutant is expected to be discharged.
Small Business Exemption - If you are a “small business,” you are exempt from the reporting requirements
for the organic toxic pollutants listed in Table 2F-3. There are two ways in which you can qualify as a small
business”. If your facility is a coal mine, and if your probable total annual production is less than 100,000 tons
per year, you may submit past production data or estimated future production (such as a schedule of
estimated total production under 30 CFR 795.14(c)) instead of conducting analyses for the organic toxic
pollutants. If your facility is not a coal mine, and if your gross total annual sales for the most recent three
years average less than $100,000 per year (in second quarter 1980 dollars), you may submit sales data for
those years instead of conducting analyses for the organic toxic pollutants. The production or sales data must
be for the facility which is the source of the discharge. The data should not be limited to production or sales
for the process or processes which contribute to the discharge, unless those are the only processes at your
facility. For sales data, in situations involving intracorporate transfer of goods and services, the transfer price
per unit should approximate market prices for those goods and services as closely as possible. Sales figures
for years after 1980 should be indexed to the second quarter of 1980 by using the gross national product
price deflator (second quarter of 1980=100). This index is available in National Income and Product Accounts
of the United States (Department of Commerce, Bureau of Economic Analysis).
Table 2F-4: For each outfall, list any pollutant in Table 2F-4 that you know or believe to be present in the
discharge and explain why you believe it to be present. No analysis is required, but if you have analytical
data, you must report them. Note: Under 40 CFR 117.12(a)(2), certain discharges of hazardous substances
(listed at 40 CFR 177.21 or 40 CFR 302.4) may be exempted from the requirements of section 311 of CWA,
which establishes reporting requirements, civil penalties, and liability for cleanup costs for spills of oil and
hazardous substances. A discharge of a particular substance may be exempted if the origin, source, and
amount of the discharged substances are identified in the NPDES permit application or in the permit, if the
permit contains a requirement for treatment of the discharge, and if the treatment is in place. To apply for an
exclusion of the discharge of any hazardous substance from the requirements of section 311, attach
additional sheets of paper to your form, setting forth the following information:
1. The substance and the amount of each substance which may be discharged.
2. The origin and source of the discharge of the substance.
3. The treatment which is to be provided for the discharge by;
a. An onsite treatment system separate from any treatment system treating your normal discharge;
b. A treatment system designed to treat your normal discharge and which is additionally capable of
treating the amount of the substance identified under paragraph 1 above; or
c.
Any combination of the above.
See 40 CFR 117.12(a)(2) and (c), published on August 29, 1979, in 44 FR 50766, or contact your Regional
Office (Table I on Form 1, Instructions), for further information on exclusions from section 311.
Part VII-D
If sampling is conducted during more than one storm event, you only need to report the information requested
in Part VII-D for the storm event(s) which resulted in any maximum pollutant concentration reported in Part
VII-A, VII-B, or VII-C.
Provide flow measurements or estimates of the flow rate, and the total amount of discharge for the storm
event(s) sampled, the method of flow measurement, or estimation. Provide the data and duration of the storm
event(s) sampled, rainfall measurements, or estimates of the storm event which generated the sampled runoff
and the duration between the storm event sampled and the end of the previous measurable (greater than 0.1
inch rainfall) storm event.
EPA Form 3510-2F (Rev. 1-92)
I-6
Part VII-E
List any toxic pollutant listed in Tables 2F-2, 2F-3, or 2F-4 which you currently use or manufacture as an
intermediate or final product or byproduct. In addition, if you know or have reason to believe that 2,3,7,8tetrachlorodibenzo-p-dioxin (TCDD) is discharged or if you use or manufacture 2,4,5-trichlorophenoxy acetic
acid (2,4,5,-T); 2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4,5,-TP); 2-(2,4,5-trichlorophenoxy) ethyl,
2,2-dichloropropionate (Erbon); 0,0-dimethyl 0-(2,4,5-trichlorphenyl) phosphorothioate (Ronnel); 2,4,5trichlorophenol (TCP); or hexachlorophene (HCP); then list TCDD. The Director may waive or modify the
requirement if you demonstrate that it would be unduly burdensome to identify each toxic pollutant and the
Director has adequate information to issue your permit. You may not claim this information as confidential;
however, you do not have to distinguish between use or production of the pollutants or list the amounts.
Item VIIl
Self explanatory. The permitting authority may ask you to provide additional details after your application is
received.
Item X
The Clean Water Act provides for severe penalties for submitting false information on this application form.
Section 309(c)(4) of the Clean Water Act provides that “Any person who knowingly makes any false material
statement, representation, or certification in any application, . . . shall upon conviction, be punished by a fine
of not more than $10,000 or by imprisonment for not more than 2 years, or by both. If a conviction of such
person is for a violation committed after a first conviction of such person under this paragraph, punishment
shall be by a fine of not more than $20,000 per day of violation, or by imprisonment of not more than 4 years,
or by both.” 40 CFR Part 122.22 requires the certification to be signed as follows:
(A) For a corporation: by a responsible corporate official. For purposes of this section, a responsible
corporate official means (i) a 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 employing more than 250 persons or having gross annual sales or expenditures exceeding
$25,000,000 (in second quarter 1980 dollars), if authority to sign documents has been assigned or
delegated to the manager in accordance with corporate procedures.
Note: EPA does not require specific assignments or delegation of authority to responsible corporate
officers identified in 122.22(a)(1)(i) The Agency will presume that these responsible corporate officers
have the requisite authority to sign permit applications unless the corporation has notified the Director to
the contrary. Corporate procedures governing authority to sign permit applications may provide for
assignment or delegation to applicable corporate position under 122.22(a)(1)(ii) rather than to specific
individuals.
(B) For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or
(C) For a municipality, State, Federal, or other public agency: by either a principal executive officer or
ranking elected official. For purposes of this section, a principal executive officer of a Federal agency
includes (i) the chief executive officer of the agency, or (ii) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrators of
EPA).
EPA Form 3510-2F (Rev. 1-92)
I-7
Table 2F-1
Codes for Treatment Units
Physical Treatment Processes
1-A
1-B
1-C
1-D
1-E
1-F
1-G
1-H
1-1
1-J
1-K
1-L
Ammonia Stripping
Dialysis
Diatomaceous Earth Filtration
Distillation
Electrodialysis
Evaporation
Flocculation
Flotation
Foam Fractionation
Freezing
Gas-Phase Separation
Grinding (Comminutors)
1-M
1-N
1-0
1-P
1-Q
1-R
1-S
1-T
1-U
1-V
1-W
1-X
Grit Removal
Microstraining
Mixing
Moving Bed Filters
Multimedia Filtration
Rapid Sand Filtration
Reverse Osmosis (Hyperfiltration)
Screening
Sedimentation (Setting)
Slow Sand Filtration
Solvent Extraction
Sorption
Chemical Treatment Processes
2-A
2-B
2-C
2-D
2-E
2-F
Carbon Adsorption
Chemical Oxidation
Chemical Precipitation
Coagulation
Dechlorination
Disinfection (Chlorine)
2-G
2-H
2-I
2-J
2-K
2-L
Disinfection (Ozone)
Disinfection (Other)
Electrochemical Treatment
Ion Exchange
Neutralization
Reduction
Biological Treatment Processes
3-A
3-B
3-C
3-D
Activated Sludge
Aerated Lagoons
Anaerobic Treatment
Nitrification-Denitrification
3-E
3-F
3-G
3-H
Pre-Aeration
Spray Irrigation/Land Application
Stabilization Ponds
Trickling Filtration
Other Processes
4-A
4-B
Discharge to Surface Water
Ocean Discharge Through Outfall
4-C
4-D
Reuse/Recycle of Treated Effluent
Underground Injection
Sludge Treatment and Disposal Processes
5-A
5-B
5-C
5-D
5-E
5-F
5-G
5-H
5-I
5-J
5-K
5-L
Aerobic Digestion
Anaerobic Digestion
Belt Filtration
Centrifugation
Chemical Conditioning
Chlorine Treatment
Composting
Drying Beds
Elutriation
Flotation Thickening
Freezing
Gravity Thickening
EPA Form 3510-2F (Rev. 1-92)
5-M
5-N
5-0
5-P
5-0
5-R
5-S
5-T
5-U
5-V
5-W
I-8
Heat Drying
Heat Treatment
Incineration
Land Application
Landfill
Pressure Filtration
Pyrolysis
Sludge Lagoons
Vacuum Filtration
Vibration
Wet Oxidation
Table 2F-2
Conventional and Nonconventional Pollutants
Bromide
Chlorine, Total Residual
Color
Fecal Coliform
Fluoride
Nitrate-Nitrite
Nitrogen, Total Organic
Oil and Grease
Phosphorus, Total
Radioactivity
Sulfate
Sulfite
Surfactants
Aluminum, Total
Barium, Total
Boron, Total
Cobalt Total
Iron, Total
Magnesium, Total
Molybdenum, Total
Manganese, Total
Tin, Total
Titanium, Total
EPA Form 3510-2F (Rev. 1-92)
I-9
Table 2F-3
Toxic Pollutants
Toxic Pollutants and Total Phenol
Antimony, Total
Arsenic, Total
Beryllium, Total
Cadmium, Total
Chromium, Total
Copper, Total
Lead, Total
Mercury, Total
Nickel, Total
Selenium, Total
Silver, Total
Thallium, Total
Zinc, Total
Cyanide, Total
Phenols, Total
GC/MS Fraction Volatiles Compounds
Acrolein
Acrylonitrile
Benzene
Bromoform
Carbon Tetrachloride
Chlorobenzene
Chlorodibromomethane
Chloroethane
2-Chloroethylvinyl Ether
Chloroform
Dichlorobromomethane
1,1-Dichloroethane
1,2-Dichloroethane
1,1-Dichloroethylene
1,2-Dichloropropane
1.3-Dichloropropylene
Ethylbenzene
Methyl Bromide
Methyl Chloride
Methylene Chloride
1,1,2,2,-Tetrachloroethane
Tetrachloroethylene
Toluene
1,2-Trans-Dichloroethylene
1,1,1-Trichloroethane
1,1,2-Trichloroethane
Trichloroethylene
Vinyl Chloride
Acid Compounds
2-Chlorophenol
2,4-Dichlorophenol
2,4-Dimethylphenol
4,6-Dinitro-O-Cresol
2,4-Dinitrophenol
2-Nitrophenol
4-Nitrophenol
p-Chloro-M-Cresol
Pentachlorophenol
Phenol
2,4,6-Trichlorophenol
2-methyl-4,6 dinitrophenol
Base/Neutral
Acenaphthene
Acenaphthylene
Anthracene
Benzidine
Benzo(a)anthracene
Benzo(a)pyrene
3,4-Benzofluoranthene
Benzo(ghi)perylene
Benzo(k)fluoranthene
Bis(2-chloroethoxy)methane
Bis(2-chloroethyl)ether
Bis(2-chloroisopropyl)ether
Bis(2-ethylyhexyl)phthalate
4-Bromophenyl Phenyl Ether
Butylbenzyl Phthalate
2-Chloronaphthalene
4-Chlorophenyl Phenyl Ether
Chrysene
Dibenzo(a,h)anthracene
1,2-Dichlorobenzene
1,3-Dichlorobenzene
1,4-Dichlorobenzene
3,3'-Dichlorobenzidine
Diethyl Phthalate
Dimethyl Phthalate
Di-N-Butyl Phthalate
2,4-Dinitrotoluene
2,6-Dinitrotoluene
Di-N-Octyphthalate
1,2-Diphenylhydrazine (as Azobenzene)
Fluroranthene
Fluorene
Hexachlorobenzene
Hexachlorobutadiene
Hexachloroethane
lndeno(1,2,3-cd)pyrene
Isophorone
Napthalene
Nitrobenzene
N-Nitrosodimethylamine
N-Nitrosodi-N-Propylamine
N-Nitrosodiphenylamine
Phenanthrene
Pyrene
1,2,4-Trichlorobenzene
Pesticides
Aldrin
Alpha-BHC
Beta-BHC
Gamma-BHC
Delta-BHC
Chlordane
4,4'-DDT
4,4'-DDE
4,4'-DDD
EPA Form 3510-2F (Rev. 1-92)
Dieldrin
Alpha-Endosulfan
Beta-Endosulfan
Endosulfan Sulfate
Endrin
Endrin Aldehyde
Heptachlor
Heptachlor Epoxide
PCB-1242
I - 10
PCB-1254
PCB-1221
PCB-1232
PCB-1248
PGB-1260
PCB-1016
Toxaphene
Table 2F-4
Hazardous Substances
Toxic Pollutant
Asbestos
Hazardous Substances
Acetaldehyde
Allyl alcohol
Allyl chloride
Amyl acetate
Aniline .
Benzonitrile
Benzyl chloride
Butyl acetate
Butylamine
Carbaryl
Carbofuran
Carbon disulfide
Chlorpyrifos
Coumaphos
Dinitrobenzene
Diquat
Disulfoton
Diuron
Epichlorohydrin
Ethion
Ethylene diamine
Ethylene dibromide
Formaldehyde
Furfural
Guthion
Isoprene
Isopropanolamine
Kelthane
Cresol
Crotonaldehyde
Kepone
Malathion
Cyclohexane
2,4-D (2,4-Dichlorophenoxyacetic
acid)
Diazinon
Dicamba
Dichlobenil
Dichlone
2,2-Dichloropropionic acid
Dichlorvos
Diethyl amine
Dimethyl amine
Mercaptodimethur
Methoxychlor
EPA Form 3510-2F (Rev. 1-92)
Methyl mercaptan
Methyl methacrylate
Methyl parathion
Mevinphos
Mexacarbate
Monoethyl amine
Monomethyl amine
Naled
I - 11
Napthenic acid
Nitrotoluene
Parathion
Phenolsulfonate
Phosgene
Propargite
Propylene oxide
Pyrethrins
Quinoline
Resorcinol
Stronthium
Strychnine
Styrene
2,4,5-T (2,4,5-Trichlorophenoxyacetic
acid)
TDE (Tetrachlorodiphenyl ethane)
2,4,5-TP [2-(2,4,5-Trichlorophenoxy)
propanoic acid]
Trichlorofan
Triethylamine
Trimethylamine
Uranium
Vanadium
Vinyl acetate
Xylene
Xylenol
Zirconium
Disclaimer
This is an updated PDF document that allows you to type your information
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
version 7.0 or higher, or if you have the full Adobe Professional version.
Instructions:
1. Type in your information
2. Save file (if desired)
3. Print the completed form
4. Sign and date the printed copy
5. Mail it to the directed contact.
FACILITY NAME AND PERMIT NUMBER:
FORM
2S
Form Approved 1/14/99
OMB Number 2040-0086
NPDES FORM 2S APPLICATION OVERVIEW
NPDES
PRELIMINARY INFORMATION
This page is designed to indicate whether the applicant is to complete Part 1 or Part 2. Review each category,
and then complete Part 1 or Part 2, as indicated. For purposes of this form, the term “you” refers to the
applicant. “This facility” and “your facility” refer to the facility for which application information is submitted.
FACILITIES INCLUDED IN ANY OF THE FOLLOWING CATEGORIES MUST COMPLETE PART 2
(PERMIT APPLICATION INFORMATION).
1.
Facilities with a currently effective NPDES permit.
2.
Facilities which have been directed by the permitting authority to submit a full permit application at this time.
ALL OTHER FACILITIES MUST COMPLETE PART 1 (LIMITED BACKGROUND INFORMATION).
EPA Form 3510-2S (Rev. 1-99)
Page 1 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
PART 1: LIMITED BACKGROUND INFORMATION
This part should be completed only by “sludge-only” facilities - that is, facilities that do not currently have, and are not applying for, an
NPDES permit for a direct discharge to a surface body of water.
For purposes of this form, the term “you” refers to the applicant. “This facility” and “your facility” refer to the facility for which application
information is submitted.
1.
Facility Information.
a.
Facility name
__________________________________________________________________
b.
Mailing Address
__________________________________________________________________
__________________________________________________________________
c.
d.
Contact person
__________________________________________________________________
Title
__________________________________________________________________
Telephone number
__________________________________________________________________
Facility Address (not P.O. B ox)
__________________________________________________________________
__________________________________________________________________
e.
Indicate the type of facility
_________ Publicly owned treatment works (POTW)
_________ Privately owned treatment works
_________ Federally owned treatment works
_________ Blending or treatment operation
_________ Surface disposal site
_________ Sewage sludge incinerator
_________ Other (describe)
__________________________________________________________________
2. Applicant Information.
a.
Applicant name
__________________________________________________________________
b.
Mailing Address
__________________________________________________________________
__________________________________________________________________
c.
d.
Contact person
__________________________________________________________________
Title
__________________________________________________________________
Telephone number
__________________________________________________________________
Is the applicant the owner or operator (or both) of this facility?
______ owner
e.
______ operator
Should correspondence regarding this permit be directed to the facility or the applicant?
______ facility
______ applicant
EPA Form 3510-2S (Rev. 1-99)
Page 2 of 23
FACILITY NAME AND PERMIT NUMBER:
3.
Form Approved 1/14/99
OMB Number 2040-0086
Sewage Sludge Amount. Provide the total dry metric tons per latest 365 day period of sewage sludge handled under the following practices:
a.
Amount generated at the facility
________________ dry metric tons
b.
Amount received from off site
________________ dry metric tons
c.
Amount treated or blended on site
________________ dry metric tons
d.
Amount sold or given away in a bag or other container for application to the land
________________ dry metric tons
e.
Amount of bulk sewage sludge shipped off site for treatment or blending
________________ dry metric tons
f.
Amount applied to the land in bulk form
________________ dry metric tons
g.
Amount placed on a surface disposal site
________________ dry metric tons
h.
Amount fired in a sewage sludge incinerator
________________ dry metric tons
i.
Amount sent to a municipal solid waste landfill
________________ dry metric tons
j.
Amount used or disposed by another practice
________________ dry metric tons
Describe
4.
____________________________________________________________________
Pollutant Concentrations. Using the table below or a separate attachment, provide existing sewage sludge monitoring data for the pollutants for
which limits in sewage sludge have been established in 40 CFR part 503 for this facility's expected use or disposal practices. If available, base
data on three or more samples taken at least one month apart and no more than four and one-half years old.
POLLUTANT
CONCENTRATION
(mg/kg dry weight)
ANALYTICAL METHOD
DETECTION LEVEL FOR ANALYSIS
ARSENIC
CADMIUM
CHROMIUM
COPPER
LEAD
MERCURY
MOLYBDENUM
NICKEL
SELENIUM
ZINC
5.
Treatment Provided At Your Facility.
a.
Which class of pathogen reduction does the sewage sludge meet at your facility?
_______ Class A
b.
_______ Class B
_______ Neither or unknown
Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce pathogens in sewage sludge:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
EPA Form 3510-2S (Rev. 1-99)
Page 3 of 23
FACILITY NAME AND PERMIT NUMBER:
c.
Form Approved 1/14/99
OMB Number 2040-0086
Which vector attraction reduction option is met for the sewage sludge at your facility?
_______ Option 1 (Minimum 38 percent reduction in volatile solids)
_______ Option 2 (Anaerobic process, with bench-scale demonstration)
_______ Option 3 (Aerobic process, with bench-scale demonstration)
_______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge)
_______ Option 5 (Aerobic processes plus raised temperature)
_______ Option 6 (Raise pH to 12 and retain at 11.5)
_______ Option 7 (75 percent solids with no unstabilized solids)
_______ Option 8 (90 percent solids with unstabilized solids)
_______ Option 9 (Injection below land surface)
_______ Option 10 (Incorporation into soil within 6 hours)
_______ Option 11 (Covering active sewage sludge unit daily)
_______ None or unknown
d.
Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce vector attraction properties of
sewage sludge:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6.
Sewage Sludge Sent to Other Facilities. Does the sewage sludge from your facility meet the Table 1 ceiling concentrations, the Table 3
pollutant concentrations, Class A pathogen requirements, and one of the vector attraction options 1-8?
_______ Yes _______ No
If yes, go to question 8 (Certification).
If no, is sewage sludge from your facility provided to another facility for treatment, distribution, use, or disposal?
______ Yes ______ No
If no, go to question 7 (Use and Disposal Sites).
If yes, provide the following information for the facility receiving the sewage sludge:
a.
Facility name
_______________________________________________________________________
b.
Mailing address
_______________________________________________________________________
_______________________________________________________________________
c.
d.
Contact person
_______________________________________________________________________
Title
_______________________________________________________________________
Telephone number
_______________________________________________________________________
Which activities does the receiving facility provide? (Check all that apply)
______ Treatment or blending
______ Sale or give-away in bag or other container
______ Land application
______ Surface disposal
______ Incineration
______ Other (describe):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
EPA Form 3510-2S (Rev. 1-99)
Page 4 of 23
FACILITY NAME AND PERMIT NUMBER:
7.
Use and Disposal Sites. Provide the following information for each site on which sewage sludge from this facility is used or disposed:
a.
Site name or number
______________________________________________________________________
b.
Contact person
______________________________________________________________________
Title
______________________________________________________________________
Telephone
______________________________________________________________________
c.
Site location (Complete 1 or 2)
1.
2.
d.
8.
Form Approved 1/14/99
OMB Number 2040-0086
Street or Route #
______________________________________________________________________
County
______________________________________________________________________
City or Town
______________________ State __________________ Zip ___________________
Latitude ____________________
Longitude____________________
Site type (Check all that apply)
____ Agricultural
____ Lawn or home garden
____ Surface disposal
____ Public Contact
____ Forest
____ Incineration
____ Reclamation
____ Municipal Solid Waste Landfill
____ Other (describe): ________________________________
Certification. Sign the certification statement below. (Refer to instructions to determine who is an officer for purposes of this certification.)
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with the
system designed to assure that qualified personnel properly gather and evaluate 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 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 and official title
________________________________________________________
Signature
________________________________________________________
Telephone number
________________________________________________________
Date signed
________________________________________________________
SEND COMPLETED FORMS TO:
EPA Form 3510-2S (Rev. 1-99)
Page 5 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
PART 2: PERMIT APPLICATION INFORMATION
Complete this part if you have an effective NPDES permit or have been directed by the permitting authority to submit a full permit
application at this time. In other words, complete this part if your facility has, or is applying for, an NPDES permit.
For purposes of this form, the term “you” refers to the applicant. “This facility” and “your facility” refer to the facility for which application
information is submitted.
APPLICATION OVERVIEW — SEWAGE SLUDGE USE OR DISPOSAL INFORMATION
Part 2 is divided into five sections (A-E). Section A pertains to all applicants. The applicability of Sections B, C, D, and E depends on your
facility's sewage sludge use or disposal practices. The information provided on this page indicates which sections of Part 2 to fill out.
1.
SECTION A: GENERAL INFORMATION.
Section A must be completed by all applicants
2.
SECTION B: GENERATION OF SEWAGE SLUDGE OR PREPARATION OF A MATERIAL DERIVED FROM SEWAGE SLUDGE.
Section B must be completed by applicants who either:
1) Generate sewage sludge, or
2) Derive a material from sewage sludge.
3.
SECTION C: LAND APPLICATION OF BULK SEWAGE SLUDGE.
Section C must be completed by applicants who either:
1) Apply sewage to the land, or
2) Generate sewage sludge which is applied to the land by others.
NOTE:
1)
4.
Applicants who meet either or both of the two above criteria are exempted from this requirement if all sewage sludge from their facility
falls into one of the following three categories:
The sewage sludge from this facility meets the ceiling and pollutant concentrations, Class A pathogen reduction requirements, and one of
vector attraction reduction options 1-8, as identified in the instructions, or
2)
The sewage sludge from this facility is placed in a bag or other container for sale or give-away for application to the land, or
3)
The sewage sludge from this facility is sent to another facility for treatment or blending.
SECTION D: SURFACE DISPOSAL
Section D must be completed by applicants who own or operate a surface disposal site.
5.
SECTION E: INCINERATION
Section E must be completed by applicants who own or operate a sewage sludge incinerator.
EPA Form 3510-2S (Rev. 1-99)
Page 6 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
A. GENERAL INFORMATION
All applicants must complete this section.
A.1. Facility Information.
a.
Facility name
__________________________________________________________________
b.
Mailing Address
___________________________________________________________________
___________________________________________________________________
c.
d.
Contact person
___________________________________________________________________
Title
___________________________________________________________________
Telephone number
___________________________________________________________________
Facility Address (not P.O. Box)
___________________________________________________________________
___________________________________________________________________
e.
Is this facility a Class I sludge management facility?
f.
Facility design flow rate: ______ mgd
g.
Total population served: ___________
h.
Indicate the type of facility:
______ Yes ______ No
______ Publicly owned treatment works (POTW)
______ Privately owned treatment works
______ Federally owned treatment works
______ Blending or treatment operation
______ Surface disposal site
______ Sewage sludge incinerator
______ Other (describe)
__________________________________________________________________
A.2. Applicant Information. If the applicant is different from the above, provide the following:
a.
Applicant name
___________________________________________________________________
b.
Mailing Address
___________________________________________________________________
___________________________________________________________________
c.
d.
Contact person
___________________________________________________________________
Title
___________________________________________________________________
Telephone number
___________________________________________________________________
Is the applicant the owner or operator (or both) of this facility?
______ owner
e.
______ operator
Should correspondence regarding this permit should be directed to the facility or the applicant.
______ facility
______ applicant
EPA Form 3510-2S (Rev. 1-99)
Page 7 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
A.3. Permit Information.
a.
Facility's NPDES permit number (if applicable):
_______________________________________________________
b.
List, on this form or an attachment, all other Federal, State, and local permits or construction approvals received or applied for that regulate
this facility's sewage sludge management practices:
Permit Number
Type of Permit
_______________________
__________________________
_______________________
__________________________
_______________________
__________________________
A.4. Indian Country. Does any generation, treatment, storage, application to land, or disposal of sewage sludge from this facility occur in Indian
Country?
______Yes
______No
If yes, describe: ______________________________________________________________
________________________________________________________________________________________________________
A.5. Topographic Map. Provide a topographic map or maps (or other appropriate map(s) if a topographic map is unavailable) that show the
following information. Map(s) should include the area one mile beyond all property boundaries of the facility:
a.
Location of all sewage sludge management facilities, including locations where sewage sludge is stored, treated, or disposed.
b.
Location of all wells, springs, and other surface water bodies, listed in public records or otherwise known to the applicant within 1/4 mile of
the facility property boundaries.
A.6. Line Drawing. Provide a line drawing and/or a narrative description that identifies all sewage sludge processes that will be employed during the
term of the permit, including all processes used for collecting, dewatering, storing, or treating sewage sludge, the destination(s) of all liquids and
solids leaving each unit, and all methods used for pathogen reduction and vector attraction reduction.
A.7. Contractor Information.
Are any operational or maintenance aspects of this facility related to sewage sludge generation, treatment, use or disposal the responsibility of a
contractor?
______Yes
______No
If yes, provide the following for each contractor (attach additional pages if necessary):
a.
Name
___________________________________________________________________
b.
Mailing Address
___________________________________________________________________
___________________________________________________________________
c.
Telephone Number
___________________________________________________________________
d.
Responsibilities of contractor
___________________________________________________________________
____________________________________________________________________________________________________
EPA Form 3510-2S (Rev. 1-99)
Page 8 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
A.8. Pollution Concentrations: Using the table below or a separate attachment, provide sewage sludge monitoring data for the pollutants for which
limits in sewage sludge have been established in 40 CFR Part 503 for this facility's expected use or disposal practices. All data must be based
on three or more samples taken at least one month apart and must be no more than four and one-half years old.
POLLUTANT
CONCENTRATION
(mg/kg dry weight)
ANALYTICAL METHOD
DETECTION LEVEL FOR ANALYSIS
ARSENIC
CADMIUM
CHROMIUM
COPPER
LEAD
MERCURY
MOLYBDENUM
NICKEL
SELENIUM
ZINC
A.9. Certification. Read and submit the following certification statement with this application. Refer to the instructions to determine who is an officer
for purposes of this certification. Indicate which parts of Form 2S you have completed and are submitting:
______ Part 1 Limited Background Information packet
Part 2 Permit Application Information packet:
______
Section A (General Information)
______
Section B (Generation of Sewage Sludge or Preparation
of a Material Derived from Sewage Sludge)
______
Section C (Land Application of Bulk Sewage Sludge)
______
Section D (Surface Disposal)
______
Section E (Incineration)
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with
the system designed to assure that qualified personnel properly gather and evaluate 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 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 and official title
_____________________________________________________________________________
Signature
___________________________________________ Date signed _______________________
Telephone number
_____________________________________________________________________________
Upon request of the permitting authority, you must submit any other information necessary to assess sewage sludge use or disposal practices at
your facility or identify appropriate permitting requirements.
SEND COMPLETED FORMS TO:
EPA Form 3510-2S (Rev. 1-99)
Page 9 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
B. GENERATION OF SEWAGE SLUDGE OR PREPARATION OF
A MATERIAL DERIVED FROM SEWAGE SLUDGE
Complete this section if your facility generates sewage sludge or derives a material from sewage sludge.
B.1. Amount Generated On Site.
Total dry metric tons per 365-day period generated at your facility: _______________________ dry metric tons
B.2. Amount Received from Off Site. If your facility receives sewage sludge from another facility for treatment, use, or disposal, provide the
following information for each facility from which sewage sludge is received. If you receive sewage sludge from more than one facility, attach
additional pages as necessary.
a.
Facility name
___________________________________________________________________
b.
Mailing Address
___________________________________________________________________
___________________________________________________________________
c.
d.
Contact person
___________________________________________________________________
Title
___________________________________________________________________
Telephone number
___________________________________________________________________
Facility Address (not P.O. Box)
___________________________________________________________________
___________________________________________________________________
e.
Total dry metric tons per 365-day period received from this facility: ______________________ dry metric tons
f.
Describe, on this form or on another sheet of paper, any treatment processes known to occur at the off-site facility, including blending
activities and treatment to reduce pathogens or vector attraction characteristics.
________________________________________________________________________________________________
________________________________________________________________________________________________
B.3. Treatment Provided At Your Facility.
a.
Which class of pathogen reduction is achieved for the sewage sludge at your facility?
_______ Class A
b.
_______ Class B
_______ Neither or unknown
Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce pathogens in sewage sludge:
________________________________________________________________________________________________
________________________________________________________________________________________________
c.
Which vector attraction reduction option is met for the sewage sludge at your facility?
_______ Option 1 (Minimum 38 percent reduction in volatile solids)
_______ Option 2 (Anaerobic process, with bench-scale demonstration)
_______ Option 3 (Aerobic process, with bench-scale demonstration)
_______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge)
_______ Option 5 (Aerobic processes plus raised temperature)
_______ Option 6 (Raise pH to 12 and retain at 11.5)
_______ Option 7 (75 percent solids with no unstabilized solids)
_______ Option 8 (90 percent solids with unstabilized solids)
_______ None or unknown
EPA Form 3510-2S (Rev. 1-99)
Page 10 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
B.3. Treatment Provided At Your Facility. (con’t)
d.
Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce vector attraction properties of
sewage sludge:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
e.
Describe, on this form or another sheet of paper, any other sewage sludge treatment or blending activities not identified in (a) - (d) above:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Complete Section B.4 if sewage sludge from your facility meets the ceiling concentrations in Table 1 of 40 CFR 503.13, the pollutant
concentrations in Table 3 of §503.13, the Class A pathogen reduction requirements in §503.32(a), and one of the vector attraction reduction
requirements in § 503.33(b)(1)-(8) and is land applied. Skip this section if sewage sludge from your facility does not meet all of these
criteria.
B.4. Preparation of Sewage Sludge Meeting Ceiling and Pollutant Concentrations, Class A Pathogen Requirements, and One of Vector
Attraction Reduction Options 1-8.
a. Total dry metric tons per 365-day period of sewage sludge subject to this section that is applied to the land: ___________ dry metric tons
b.
Is sewage sludge subject to this section placed in bags or other containers for sale or give-away for application to the land?
_______Yes
_______No
Complete Section B.5. if you place sewage sludge in a bag or other container for sale or give-away for land application. Skip this section if
the sewage sludge is covered in Section B.4.
B.5. Sale or Give-Away in a Bag or Other Container for Application to the Land.
a. Total dry metric tons per 365-day period of sewage sludge placed in a bag or other container at your facility for sale or give-away for
application to the land: _________________________ dry metric tons
b.
Attach, with this application, a copy of all labels or notices that accompany the sewage sludge being sold or given away in a bag or other
container for application to the land.
Complete Section B.6 if sewage sludge from your facility is provided to another facility that provides treatment or blending. This section
does not apply to sewage sludge sent directly to a land application or surface disposal site. Skip this section if the sewage sludge is
covered in Sections B.4 or B.5. If you provide sewage sludge to more than one facility, attach additional pages as necessary.
B.6. Shipment Off Site for Treatment or Blending.
a.
Receiving facility name
_______________________________________________________________________
b.
Mailing address
_______________________________________________________________________
_______________________________________________________________________
c.
d.
Contact person
_______________________________________________________________________
Title
_______________________________________________________________________
Telephone number
_______________________________________________________________________
Total dry metric tons per 365-day period of sewage sludge provided to receiving facility:
EPA Form 3510-2S (Rev. 1-99)
______________________
Page 11 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
B.6. Shipment Off Site for Treatment or Blending. (con’t)
e.
Does the receiving facility provide additional treatment to reduce pathogens in sewage sludge from your facility? ____ Yes ____ No
Which class of pathogen reduction is achieved for the sewage sludge at the receiving facility?
______ Class A
______ Class B
______ Neither or unknown
Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce pathogens in sewage
sludge:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
f.
Does the receiving facility provide additional treatment to reduce vector attraction characteristics of the sewage sludge?
______Yes
______No
Which vector attraction reduction option is met for the sewage sludge at the receiving facility?
______ Option 1 (Minimum 38 percent reduction in volatile solids)
______ Option 2 (Anaerobic process, with bench-scale demonstration)
______ Option 3 (Aerobic process, with bench-scale demonstration)
______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge)
______ Option 5 (Aerobic processes plus raised temperature)
______ Option 6 (Raise pH to 12 and retain at 11.5)
______ Option 7 (75 percent solids with no unstabilized solids)
______ Option 8 (90 percent solids with unstabilized solids)
______ None
Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce vector attraction
properties of sewage sludge.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
g.
Does the receiving facility provide any additional treatment or blending activities not identified in (c) or (d) above?
____ Yes ____ No
If yes, describe, on this form or another sheet of paper, the treatment or blending activities not identified in (c) or (d) above:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
h.
If you answered yes to (e), (f), or (g), attach a copy of any information you provide the receiving facility to comply with the “notice and
necessary information” requirement of 40 CFR 503.12(g).
i.
Does the receiving facility place sewage sludge from your facility in a bag or other container for sale or give-away for application to the
land?
______ Yes
______ No
If yes, provide a copy of all labels or notices that accompany the product being sold or given away.
Complete Section B.7 if sewage sludge from your facility is applied to the land, unless the sewage sludge is covered in:
•
Section B.4 (it meets Table 1 ceiling concentrations, Table 3 pollutant concentrations, Class A pathogen requirements, and one of
vector attraction reduction options 1-8); or
•
Section B.5 (you place it in a bag or other container for sale or give-away for application to the land); or
•
Section B.6 (you send it to another facility for treatment or blending).
B.7. Land Application of Bulk Sewage Sludge.
a.
Total dry metric tons per 365-day period of sewage sludge applied to all land application sites: _______________ dry metric tons
EPA Form 3510-2S (Rev. 1-99)
Page 12 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
B.7. Land Application of Bulk Sewage Sludge. (con’t)
b.
Do you identify all land application sites in Section C of this application?
______ Yes
______ No
If no, submit a copy of the land application plan with application (see instructions).
c.
Are any land application sites located in States other than the State where you generate sewage sludge or derive a material from sewage
sludge? _______ Yes _______ No
If yes, describe, on this form or another sheet of paper, how you notify the permitting authority for the States where the land application
sites are located. Provide a copy of the notification.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Complete Section B.8 if sewage sludge from your facility is placed on a surface disposal site.
B.8. Surface Disposal.
a.
Total dry metric tons of sewage sludge from your facility placed on all surface disposal sites per 365-day period: ________ dry metric tons
b.
Do you own or operate all surface disposal sites to which you send sewage sludge for disposal?
_______ Yes _______ No
If no, answer B.8.c through B.8.f for each surface disposal site that you do not own or operate. If you send sewage sludge to more than
one such surface disposal site, attach additional pages as necessary.
c.
Site name or number
_______________________________________________________________________
d.
Contact person
_______________________________________________________________________
Title
_______________________________________________________________________
Telephone number
_______________________________________________________________________
Contact is
_________Site owner
Mailing address
_______________________________________________________________________
e.
_________Site operator
_______________________________________________________________________
f.
Total dry metric tons of sewage sludge from your facility placed on this surface disposal site per 365-day period: ________ dry metric tons
Complete Section B.9 if sewage sludge from your facility is fired in a sewage sludge Incinerator.
B.9. Incineration.
a.
Total dry metric tons of sewage sludge from your facility fired in all sewage sludge incinerators per 365-day period: ______ dry metric tons
b.
Do you own or operate all sewage sludge incinerators in which sewage sludge from your facility is fired?
______ Yes
______ No
If no, complete B.9.c through B.9.f for each sewage sludge incinerator that you do not own or operate. If you send sewage sludge to more
than one such sewage sludge incinerator, attach additional pages as necessary.
c.
Incinerator name or number: ___________________________________________________________________
d.
Contact person:
___________________________________________________________________
Title:
___________________________________________________________________
Telephone number:
___________________________________________________________________
Contact is:
_________ Incinerator owner
EPA Form 3510-2S (Rev. 1-99)
_________ Incinerator operator
Page 13 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
B.9. Incineration. (con’t)
e.
Mailing address:
___________________________________________________________________
___________________________________________________________________
f.
Total dry metric tons of sewage sludge from your facility fired in this sewage sludge incinerator per 365-day period: ______ dry metric tons
Complete Section B.10 if sewage sludge from this facility is placed on a municipal solid waste landfill.
B.10.
Disposal in a Municipal Solid Waste Landfill. Provide the following information for each municipal solid waste landfill on which sewage
sludge from your facility is placed. If sewage sludge is placed on more than one municipal solid waste landfill, attach additional pages as
necessary.
a.
Name of landfill
___________________________________________________________________
b.
Contact person
___________________________________________________________________
Title
___________________________________________________________________
Telephone number
___________________________________________________________________
Contact is
_________ Landfill owner
Mailing address
___________________________________________________________________
c.
_________ Landfill operator
___________________________________________________________________
d.
e.
Location of municipal solid waste landfill:
Street or Route #
__________________________________________________________________
County
__________________________________________________________________
City or Town
____________________________
State ___________
Zip _______________
Total dry metric tons of sewage sludge from your facility placed in this municipal solid waste landfill per 365-day period:
_______________________ dry metric tons
f.
List, on this form or an attachment, the numbers of all other Federal, State, and local permits that regulate the operation of this
municipal solid waste landfill.
Permit Number
_______________________
Type of Permit
__________________________
_______________________
__________________________
_______________________
__________________________
g.
Submit, with this application, information to determine whether the sewage sludge meets applicable requirements for disposal of
sewage sludge in a municipal solid waste landfill (e.g., results of paint filter liquids test and TCLP test)
h.
Does the municipal solid waste landfill comply with applicable criteria set forth in 40 CFR Part 258?
_______ Yes _______ No
EPA Form 3510-2S (Rev. 1-99)
Page 14 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
C. LAND APPLICATION OF BULK SEWAGE SLUDGE
Complete Section C for sewage sludge that is applied to the land, unless any of the following conditions apply:
•
•
•
The sewage sludge meets the Table 1 ceiling concentrations, the Table 3 pollutant concentrations, Class A pathogen
requirements, and one of vector attraction reduction options 1-8 (fill out B.4 Instead); or
The sewage sludge is sold or given away in a bag or other container for application to the land (fill out B.5 Instead); or
You provide the sewage sludge to another facility for treatment or blending (fill out B.6 instead).
Complete Section C for every site on which the sewage sludge that you reported in Section B.7 is applied.
C.1. Identification of Land Application Site.
a. Site name or number
_______________________________________________________________________
b.
Site location (Complete 1 and 2).
1.
2.
Street or Route #
_______________________________________________________________________
County
_______________________________________________________________________
City or Town
___________________________
Latitude ____________________
State ___________ Zip _____________________
Longitude ____________________
Method of latitude/longitude determination
______ USGS map
c.
______ Field survey
Topographic map. Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site location.
C.2. Owner Information.
a. Are you the owner of this land application site?
b.
______ Other
______ Yes
______ No
If no, provide the following information about the owner:
Name
__________________________________________________________________________
Telephone number
__________________________________________________________________________
Mailing Address
__________________________________________________________________________
__________________________________________________________________________
C.3. Applier Information.
a. Are you the person who applies, or who is responsible for application of, sewage sludge to this land application site?
______ Yes
______ No
b.
If no, provide the following information for the person who applies:
Name
__________________________________________________________________________
Telephone number
__________________________________________________________________________
Mailing Address
__________________________________________________________________________
__________________________________________________________________________
C.4. Site Type: Identify the type of land application site from among the following.
______ Agricultural land
______ Forest
______ Reclamation site
______ Other. Describe:
EPA Form 3510-2S (Rev. 1-99)
______ Public contact site
_________________________________________
Page 15 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
C.5. Crop or Other Vegetation Grown on Site.
a.
What type of crop or other vegetation is grown on this site?
_______________________________________________________________________________________________
b.
What is the nitrogen requirement for this crop or vegetation?
_______________________________________________________________________________________________
C.6. Vector Attraction Reduction.
Are any vector attraction reduction requirements met when sewage sludge is applied to the land application site?
______ Yes
______ No
If yes, answer C.6.a and C.6.b;
a.
Indicate which vector attraction reduction option is met:
______ Option 9 (Injection below land surface)
______ Option 10 (Incorporation into soil within 6 hours)
b.
Describe, on this form or another sheet of paper, any treatment processes used at the land application site to reduce vector attraction
properties of sewage sludge:
____________________________________________________________________________________________
____________________________________________________________________________________________
Complete Question C.7 only if the sewage sludge applied to this site since July 20, 1993, is subject to the cumulative pollutant loading
rates (CPLRs) in 40 CFR 503.13(b)(2).
C.7. Cumulative Loadings and Remaining Allotments.
a.
Have you contacted the permitting authority in the State where the bulk sewage sludge subject to CPLRs will be applied, to ascertain
whether bulk sewage sludge subject to CPLRs has been applied to this site on or since July 20, 1993?
______ Yes ______ No
If no, sewage sludge subject to CPLRs may not be applied to this site.
If yes, provide the following information:
b.
Permitting authority
___________________________________________________________________
Contact Person
__________________________________________________________________
Telephone number
___________________________________________________________________
Based upon this inquiry, has bulk sewage sludge subject to CPLRs been applied to this site since July 20, 1993?
______ Yes
______ No
If no, skip C.7.c.
EPA Form 3510-2S (Rev. 1-99)
Page 16 of 23
FACILITY NAME AND PERMIT NUMBER:
c.
Form Approved 1/14/99
OMB Number 2040-0086
Provide the following information for every facility other than yours that is sending, or has sent, bulk sewage sludge to CPLRs to this site
since July 20, 1993. If more than one such facility sends sewage sludge to this site, attach additional pages as necessary.
Facility name
_______________________________________________________________________
Mailing Address
_______________________________________________________________________
_______________________________________________________________________
Contact person
_______________________________________________________________________
Title
_______________________________________________________________________
Telephone number
_______________________________________________________________________
EPA Form 3510-2S (Rev. 1-99)
Page 17 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
D. SURFACE DISPOSAL
Complete this section if you own or operate a surface disposal site.
Complete Sections D.1 - D.5 for each active sewage sludge unit.
D.1. Information on Active Sewage Sludge Units.
a.
Unit name or number:
b.
Unit location (Complete 1 and 2).
1.
2.
______________________________________________________________________
Street or Route #
__________________________________________________________________________
County
__________________________________________________________________________
City or Town
__________________________
Latitude____________________
State _____________ Zip _______________________
Longitude____________________
Method of latitude/longitude determination:
______ USGS map
______ Field survey
______ Other
c.
Topographic map. Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site location.
d.
Total dry metric tons of sewage sludge placed on the active sewage sludge unit per 365-day period: __________________ dry metric tons
e.
Total dry metric tons of sewage sludge placed on the active sewage sludge unit over the life of the unit: _______________ dry metric tons
f.
Does the active sewage sludge unit have a liner with a maximum hydraulic conductivity of 1 × 10-7 cm/sec?
______ Yes ______ No
If yes, describe the liner (or attach a description):
______________________________________________________________________________________________
______________________________________________________________________________________________
g.
Does the active sewage sludge unit have a leachate collection system?
______ Yes
______ No
If yes, describe the leachate collection system (or attach a description). Also describe the method used for leachate disposal and provide
the numbers of any Federal, State, or local permit(s) for leachate disposal:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
h.
If you answered no to either D.1.f. or D.1.g., answer the following question:
Is the boundary of the active sewage sludge unit less than 150 meters from the property line of the surface disposal site?
______ Yes
______ No
If yes, provide the actual distance in meters: __________________________
Provide the following information:
Remaining capacity of active sewage sludge unit, in dry metric tons:
_______________________ dry metric tons
Anticipated closure date for active sewage sludge unit, if known: _______________________ (MM/DD/YYYY)
Provide, with this application, a copy of any closure plan that has been developed for this active sewage sludge unit.
EPA Form 3510-2S (Rev. 1-99)
Page 18 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
D.2. Sewage Sludge from Other Facilities. Is sewage sent to this active sewage sludge unit from any facilities other than your facility?
______ Yes
______ No
If yes, provide the following information for each such facility. If sewage sludge is sent to this active sewage sludge unit from more than one
such facility, attach additional pages as necessary.
a.
Facility name
_______________________________________________________________________
b.
Mailing Address
_______________________________________________________________________
_______________________________________________________________________
c.
d.
Contact person
_______________________________________________________________________
Title
_______________________________________________________________________
Telephone number
_______________________________________________________________________
Which class of pathogen reduction is achieved before sewage sludge leaves the other facility?
______ Class A
e.
______ Class B
______ None or unknown
Describe, on this form or another sheet of paper, any treatment processes used at the other facility to reduce pathogens in sewage sludge:
___________________________________________________________________________________________
___________________________________________________________________________________________
f.
Which vector attraction reduction option is met for the sewage sludge at the receiving facility?
______ Option 1 (Minimum 38 percent reduction in volatile solids)
______ Option 2 (Anaerobic process, with bench-scale demonstration)
______ Option 3 (Aerobic process, with bench-scale demonstration)
______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge)
______ Option 5 (Aerobic processes plus raised temperature)
______ Option 6 (Raise pH to 12 and retain at 11.5)
______ Option 7 (75 percent solids with no unstabilized solids)
______ Option 8 (90 percent solids with unstabilized solids)
______ None or unknown
g.
Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce vector attraction
properties of sewage sludge
_____________________________________________________________________________________________
_____________________________________________________________________________________________
h.
Describe, on this form or another sheet of paper, any other sewage sludge treatment activities performed by the other facility that are not
identified in (d) - (g) above:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
D.3. Vector Attraction Reduction
a.
Which vector attraction option, if any, is met when sewage sludge is placed on this active sewage sludge unit?
______ Option 9 (Injection below and surface)
______ Option 10 (Incorporation into soil within 6 hours)
______ Option 11 (Covering active sewage sludge unit daily)
EPA Form 3510-2S (Rev. 1-99)
Page 19 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
D.3. Vector Attraction Reduction. (con’t)
b.
Describe, on this form or another sheet of paper, any treatment processes used at the active sewage sludge unit to reduce vector attraction
properties of sewage sludge:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
D.4. Ground-Water Monitoring.
a.
Is ground-water monitoring currently conducted at this active sewage sludge unit, or are ground-water monitoring data otherwise available
for this active sewage sludge unit?
______ Yes
______ No
If yes, provide a copy of available ground-water monitoring data. Also, provide a written description of the well locations, the approximate
depth to ground-water, and the ground-water monitoring procedures used to obtain these data.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
b.
Has a ground-water monitoring program been prepared for this active sewage sludge unit?
______ Yes
______ No
If yes, submit a copy of the ground-water monitoring program with this permit application.
c.
Have you obtained a certification from a qualified ground-water scientist that the aquifer below the active sewage sludge unit has not been
contaminated?
______ Yes
______ No
If yes, submit a copy of the certification with this permit application.
D.5. Site-Specific Limits. Are you seeking site-specific pollutant limits for the sewage sludge placed on the active sewage sludge unit?
______ Yes
______ No
If yes, submit information to support the request for site-specific pollutant limits with this application.
EPA Form 3510-2S (Rev. 1-99)
Page 20 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
E. INCINERATION
Complete this section if you fire sewage sludge in a sewage sludge incinerator.
Complete this section once for each incinerator in which you fire sewage sludge. If you fire sewage sludge in more than one sewage
sludge incinerator, attach additional copies of this section s necessary.
E.1. Incinerator Information.
a.
Incinerator name or number: _______________________________________________________________________
b.
Incinerator location (Complete 1 and 2).
1.
2.
Street or Route #
_______________________________________________________________________
County
_______________________________________________________________________
City or Town
_____________________________ State ______________ Zip __________________
Latitude____________________
Longitude____________________
Method of latitude/longitude determination:
______ USGS map
______ Field survey
E.2. Amount Fired. Dry metric tons per 365-day period of sewage sludge fired in the sewage sludge incinerator:
______ Other
_____________ dry metric tons
E.3. Beryllium NESHAP.
a. Is the sewage sludge fired in this incinerator “beryllium-containing waste,” as defined in 40 CFR Part 61.31? ______ Yes
______ No
Submit, with this application, information, test data, and description of measures taken that demonstrate whether the sewage sludge
incinerated is beryllium-containing waste, and will continue to remain as such.
b.
If the answer to (a) is yes, submit with this application a complete report of the latest beryllium emission rate testing and documentation
of ongoing incinerator operating parameters indicating that the NESHAP emission rate limit for beryllium has been and will continue to be
met.
E.4. Mercury NESHAP.
a.
How is compliance with the mercury NESHAP being demonstrated?
______ Stack testing (if checked, complete E.4.b)
______ Sewage sludge sampling (if checked, complete E.4.c)
b.
If stack testing is conducted, submit the following information with this application:
A complete report of stack testing and documentation of ongoing incinerator operating parameters indicating that the incinerator has met,
and will continue to meet, the mercury NESHAP emission rate limit.
Copies of mercury emission rate tests for the two most recent years in which testing was conducted.
c.
If sewage sludge sampling is used to demonstrate compliance, submit a complete report of sewage sludge sampling and documentation of
ongoing incinerator operating parameters indicating that the incinerator has met, and will continue to meet the mercury NESHAP emission
rate limit.
E.5. Dispersion Factor.
a. Dispersion factor, in micrograms/cubic meter per gram/second: __________________________
b.
Name and type of dispersion model:
c.
Submit a copy of the modeling results and supporting documentation with this application.
EPA Form 3510-2S (Rev. 1-99)
_________________________________________________
Page 21 of 23
FACILITY NAME AND PERMIT NUMBER:
Form Approved 1/14/99
OMB Number 2040-0086
E.6. Control Efficiency.
a. Control efficiency, in hundredths, for the following pollutants:
b.
Arsenic:
_______
Chromium:
_______
Cadmium:
_______
Lead:
_______
Nickel:
_______
Submit a copy of the results or performance testing and supporting documentation (including testing dates) with this application.
E.7. Risk Specific Concentration for Chromium.
a.
Risk specific concentration (RSC) used for chromium, in micrograms per cubic meter: ______________
b.
Which basis was used to determine the RSC?
____Table 2 in 40 CFR 503.43
____Equation 6 in 40 CFR 503,43 (site-specific determination)
c.
If Table 2 was used, identify the type of incinerator used as the basis:
____Fluidized bed with wet scrubber
____Fluidized bed with wet scrubber and wet electrostatic precipitator
____Other types with wet scrubber
____Other types with wet scrubber and wet electrostatic precipitator
d.
If Equation 6 was used, provide the following:
Decimal fraction of hexavalent chromium concentration to total chromium concentration in stack exit gas:
_____________
Submit results of incinerator stack tests for hexavalent and total chromium concentrations, including date(s) of test, with this application.
E.8. Incinerator Parameters
a. Do you monitor Total Hydrocarbons (THC) in the sewage sludge incinerator's exit gas?
Do you monitor Carbon Monoxide (CO) in the sewage sludge incinerator's exit gas?
b.
Incinerator type: _______________________
c.
Incinerator stack height, in meters: ______________________
Indicate whether value submitted is:
______ Actual stack height
Yes
No
Yes
No
______ Creditable stack height
E.9. Performance Test Operating Parameters
a.
Maximum Performance Test Combustion Temperature:
_______________________________
b.
Performance test sewage sludge feed rate, in dry metric tons/day: _______________________
indicate whether value submitted is:
______ Average use
______ Maximum design
Submit, with this application, supporting documents describing how the feed rate was calculated.
c.
Submit, with this application, information documenting the performance test operating parameters for the air pollution control device(s) used
for this sewage sludge incinerator.
EPA Form 3510-2S (Rev. 1-99)
Page 22 of 23
FACILITY NAME AND PERMIT NUMBER:
E.10.
E.11.
Form Approved 1/14/99
OMB Number 2040-0086
Monitoring Equipment. List the equipment in place to monitor the following parameters:
a. Total hydrocarbons or carbon monoxide: _________________________________________________________
b.
Percent oxygen:
_________________________________________________________
c.
Moisture content:
_________________________________________________________
d.
Combustion temperature:
_________________________________________________________
e.
Other:
_________________________________________________________
Air Pollution Control Equipment. Submit, with this application, a list of all air pollution control equipment used with this sewage sludge
incinerator.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
EPA Form 3510-2S (Rev. 1-99)
Page 23 of 23
Additional Information, if provided, will appear on the following pages.
NPDES FORM 2S Additional Information
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF INTENT (NOI) FOR STORMWATER DISCHARGES ASSOCIATED WITH
INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT
NPDES
FORM
3510-6
Form Approved.
OMB No. 2040-0086
Submission of this completed Notice of Intent (NOI) constitutes notice that the operator identified in Section B of this form requests authorization to discharge pollutants
to waters of the United States from the facility or site identified in Section C under EPA’s NPDES Stormwater Multi-Sector General Permit (MSGP) for industrial
stormwater. Submission of this NOI constitutes your notice to EPA that the facility identified in Section C of this form meets the eligibility conditions of Part 1.1 of the
MSGP. Please read and make sure you comply with all eligibility requirements, including the requirement to prepare a stormwater pollution prevention plan. Refer to the
instructions at the end of this form to complete your NOI.
A. Permit
Number:
(see Appendix C of the MSGP for the list of
eligible permit numbers)
R
Tracking Number (EPA Use
Only):
B. Facility Operator Information
1. Name:
2. IRS Employer Identification Number (EIN):
–
3. Mailing Address:
a. Street:
c. State:
b. City:
-
e. Phone:
f. Fax
(optional):
-
-
-
d. Zip Code:
-
g. E-mail: _________________________________________
C. Facility Information
1. Facility Name:
2. Have stormwater discharges from your site been covered previously under an NPDES permit?
YES
NO
a. If yes, provide the Tracking Number if you had coverage under EPA’s MSGP 2000
or the NPDES permit number if you had coverage under an EPA individual permit.
b.1 If no, was your facility in operation and discharging stormwater prior to October 30, 2005?
YES
b.2 If no to C.2.b.1, did your facility commence discharging after October 30, 2005 and before January 5, 2009?
NO
YES
NO
3. Location Address:
a. Street
b. City:
d. State:
c. County or similar government subdivision:
f. Latitude: (use
any one of the
three formats
provided.)
e. Zip Code:
-
1. ___ ___° ___ ___΄ ___ ___˝ N (degrees, minutes, seconds) g. Longitude: 1. ___ ___ ___° ___ ___΄ ___ ___˝ W (degrees, minutes, seconds)
(use any of
2. ___ ___ ___° ___ ___. ___ ___΄ W (degrees, minutes, decimal)
2. ___ ___° ___ ___. ___ ___΄ N (degrees, minutes, decimal) these 3
formats)
3. ___ ___ ___. ___ ___ ___ ___° W (degrees decimal)
3. ___ ___. ___ ___ ___ ___° N ( degrees decimal)
h. Lat/Long Data Source:
USGS topographic map
EPA web site
GPS
Other: _______________________________________________
If you used a USGS topographic map, what was the scale? __________________________________________________________________________
4. Estimated area of industrial activity at your site exposed to stormwater:
5. Is this a federal facility?
YES
(acres)
NO
6. Is your facility located on Indian Country lands?
YES
NO
If yes, name of reservation, or if not part of a reservation, put “Not Applicable:” ___________________________________________________________
EPA FORM 3510-6 (Revised 09-2008)
Page 1 of 7
D. Discharge information
1. Does your facility discharge stormwater into a Municipal Separate Storm Sewer System (MS4)?
YES
NO
If yes, name of MS4 operator: ___________________________________________________________________________________________________
2. Receiving Waters and Wetlands (Note: If additional space is needed for this question, fill out Attachment 1.)
If you answered yes to question D.2.b, then answer the following three questions:
a. What is the name(s) of your receiving water(s)
that receive stormwater directly and/or through an
MS4)?
b. Are any of your
discharges directly
into any segment of
If your receiving water is impaired then identify the
an “impaired”
name of the impaired segment, if applicable, in
water?
parentheses following the receiving water name.
b.2. Are the
pollutant(s) causing
the impairment
present in your
discharge?
b.1. What pollutant(s) are causing the
impairment?
b.3. Has a TMDL
been completed for
the pollutant(s)
causing the
impairment?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
3. Water Quality Standards (for new dischargers only)
a. Are any of your discharges into any portion of a receiving water designated by the state or tribal authority under its antidegradation policy as a Tier 2 (or Tier
2.5) water (water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water)?
YES
NO
b. Has the receiving water(s) been designated by the state or tribal authority under its antidegradation policy as a Tier 3 water (Outstanding Natural Resource
Water)?
YES
NO
4. Federal Effluent Limitation Guidelines and Sector-Specific Requirements
a. Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines?
YES
NO
b. If yes, which effluent limitation guidelines apply to your stormwater discharges?
40 CFR Part/Subpart
Eligible Discharges
Affected MSGP Sector
Part 411, Subpart C
Runoff from material storage piles at cement manufacturing facilities
E
Part 418 Subpart A
Runoff from phosphate fertilizer manufacturing facilities that comes
into contact with any raw materials, finished product, by-products or
waste products (SIC 2874)
C
Coal pile runoff at steam electric generating facilities
O
Part 423
Part 429, Subpart I
Part 436, Subpart B, C, or D
Discharges resulting from spray down or intentional wetting of logs at
wet deck storage areas
Mine dewatering discharges at crushed stone mines, construction
sand and gravel mines, or industrial sand mines
Part 443, Subpart A
Runoff from asphalt emulsion facilities
Part 445, Subparts A & B
Runoff from hazardous waste and non-hazardous waste landfills
Check if Applicable
A
J
D
K, L
c. If you are a Sector S (Air Transportation) facility, do you anticipate using more than 100,000 gallons of glycol-based deicing/anti-icing chemicals and/or 100 tons
or more of urea on an average annual basis?
YES
NO
5. Identify the 4-digit Standard Industrial Classification (SIC) code or 2-letter Activity Code that best represents the products produced or services rendered for which
your facility is primarily engaged, as defined in MSGP:
Primary SIC Code:
OR
Primary Activity Code
6. Identify the applicable sector(s) and subsector(s) of industrial activity, including co-located industrial activity, for which you are requesting permit coverage:
a.
Sector
Subsector
b.
Sector
Subsector
c.
Sector
Subsector
d.
Sector
Subsector
e.
Sector
Subsector
f.
Sector
Subsector
7.a. Is your site presently inactive and unstaffed?
YES
NO
b1. If yes, is your site expected to be inactive and unstaffed for the entire permit term?
YES
NO
b2. If you select “no” in 7.b1 above, then indicate the length of time that you expect your facility to be inactive and unstaffed _______________________________
EPA FORM 3510-6 (Revised 09-2008)
Page 2 of 7
E. Stormwater Pollution Prevention Plan (SWPPP) Contact Information
1a. SWPPP Contact Name:
-
b. Phone:
-
Ext.
c. E-mail:
2. URL of SWPPP (if applicable): __________________________________________________________________________________________________________
F. Endangered Species Protection
1. Using the instructions in Appendix E of the MSGP, under which criterion listed in Part 1.1.4.5 are you eligible for coverage under this permit?
A
B
C
D
E
F
2. If you select criterion E from Part 1.1.4.5:
a. What federally-listed species or federally-designated critical habitat are in your “action area?”_______________________________________________________
__________________________________________________________________________________________________________________________________
b. List the pollutants expected to be present in your discharge ________________________________________________________________________________
__________________________________________________________________________________________________________________________________
c. If you are an existing discharger, do you have effluent monitoring data from EPA’s MSGP 2000, or another previous NPDES permit?
c.1 If no, why not?
No monitoring required for my sector
Inactive/unstaffed site
YES
NO
Other _______________________________
c.2 Do you have any other data characterizing pollutants in your stormwater (describe)? ____________________________________________________
c.3 If you have benchmark monitoring data, did you exceed any of the applicable benchmarks?
YES
NO
c.4 Did you exceed any applicable effluent limitation guideline or cause or contribute to an exceedance of a State or Tribal water quality standard?
YES
NO
c.5 If you answered “yes” to either question F.2.c.3 or F.2.c.4 above, for what pollutant(s)? _________________________________________________________
d. Attach documentation supporting criterion E eligibility. Documentation should address species and habitat listed in F.2.a and the potential effects of pollutants listed
in F.2.b (including any monitoring data for these pollutants) on the listed species and habitat.
3. If you select criterion F from Part 1.1.4.5, provide the operator’s NPDES
Tracking Number under which you are certifying eligibility:
G. Historic Preservation
Using the instructions in Appendix F of the MSGP, under which criterion listed in Part 1.1.4.6 are you eligible for coverage under this permit?
A
B
C
D
H. Certifier Name and Title
I certify under penalty of law that I meet the eligibility conditions of this permit and 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 gather and evaluate 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, I certify that the information submitted is, to the best
of my knowledge and belief, true, accurate, and complete. I certify that I am aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations.
Print Name:
Title:
Signature: _________________________________________________________________________________
Date:
E-mail:
NOI Preparer (Complete if NOI was prepared by someone other than the certifier)
Prepared by:
Organization:
Phone:
-
EPA FORM 3510-6 (Revised 09-2008)
-
Ext.
E-mail:
Page 3 of 7
Attachment 1. (Fill in as necessary if more space is required for D.2 a-e)
a. What is the name(s) of your receiving water(s)
that receive stormwater from your facility (directly
and/or through an MS4)?
b. Are any of your
discharges directly
into any segment of
If your receiving water is impaired then identify the
an “impaired”
name of the impaired segment, if applicable, in
water?
parentheses following the receiving water name.
EPA FORM 3510-6 (Revised 09-2008)
If you answered yes to question D.2.b, then answer the following three questions:
b.1. What pollutant(s) are causing the
impairment?
b.2. Are the
b.3. Has a TMDL
pollutant(s) causing been completed for
the impairment
the pollutant(s)
present in your
causing the
discharge?
impairment?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
NO
YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
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YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Page 4 of 7
Instructions for Completing the Notice of Intent for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the Multi-Sector General Permit (MSGP)
NOI Submittal Deadlines/Discharge Authorization Dates
Category
NOI Deadline
Discharge Authorization Date1
Existing Dischargers - in No later than January
30 days after EPA posts your
operation as of October 5, 2009.
NOI. Your authorization under
30, 2005 and authorized
the MSGP 2000 is automatically
for coverage under
continued until you have been
MSGP 2000.
granted coverage under this
permit or an alternative permit,
or coverage is otherwise
terminated.
As soon as possible
30 days after EPA posts your
New Dischargers or
New Sources - have
but no later than
NOI.
commenced discharging January 5, 2009.
between October 30,
2005 and January 5,
2009.
A minimum of 60 days If you post your SWPPP on the
New Dischargers or
Internet, 30 days after EPA
prior to commencing
New Sources operation of the facility, posts your NOI. Otherwise, 60
commence discharging
days after EPA posts your NOI.
or a minimum of 30
after January 5, 2009.
days if your SWPPP is
posted on the Internet
during this period and
the Internet address
(i.e., URL) to your
SWPPP is provided on
the NOI form.
New Owner/Operator of A minimum of 30 days 30 days after EPA posts your
Existing Discharger prior to date that the
NOI.
transfer of ownership
transfer will take place
and/or operation of a
to the new
facility whose discharge owner/operator.
is authorized under this
permit
Immediately, to
If you post your SWPPP on the
Other Eligible
Dischargers - in
minimize the time
Internet, 30 days after EPA
operation prior to
discharges from the
posts your NOI. Otherwise, 60
October 30, 2005 but
facility will continue to
days after EPA posts your NOI.
not covered under the
be unauthorized.
MSGP 2000 or another
NPDES permit.
1
Based on a review of your NOI or other information, EPA may delay your
authorization for further review, notify you that additional effluent limitations are
necessary, or may deny coverage under this permit and require submission of an
application for an individual NPDES permit, as detailed in MSGP Part 1.6. In these
instances, EPA will notify you in writing of the delay or the request for submission of an
individual NPDES permit application. EPA will post these NOIs on its website at
www.epa.gov/npdes/enoi.
Who Must File a Notice of Intent with EPA?
Under section 402(p) of the Clean Water Act (CWA) and regulations at 40 CFR
Part 122, stormwater discharges associated with industrial activity are prohibited to
waters of the United States unless authorized under a National Pollutant Discharge
Elimination System (NPDES) permit. You can obtain coverage under the MSGP by
submitting a completed NOI if you operate a facility:
• that is located in a jurisdiction where EPA is the permitting authority, listed in
Appendix C of the MSGP,
• that discharges stormwater associated with industrial activities, identified in
Appendix D of the MSGP,
• that meets the eligibility requirements in Part 1.1 of the permit,
• that develops a stormwater pollution prevention plan (SWPPP) in accordance
with Part 5 of the MSGP; and
• that installs and implements control measures in accordance with Part 2 to
meet numeric and non-numeric effluent limits.
If you are unsure if you need an NPDES stormwater permit, contact your EPA or
State NPDES stormwater permit program. Contacts are listed at
www.epa.gov/npdes/stormwatercontacts.
One NOI must be submitted for each facility or site for which you are seeking
permit coverage. You do not need to submit separate NOIs for each type of
industrial activity present at your facility, provided your SWPPP covers all activities.
When to File the NOI Form
Do not file your NOI until you have obtained and thoroughly read a copy of the
MSGP. A copy of the MSGP is located on the EPA website
(www.epa.gov/npdes/stormwater/msgp). The MSGP describes procedures to
ensure your eligibility, prepare your SWPPP, install and implement appropriate
stormwater control measures, and complete the NOI form questions – all of which
must be done before you sign the NOI certification statement attesting to the
EPA FORM 3510-6 (Revised 09-2008)
accuracy and completeness of your NOI. You will also need a copy of the MSGP
once you have obtained coverage so that you can comply with the implementation
requirements of the permit.
Where to File the NOI Form
EPA encourages you to complete the NOI form electronically via the Internet.
EPA’s Electronic Notice of Intent System (eNOI) can be found at
www.epa.gov/npdes/enoi. Filing electronically is the fastest way to obtain permit
coverage and help ensure that your NOI is complete. If you choose not to file
electronically, you must send the NOI to one of the addresses listed below.
NOIs sent regular mail:
Stormwater Notice Processing Center (4203M)
USEPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
NOIs sent overnight/express mail:
Stormwater Notice Processing Center
EPA East Building, Rm. 7420
1201 Constitution Avenue, NW
Washington, DC 20004
202-564-9545
If you have questions, please contact EPA’s Stormwater Notice Processing
Center toll free at (866) 352-7755.
• If you file a paper NOI, please submit the original with a signature in ink –
Do Not Send Copies. Also, faxed copies will not be accepted.
• Your SWPPP does not need to be submitted for review unless specifically
requested by EPA or as otherwise required in Part 9 of the MSGP (State,
Territory, and Tribal requirements). You must keep a copy of your SWPPP
on-site or otherwise make it available to facility personnel responsible for
implementing provisions of the permit.
Completing the NOI Form
To complete this form, type or print in uppercase letters in the appropriate areas
only. Please make sure you complete all questions. Make sure you make a
photocopy for your records before you send the completed original form to the
address above. You may also use this paper form as a checklist for the information
you will need when filing an NOI electronically via EPA’s eNOI system.
Section A. Permit Number
Appendix C of the MSGP 2008 contains a list of geographic areas covered by
the permit. If your facility is located in one of the listed areas, include the appropriate
permit number in this section. (For example, if you facility is located in
Massachusetts, and not on Indian Lands, you would write MAR050000 in this
space.) If your facility is located in an area not covered by the MSGP, please
contact your EPA Region, state or territorial NPDES stormwater coordinator (see
www.epa.gov/npdes/stormwatercontacts for a list of contacts).
Section B. Facility Operator Information
1. Provide the legal name of the person, firm, public organization or any other
public entity that operates the facility described in this application. An operator of
a facility is a legal entity that controls the operation of the facility.
2. Provide the Employer Identification Number (EIN from the Internal Revenue
Service (IRS)), commonly referred to as your taxpayer ID number. If the operator
does not have an EIN, enter “NA” in the space provided.
3. Provide the operator’s mailing address, telephone number, fax number
(optional), and email address. Correspondence will be sent to this address.
Section C. Facility Information
1. Enter the facility’s official or legal name. Unless the name of your facility has
changed, please use the same name provided on prior NOIs or permit
applications. You can use EPA’s NOI Search website
(www.epa.gov/npdes/noisearch) to view your previous NOI.
2. Indicate if industrial stormwater discharges from your facility were previously
covered by an NPDES permit.
2a.If your facility was covered by EPA’s MSGP-2000, please include the tracking
number that you received in your confirmation letter or email from EPA’s
Stormwater Notice Processing Center. You can find the tracking number
assigned to your previous NOI on EPA’s NOI Search website
(www.epa.gov/npdes/noisearch).
2b1.If your facility was not previously covered by an NPDES permit and discharged
industrial stormwater, then indicate if it was in operation before October 30,
2005 and not covered under the MSGP 2000. If you select “yes” to this question
then you have a 30 day waiting period before you are authorized to discharge.
2b2.If you select “no” in C.2.b.1, then indicate if your facility discharged stormwater
between October 30, 2005 and January 5, 2009. If you select “yes” to this
Page 5 of 7
question then you have a 30 day waiting period before you are authorized to
discharge. If you select “no” to this question and you post your SWPPP on the
Internet and provide EPA the URL in E.2, then you have a 30 day waiting period
before you are authorized to discharge. If you select “no” to this question, but do
not post your SWPPP on the Internet and therefore do not answer E.2, then you
have a 60 day waiting period before you are authorized to discharge.
3.a-e. Enter the street address, including city, state, zip code, county or similar
government subdivision of the actual physical location of the facility. Do not use
a P.O. Box.
3.f-g. Provide the facility latitude and longitude in one of three formats: (1) degrees,
minutes, seconds; (2) degrees, minutes, decimal; or(3) degrees decimal. You
can obtain your facility’s latitude and longitude though Global Positioning
System (GPS) receivers, U.S. Geological Survey (USGS) quadrangle or
topographic maps, and EPA’s web-based siting-tools, among other methods.
Refer to www.epa.gov/npdes/stormwater/msgp for guidance on the use of these
methods. For consistency, EPA requests you take measurements from the
location of your facility’s stormwater outfall. Outfalls are locations where the
stormwater exits the facility, including pipes, ditches, swales, and other
structures that transport stormwater. If there is more than one outfall present,
measure at the primary outfall (i.e., the outfall with the largest volume of
stormwater discharge associated with industrial activity).
3.h. Identify the data source that you used to determine the facility latitude and
longitude. If you did not use a USGS quadrangle or topographic map, the EPA
website, or GPS receivers, then select “Other” and write the method used on
the line provided. If you used a USGS quadrangle or topographic map, write the
map scale on the line provided. Scale should be identified on the map.
4. Enter the estimated area of industrial activity at your site exposed to
stormwater, in acres.
5. Indicate if the facility is considered a “federal facility” - Federal facilities include
any buildings, installations, structures, land, public works, equipment, aircraft,
vessels, and other vehicles and property, owned or leased by the federal
government.
6. Indicate whether the facility is located in Indian Country, and, if so, provide the
name of the reservation, if applicable.
Section D. Discharge Information
1. Indicate whether stormwater from your site will be discharged into a municipal
separate storm sewer system (MS4). An MS4 is a conveyance or system of
conveyances, including roads with drainage systems, municipal streets, catch
basins, storm drains, curbs and gutters, ditches and man-made channels,
owned or operated by a state, city, town, borough, county, parish, district,
association or other public body, used to collect or convey stormwater. If you
check “Yes” then identify the name of the MS4 operator on the line provided. If
you are uncertain of the MS4 operator, contact your local government for that
information. MS4s are different than combined sewers, which are designed to
convey both stormwater and sanitary wastewater. Discharges to combined
sewers do not require an NPDES permit but may be subject to other CWA
requirements (contact the combined sewer operator for more information).
2. Enter information regarding your discharge. If additional space is needed fill out
Attachment 1.
2a. Indicate in column “a” of the table the name(s) of the receiving water(s) into
which stormwater from your facility will discharge. Also provide in parentheses
the name of the impaired water (and segment, if applicable) into which your
stormwater is discharged. If you identified more than on receiving water for your
facility, indicate the first receiving water and complete question 2b and 2.b.1-3 (if
applicable), before entering the next receiving water. The EPA’s Water Locator
Tool can help you identify the closest receiving water to your facility
(www.epa.gov/npdes/msgp). Your receiving water may be a lake, stream, river,
ocean, wetland or other waterbody, and may or may not be located adjacent to
your facility. Your stormwater may discharge directly to the receiving water or
indirectly via a storm sewer system, an open drain or ditch, or other conveyance
structure. Do NOT list a man-made conveyance, such as a storm sewer system,
as your receiving water. Indicate the first receiving water your stormwater
discharge enters. For example, if your discharge enters a storm sewer system,
that empties into Trout Creek, which flows into Pine River, your receiving water is
Trout Creek, because it is the first waterbody your discharge will reach. Similarly,
a discharge into a ditch that feeds Spring Creek should be identified as “Spring
Creek” since the ditch is a manmade conveyance. If you discharge into a
municipal separate storm sewer system (MS4), you must identify the waterbody
into which that portion of the storm sewer discharges. That information should be
readily available from the operator of the MS4.
2b. Indicate in column “b” of the table whether you discharge directly to an impaired
water (lake, stream segment, estuary, etc), listed as “impaired” under section
303(d) of the Clean Water Act. Each state water quality agency maintains a list of
waters that are impaired. Most state agencies publish these lists online. The
EPA’s Water Locator Tool may also help you identify if the nearest receiving
water is impaired (www.epa.gov/npdes/msgp). If you discharge into a stream
EPA FORM 3510-6 (Revised 09-2008)
segment that is upstream of a listed impaired water but which is not itself on the
State’s impaired waters list, answer “no” to this question. In this case,
requirements in the MSGP for discharges into impaired waters do not apply to
you, unless notified otherwise by EPA.
Answer the following three questions only if you answered “Yes” to D 2.b:
2b1. Provide the pollutant(s) listed as causing the impairment in the water identified
in D.2.b.1 above. Enter each pollutant individually on a separate row in the
table.
2b2. Out of the pollutant(s) that you identified in D.2.b.1 above, indicate which
pollutants you believe will be present in your discharge. If you do not expect the
pollutant(s) to be in your discharge, then select “no.”
2b3.Indicate the pollutant(s) that have a Total Maximum Daily Load (TMDL) for the
impaired stream segment that you identified in D.2.b.2 above. Check with your
state water quality agency for lists of waters with approved or established
TMDLs. See www.epa.gov/npdes/msgp for more information.
3. Water Quality Standards
3a.If you selected “no” in C.2 indicating that stormwater discharges from your facility
have not been previously covered under an NPDES permit, then you are
considered a new discharger and must answer this question; otherwise you are
considered an existing discharger and may skip this question. State water
quality agencies are responsible for setting water quality standards for waters
within the state’s boundaries. Check EPA’s website (www.epa.gov/npdes/msgp)
to determine if the water(s) that you discharge into are designated as a “Tier 2
(or Tier 2.5) water” (See Appendix A of the MSGP 2008 for definitions of “Tier 2
water” and “Tier 2.5 water”). If you discharge into these waters, EPA may impose
additional permit conditions to ensure that you do not violate the State’s
antidegradation policy.
3.b Idenitfy whether your receiving water is designated as a Tier 3 waterbody. Go to
www.epa.gov/npdes/msgp for a list of Tier 3 waterbodies. Note that new
discharges into designated Tier 3 waters are not eligible for coverage under the
MSGP 2008.
4. Federal Effluent Limitation Guidelines and Sector-Specific Requirements
4.a-b. Depending on your industrial activities, your facility may be subject to effluent
limitation guidelines which include additional effluent limits and monitoring
requirements for your facility. Please review these requirements, described in
Part 2.1.3 of the MSGP, and check any appropriate boxes on the NOI form.
4.c. For Sector S facilities (Air Transportation), indicate whether you anticipate that
the entire airport facility will use more than 100,000 gallons of glycol-based
deicing/anti-icing chemicals and/or 100 tons or more of urea on an average
annual basis. If so, additional effluent limits and monitoring conditions apply to
your discharge (see Part 8 Sector S of the MSGP 2008).
5. List the four-digit Standard Industrial Classification (SIC) code and/or two
character activity code that best describes the primary industrial activities
performed by your facility under which you are required to obtain permit
coverage. Your primary industrial activity includes any activities performed onsite which are (1) identified by the facility’s one SIC code for which the facility is
primarily engaged; and (2) included in the narrative descriptions of 40 CFR
122.26(b)(14)(i), (iv), (v), or (vii), and (ix). See Appendix D of the MSGP for a
complete list of SIC codes and activities codes.
6. If your site has co-located industrial activities that are not identified as your
primary industrial activity, identify the sector and subsector codes that describe
these other industrial activities. For a complete list of sector and subsector
codes, see Appendix D of the MSGP.
7.a-b Indicate whether your facility is currently inactive and unstaffed. If so then
indicate whether your facility will be inactive and unstaffed for the entire permit
term, or if not, specify the specific length of time in units of days, weeks, months,
or years (e.g. 3 months) that you expect the facility to be inactive and unstaffed.
Section E. Facility Contact Information and SWPPP Location
1.a-c. Identify the name, telephone number, and email address of the person who
will serve as a contact for EPA on issues related to stormwater management at
your facility. This person should be able to answer questions related to
stormwater discharges, the SWPPP, and other issues related to stormwater
permit coverage, or have immediate access to individuals with that knowledge.
This person does not have to be the facility operator, but should have intimate
knowledge of stormwater management activities at the facility.
2. If you are making your Stormwater Pollution Prevention Plan publicly available
on a website provide the appropriate Internet URL address. (Please note that by
posting your SWPPP on the web, you may qualify for a shortened authorization
waiting period. See Table 1-2 of the MSGP for more information.)
Section F. Endangered Species Protection
1. Based on the instruction provided in Appendix E of the MSGP 2008, indicate
which permit criterion (A,B,C,D,E, or F) listed in Part 1.1.4.5 you are using to
satisfy your eligibility obligations for protection of endangered and threatened
species, and designated critical habitat.
Page 6 of 7
2.a. If you select criterion E (not likely to adversely affect), list those federally-listed
endangered or threatened species and any federally-listed designated critical
habitat expected to exist in proximity to your facility.
2.b List the pollutants that you expect to be present in your stormwater discharge.
Include any pollutants that you may have included in D.2.b.3 above.
2.c If you selected “yes” in C.2 then you are considered an existing discharger and
must answer all the questions in F.2.c.1--5; otherwise you are considered a new
discharger and may skip the questions under F.2.c. If you are an existing
discharger who was previously covered under the MSGP 2000, indicate
whether you have any previous effluent monitoring data.
2.c1-2.If you select “No,” to F.2.c then indicate why you don’t have any data. Also
indicate if you have any other data characterizing pollutants in your stormwater
discharge.
2.c.3. If you select “Yes,” to F.2.c then indicate whether you exceeded any
benchmark.
2.c.4 Indicate whether you have exceeded any applicable effluent limitation
guideline, or caused or contributed to an exceedance of state or tribal water
quality requirement(s).
2.c.5. If you select “Yes” to F.2.c.3.and/or F.2.c.4 then indicate the pollutant
parameters for which you exceeded the benchmark, applicable effluent
limitation guideline, or State or Tribal water quality requirement(s).
2.d. Attach your supporting rationale for your determination of the applicability of
Criterion E for your facility (applies to both new and existing dischargers). Your
documentation should address species and habitat listed in F.2.a and the
potential effects of pollutants listed in F.2.b on the listed species and habitat.
This should include consideration of any available data characterizing pollutants
in your stormwater discharge, or in the discharge of similar facilities if data for
you facility is not available, that may be of concern to listed species.
3. If you select Criterion F (already addressed in another operator’s valid
certification), provide the tracking number that the operator received in their
confirmation letter or email from EPA’s NOI Processing Center (see Appendix
E). You can find the tracking number assigned to your previous NOI on EPA’s
NOI Search website (www.epa.gov/npdes/noisearch). An example where
criterion F may apply includes airports where several individual airlines have
applied for coverage under the MSGP, and the entire airport also has applied
for or obtained coverage. If the airport has already certified under Appendix E,
and that certification addresses any potential impacts from the individual
airlines, then the airlines may reference the airport’s permit tracking number.
information to or for a Federal agency. This includes the time needed to review
instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information, processing and
maintaining information, and disclosing and providing information; adjust the existing
ways to comply with any previously applicable instructions and requirements; train
personnel to be able to respond to a collection of information; search data sources;
complete and review the collection of information; and transmit or otherwise disclose
the information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number. Send comments regarding the burden estimate, any other
aspect of the collection of information, or suggestions for improving this form,
including any suggestions which may increase or reduce this burden to: Director,
Office of Environmental Information Services, Collection Services Division (2823),
USEPA, 1200 Pennsylvania Avenue, NW, Washington, DC 20460. Include the OMB
control number of this form on any correspondence. Do not send the completed NOI
form to this address.
Section G. Historic Preservation
Based on the instruction provided in Appendix F of the MSGP 2008, indicate
which permit criterion (A, B, C, or D) listed in Part 1.1.4.6 of the MSGP you used to
satisfy your eligibility obligations for protection of historic properties.
Section H. Certification
Certification statement and signature (see Section B.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.) Federal statutes provide for severe penalties for
submitting false information on this application form. Federal 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.
If the NOI was prepared by someone other than the certifier (for example, if the
NOI was prepared by the facility SWPPP contact or a consultant for the certifier’s
signature), include the name, organization, phone number and email address of the
NOI preparer.
Paperwork Reduction Act Notice
Public reporting burden for this certification is estimated to average 3.7 hours per
certification, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Burden means the total time, effort, or financial
resources expended by persons to generate, maintain, retain, or disclose to provide
EPA FORM 3510-6 (Revised 09-2008)
Page 7 of 7
This Form Replaces Previous Form 2040-0086 (Please See Instructions Before Completing This Form)
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER A NPDES GENERAL PERMIT
FOR STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY
NPDES
FORM
3510-7
Form Approved.
OMB No. 2040-0086
Submission of this Notice of Termination (NOT) constitutes notice that the party identified in Section B of this form is no longer authorized to discharge stormwater
associated with industrial activity under the NPDES program for the facility identified in Section C of this form. All necessary information must be included on this form.
Refer to the instructions at the end of this form.
A. Permit Number:
1. NPDES Permit Tracking Number:
2. Reason for Termination (check one only):
You transferred operational control to another operator.
b.
You no longer have a stormwater discharge associated with industrial activity subject to regulation under the
a.
NPDES program, and you have already implemented necessary sediment and erosion controls as required by
Part 2.1.2.5.
c.
d.
You are a Sector G, H, or J facility and you have met the applicable termination requirements.
You obtained coverage under an alternative NPDES permit.
B. Facility Operator Information
1. Name:
2. IRS Employer Identification Number (EIN):
–
3. Mailing Address:
a. Street:
c. State:
b. City:
e. Phone:
-
-
f. Fax
(optional):
-
-
d. Zip Code:
-
g. E-mail: ____________________________________________
C. Facility Information
1. Facility Name:
2. Location Address:
a. Street
b. City:
c. County or similar government subdivision:
d. State:
e. Zip Code:
-
D. Certifier Name and Title
I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A.2 above. I understand that by submitting this
Notice of Termination, I am no longer authorized to discharge stormwater associated with industrial activity under this general permit, and that discharging pollutants in
stormwater associated with industrial activity to waters of the United States is unlawful under the Clean Water Act where the discharge is not authorized by a NPDES
permit. I also understand that the submittal of this Notice of Termination does not release an operator from liability for any violations of this permit or the Clean Water
Act.
Print Name:
Title:
Signature:
Date:
E-mail: ___________________________________________________________________________________________
EPA FORM 3510-7 (Revised 09-2008)
Page 1 of 2
Instructions for Completing the Notice of Termination for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the Multi-Sector General Permit
(MSGP)
Who May File Notice of Termination (NOT) Form
Section B. Facility Operator Information
Permittees currently covered by EPA’s NPDES Stormwater Multi-Sector General
Permit may submit a Notice of Termination (NOT) form. You must submit an NOT
within 30 days after one or more of the following conditions have been met:
1. Give the legal name of the person, firm, public organization, or any other entity that
operates the facility described in this application. The operator of the facility is the
legal entity which controls the facility’s operation, rather than the plant or site manager.
Do not use a colloquial name.
• a new owner or operator has assumed responsibility for the facility; or
• you have ceased operations at the facility and there are not or no longer will be
discharges of stormwater associated with industrial activity from the facility, and
you have already implemented necessary sediment and erosion controls as
required by Part 2.1.2.5;
• you are a Sector G, H, or J facility and you have met the applicable termination
requirements; or
• you have obtained coverage under an individual or alternative general permit for
all discharges required to be covered by an NPDES permit.
See the MSGP Part 1.4 for more information.
Where to File NOT form
EPA encourages you to complete the NOT form online, via the Internet. The Electronic
Notice of Intent System (eNOI) is found at www.epa.gov/npdes/eNOI. If you cannot
access the electronic system, you must send the NOT to the address listed below.
NOTs sent regular mail:
Stormwater Notice of Termination (4203M)
USEPA
1200 Pennsylvania Avenue, NW
Washington, D.C. 20460
NOTs sent overnight/express
Stormwater Notice of Termination
US EPA East Building, Rm 7420
1201 Constitution Avenue, NW
Washington, D.C. 20004
(202) 564-9545
Completing the Form
To complete this form, type or print in uppercase letters in the appropriate areas only.
Please make sure you complete all questions. Make sure you make a photocopy for
your records before you send the completed original form to the address above.
Please use ink when you sign the original document – DO NOT send copies. If you
have any questions about this form, you may call the EPA’s Stormwater Notice
Processing Center at (866) 352-7755.
2-3. Enter the facility operator’s IRS Employer Identification Number (also know as the
tax payer ID number). Enter the complete mailing address, email address and
telephone number of the operator. This address will be used for any future
correspondence between EPA and the facility operator.
Section C. Facility Information
1-2. Enter the facility’s official or legal name and complete address, including city,
county or similar government subdivision, state, and ZIP code.
Section D. Certification
Certification statement and signature (see Section B.11 of Appendix B of the MSGP for
more information). Enter certifier’s printed name, title and email address. Sign and
date the form. Federal statutes provide for severe penalties for submitting false
information on this application form. Federal 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 the principal
business function, or any other person who performs similar policy or decision making
functions, or (ii) the manager of one or more manufacturing, production, or operating
facilities employing more than 250 persons or having gross annual sales or
expenditures exceeding $25 million (in second-quarter 1980 dollars), if 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 municipality State, Federal, or other facility: by either a principal executive office
or ranking elected official.
Paperwork Reduction Act Notice
Public reporting burden for this application is estimated to average 0.5 hours per
application, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding the burden estimate, any other
aspect of the collection of information, or suggestions for improving this form, including
any suggestions which may increase or reduce this burden to: Director, Office of
Section A. Permit Information
Environmental Information Services, Collection Services Division (2823), USEPA, 1200
1. Enter the NPDES tracking number assigned by EPA’s Stormwater Notice Processing Pennsylvania Avenue, NW, Washington, DC 20460. Include the OMB control number
Center to the facility. If you do not know the tracking number, you can find the tracking of this form on any correspondence. Do not send the completed NOT form to this
address.
number assigned to your previous NOI on EPA’s NOI Search website
(www.epa.gov/npdes/noisearch).
2. Indicate your reason for submitting this Notice of Termination by checking the
appropriate box (see MSGP Part 1.4 for more information).
EPA FORM 3510-7 (Revised 09-2008)
Page 2 of 2
General Permit
Appendix E - Notice of Intent Form and Instructions
From the effective date of this permit, operators are to use the Notice of Intent Form
contained in this Appendix to obtain permit coverage.
Small and Large Construction Activities
E-1
This Form Replaces Form 3510-9 (8-98)
Refer to the Following Pages for Instructions
Form Approved OMB Nos. 2040-0188 and 2040-0211
United States Environmental Protection Agency
Washington, DC 20460
Notice of Intent (NOI) for Storm Water Discharges Associated with
Construction Activity Under an NPDES General Permit
NPDES
FORM
Submission of this Notice of Intent (NOI) constitutes notice that the party identified in Section II of this form requests authorization to
discharge pursuant to the NPDES Construction General Permit (CGP) permit number identified in Section I of this form. Submission of this
NOI also constitutes notice that the party identified in Section II of this form meets the eligibility requirements of the CGP for the project
identified in Section III of this form. Permit coverage is required prior to commencement of construction activity until you are eligible to
terminate coverage as detailed in the CGP. To obtain authorization, you must submit a complete and accurate NOI form. Refer to the
instructions at the end of this form.
I. Permit Number
II. Operator Information
Name:
IRS Employer Identification Number (EIN):
–
Mailing Address:
Street:
State:
City:
-
Phone:
-
Fax (optional):
-
-
Zip Code:
-
E-mail:
III. Project/Site Information
Project/Site Name:
Project Street/Location:
City:
State:
-
Zip Code:
County or similar government subdivision:
Latitude/Longitude (Use one of three possible formats, and specify method)
Latitude 1. __ __° __ __΄ __ __˝ N (degrees, minutes, seconds)
Method:
Longitude 1. __ __ __° __ __΄ __ __˝ W (degrees, minutes, seconds)
2. __ __° __ __. __ __΄ N (degrees, minutes, decimal)
2. __ __ __° __ __. __ __΄ W (degrees, minutes, decimal)
3. __ __. __ __ __ __° N ( degrees decimal)
3. __ __ __. __ __ __ __° W (degrees decimal)
U.S.G.S. topographic map
EPA web site
GPS
Other:
If you used a U.S.G.S. topographic map, what was the scale? ________________________________________________________
Project located in Indian Country?
YES
NO
If yes, name of reservation, or if not part of a reservation, put “Not Applicable:” ___________________________________________
/
Estimated Project Start Date:
Month
/
Day
Year
Estimated Area to be Disturbed (to the nearest quarter acre):
EPA FORM 3510-9 (Rev. 11/2008)
/
Estimated Project Completion Date:
Month
/
Day
Year
.
Page 1 of 4
IV. SWPPP Information
Has the SWPPP been prepared in advance of filing this NOI?
YES
Address in Section II
Location of SWPP for Viewing:
If other:
NO
Address in Section III
Other
SWPPP Street:
City:
State:
-
Zip Code:
SWPPP Contact Information (if different than that in Section II):
Name:
-
Phone:
-
Fax (optional):
-
-
E-mail:
V. Discharge Information
Identify the name(s) of waterbodies to which you discharge. ___________________________________________________________________
___________________________________________________________________________________________________________________
Is this discharge consistent with the assumptions and requirements of applicable EPA approved or established TMDL(s)?
YES
NO
VI. Endangered Species Protection
Under which criterion of the permit have you satisfied your ESA eligibility obligations?
A
B
C
D
E
F
If you select criterion F, provide permit tracking number of operator under which you are certifying eligibility:
VII. Certification Information
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.
Print Name:
Title:
Signature: _____________________________________________________________________________ Date:
E-mail: ________________________________________________________________________________
NOI Preparer (Complete if NOI was prepared by someone other than the certifier)
Prepared by:
Organization:
Phone:
-
-
EPA FORM 3510-9 (Rev. 11/2008)
Ext.
E-mail:
Page 2 of 4
Instructions for Completing EPA Form 3510-9
Notice of Intent (NOI) for Storm Water Discharges Associated with
Construction Activity Under an NPDES General Permit
NPDES Form Date
This Form Replaces Form 3510-9 (8/98)
Who Must File an NOI Form
Under the provisions of the Clean Water Act, as amended (33
U.S.C. 1251 et. seq.; the Act), federal law prohibits storm
water discharges from certain construction activities to waters
of the U.S. unless that discharge is covered under a National
Pollutant Discharge Elimination System (NPDES) Permit.
Operator(s) of construction sites where one or more acres are
disturbed, smaller sites that are part of a larger common plan
of development or sale where there is a cumulative
disturbance of at least one acre, or any other site specifically
designated by the Director, must submit an NOI to obtain
coverage under an NPDES general permit. Each person, firm,
public organization, or any other entity that meets either of the
following criteria must file this form: (1) they have operational
control over construction plans and specifications, including
the ability to make modifications to those plans and
specifications; or (2) they have day-to-day operational control
of those activities at the project necessary to ensure
compliance with SWPPP requirements or other permit
conditions. If you have questions about whether you need an
NPDES storm water permit, or if you need information to
determine whether EPA or your state agency is the permitting
authority, refer to www.epa.gov/npdes/stormwater/cgp or
telephone the Storm Water Notice Processing Center at (866)
352-7755.
Where to File NOI Form
See the applicable CGP for information on where to send your
completed NOI form.
Completing the Form
Obtain and read a copy of the appropriate EPA Storm Water
Construction General Permit for your area. To complete this
form, type or print 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 one space for breaks
between words, but not for punctuation marks unless they are
needed to clarify your response. If you have any questions on
this form, refer to www.epa.gov/npdes/stormwater/cgp or
telephone the Storm Water Notice Processing Center at (866)
352-7755. Please submit original document with signature in
ink . do not send a photocopied signature.
Form Approved OMB Nos. 2040-0188 and 2040-0211
IRS), also commonly referred to as your taxpayer ID. If the
applicant does not have an EIN enter “NA” in the space
provided. Also provide the operator’s mailing address,
telephone number, fax number (optional) and e-mail address
(to be notified via e-mail of NOI approval when available).
Correspondence for the NOI will be sent to this address.
Section III. Project/Site Information
Enter the official or legal name and complete street address,
including city, state, zip code, and county or similar
government subdivision of the project or site. If the project or
site lacks a street address, indicate the general location of the
site (e.g., Intersection of State Highways 61 and 34).
Complete site information must be provided for permit
coverage to be granted.
The applicant must also provide the latitude and longitude of
the facility either in degrees, minutes, seconds; degrees,
minutes, decimal; or decimal format. The latitude and longitude
of your facility can be determined in several different ways,
including through the use of global positioning system (GPS)
receivers, U.S. Geological Survey (U.S.G.S.) topographic or
quadrangle maps, and EPA’s web-based siting tools, among
others. Refer to www.epa.gov/npdes/stormwater/cgp for further
guidance on the use of these methodologies. For consistency,
EPA requests that measurements be taken from the
approximate center of the construction site. Applicants must
specify which method they used to determine latitude and
longitude. If a U.S.G.S. topographic map is used, applicants are
required to specify the scale of the map used.
Indicate whether the project is in Indian country, and if so,
provide the name of the Reservation. If the project is in Indian
Country Lands that are not part of a Reservation, indicate “not
applicable” in the space provided.
Enter the estimated construction start and completion dates
using four digits for the year (i.e., 05/27/1998). Enter the
estimated area to be disturbed including but not limited to:
grubbing, excavation, grading, and utilities and infrastructure
installation. Indicate to the nearest quarter acre. Note: 1 acre
= 43,560 sq. ft.
Section I. Permit Number
Provide the number of the permit under which you are
applying for coverage (see Appendix B of the general permit
for the list of eligible permit numbers).
Section IV. SWPPP Information
Indicate whether or not the SWPPP was prepared in advance
of filing the NOI form. Check the appropriate box for the
location where the SWPPP may be viewed. Provide the
name, fax number (optional), and e-mail address of the
contact person if different than that listed in Section II of the
NOI form.
Section II. Operator Information
Provide the legal name of the person, firm, public
organization, or any other entity that operates the project
described in this application. An operator of a project is a legal
entity that controls at least a portion of site operations and is
not necessarily the site manager. Provide the employer
identification number (EIN from the Internal Revenue Service;
Section V. Discharge Information
Enter the name(s) of receiving waterbodies to which the
project’s storm water will discharge. These should be the first
bodies of water that the discharge will reach. (Note: If you
discharge to more than one waterbody, please indicate all
such waters in the space provided and attach a separate
sheet if necessary.) For example, if the discharge leaves your
EPA FORM 3510-9 (Rev. 11/2008)
Page 3 of 4
Instructions for Completing EPA Form 3510-9
Notice of Intent (NOI) for Storm Water Discharges Associated with
Construction Activity Under an NPDES General Permit
NPDES Form Date
This Form Replaces Form 3510-9 (8/98)
site and travels through a roadside swale or a storm sewer
and then enters a stream that flows to a river, the stream
would be the receiving waterbody. Waters of the U.S. include
lakes, streams, creeks, rivers, wetlands, impoundments,
estuaries, bays, oceans, and other surface bodies of water
within the confines of the U.S. and U.S. coastal waters.
Waters of the U.S. do not include man-made structures
created solely for the purpose of wastewater treatment. U.S.
Geological Survey topographical maps may be used to make
this determination. If the map does not provide a name, use a
format such as “unnamed tributary to Cross Creek”. If you
discharge into a municipal separate storm sewer system
(MS4), you must identify the waterbody into which that portion
of the storm sewer discharges. That information should be
readily available from the operator of the MS4.
Indicate whether your storm water discharges from
construction activities will be consistent with the assumptions
and requirements of applicable EPA approved or established
TMDL(s).
To
answer
this
question,
refer
to
www.epa.gov/npdes/stormwater/cgp for state- and regionalspecific TMDL information related to the construction general
permit. You may also have to contact your EPA regional office
or state agency. If there are no applicable TMDLs or no
related requirements, please check the “yes” box in the NOI
form.
Section VI. Endangered Species Information
Indicate for which criterion (i.e., A, B, C, D, E, or F) of the
permit the applicant is eligible with regard to protection of
federally listed endangered and threatened species, and
designated critical habitat. See Part 1.3.C.6 and Appendix C
of the permit. If you select criterion F, provide the permit
tracking number of the operator under which you are certifying
eligibility. The permit tracking number is the number assigned
to the operator by the Storm Water Notice Processing Center
after EPA acceptance of a complete NOI.
Section VII. Certification Information
All applications, including NOIs, must be signed as follows:
For a corporation: By a responsible corporate officer. For the
purpose of this Section, a responsible corporate officer
means:
(i) a 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
EPA FORM 3510-9 (Rev. 11/2008)
Form Approved OMB Nos. 2040-0188 and 2040-0211
delegated to the manager in accordance with corporate
procedures.
For a partnership or sole proprietorship: By a general partner
or the proprietor, respectively; or
For a municipality, state, federal, or other public agency: By
either a principal executive officer or ranking elected official.
For purposes of this Part, a principal executive officer of a
federal agency includes (i) the chief executive officer of the
agency, or (ii) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrator of EPA).
Include the name, title, and email address of the person
signing the form and the date of signing. An unsigned or
undated NOI form will not be considered eligible for permit
coverage. If the NOI was prepared by someone other than the
certifier (for example, if the NOI was prepared by the facility
SWPPP contact or a consultant for the certifier’s signature),
include the name, organization, phone number and email
address of the NOI preparer.
Paperwork Reduction Act Notice
Public reporting burden for this application is estimated to
average 3.7 hours. This estimate includes time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid
OMB control number. Send comments regarding the burden
estimate, any other aspect of the collection of information, or
suggestions for improving this form, including any suggestions
which may increase or reduce this burden to: Chief,
Information Policy Branch 2136, U.S. Environmental
Protection, Agency, 1200 Pennsylvania Avenue, NW,
Washington, D.C. 20460. Include the OMB control number on
any correspondence. Do not send the completed form to this
address.
Visit this website for mailing instructions:
www.epa.gov/npdes/stormwater/mail
Visit this website for instructions on how to submit
electronically:
www.epa.gov/npdes/stormwater/enoi
Page 4 of 4
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NPDES
FORM
3510-11
Form Approved
OMB No. 2040-0211
NO EXPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORMWATER
PERMITTING
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its
stormwater discharges associated with industrial activity in the State identified in Section B under EPA’s Stormwater Multi Sector General Permit
due to the existence of a condition of no exposure.
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to
prevent exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment
or activities, industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities
include the storage, loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product.
A storm resistant shelter is not required for the following industrial materials and activities:
– drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. “Sealed”
means banded or otherwise secured and without operational taps or valves;
– adequately maintained vehicles used in material handling; and
– final products, other than products that would be mobilized in stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES
permitting is available on a facility-wide basis only, not for individual outfalls. If any industrial activities or materials are or will be exposed to
precipitation, the facility is not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility
or site, and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM.
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4.
A. Facility Operator Information
1.
Name:
-
2. Phone:
-
3. Email:
4. Mailing Address:
a. Street
c. State
b. City:
d. Zip Code:
–
B. Facility/Site Location Information
1. Facility Name:
2. a. Street Address:
c. County:
b. City:
–
e. Zip Code:
d. State:
3. Is the facility located on Indian Lands?
YES
NO
4. Is this a Federal facility?
YES
NO
5. a. Latitude:
°
'
"
b. Longitude:
°
'
6. a. Was the facility or site previously covered under an NPDES stormwater permit?
"
YES
NO
b. If yes, enter NPDES permit number or tracking number:
7. SIC/Activity Codes:
Secondary
(if applicable):
Primary:
8. Total size of site associated with industrial activity:
acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion?
YES
NO
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no
exposure exclusion. However, your permitting authority may use this information in considering whether stormwater discharges from your site
are likely to have an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre
EPA Form 3510-11 (09-08)
One to five acres
More than five acres
Page 1 of 4
C.
Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either “Yes” or “No” in the appropriate box.) If you answer “Yes” to any of these questions
(1) through (11), you are not eligible for the no exposure exclusion.
Yes
No
1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing or cleaning
industrial machinery or equipment remain and are exposed to stormwater
2. Materials or residuals on the ground or in stormwater inlets from spills/leaks
3. Materials or products from past industrial activity
4. Material handling equipment (except adequately maintained vehicles)
5. Materials or products during loading/unloading or transporting activities
6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
exposure to stormwater does not result in the discharge of pollutants)
7. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
8. Materials or products handled/stored on roads or railways owned or maintained by the discharger
9. Waste material (except waste in covered, non leaking containers [e.g., dumpsters])
10. Application or disposal of process wastewater (unless otherwise permitted)
11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(i.e., under an air quality control permit) and evident in the stormwater outflow
D. Certification Statement
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of “no exposure” and obtaining
an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities or materials from the
industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, if
requested, to the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I
understand that I must allow the NPDES permitting authority, or MS4 operator where the discharge is into the local MS4, to perform inspections
to confirm the condition of no exposure and to make such inspection reports publicly available upon request. I understand that I must obtain
coverage under an NPDES permit prior to any point source discharge of stormwater from the facility.
Additionally, 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.
Print Name:
Print Title:
Signature:
Date:
/
Mo
/
Day
Year
Email:
EPA Form 3510-11 (09-08)
Page 2 of 4
Instructions for the NO EXPOSURE CERTIFICATION for Exclusion from NPDES Stormwater Permitting
Who May File a No Exposure Certification
Section B. Facility/Site Location Information
Federal law at 40 CFR Part 122.26 prohibits point source
discharges of stormwater associated with industrial activity to waters
of the U.S. without a National Pollutant Discharge Elimination
System (NPDES) permit. However, NPDES permit coverage is not
required for discharges of stormwater associated with industrial
activities identified at 40CFR 122.26(b)(14)(i)-(ix) and (xi) if the
discharger can certify that a condition of “no exposure” exists at the
industrial facility or site.
1. Enter the official or legal name of the facility or site.
Stormwater discharges from construction activities identified in
40 CFR 122.26(b)(14)(x) and (b)(15) are not eligible for the no
exposure exclusion.
4. Indicate whether the industrial facility is operated by a
department or agency of the Federal Government (see also
Section 313 of the Clean Water Act).
Obtaining and Maintaining the No Exposure Exclusion
This form is used to certify that a condition of no exposure exists at
the industrial facility or site described herein. This certification is only
applicable in jurisdictions where EPA is the NPDES permitting
authority and must be re-submitted at least once every five years.
The industrial facility operator must maintain a condition of no
exposure at its facility or site in order for the no exposure exclusion
to remain applicable. If conditions change resulting in the exposure
of materials and activities to stormwater, the facility operator must
obtain coverage under an NPDES stormwater permit immediately.
Where to File the No Exposure Certification Form
No Exposure Forms sent regular mail:
Forms sent overnight/express:
SW No Exposure Certification (4203M)
SW No Exposure Certification
USEPA
US EPA East Building, Rm. 7420
1200 Pennsylvania Avenue, NW
1201 Constitution Avenue, NW
Washington, D.C. 20460
Washington, D.C. 20004
(202) 564-9545
Completing the Form
You must type or print, using uppercase letters, in appropriate areas
only. Enter only one character per space (i.e., between the marks).
Abbreviate if necessary to stay within the number of characters
allowed for each item. Use one space for breaks between words.
One form must be completed for each facility or site for which you
are seeking to certify a condition of no exposure. Additional
guidance on completing this form can be accessed at EPA’s
website: www.epa.gov/npdes/stormwater. Please make sure you
have addressed all applicable questions and have made a
photocopy for your records before sending the completed form to
the above address.
Section A. Facility Operator Information
1. Provide the legal name of the person, firm, public organization, or
any other entity that operates the facility or site described in this
certification. The name of the operator may or may not be the
same as the name of the facility. The operator is the legal entity
that controls the facility’s operation, rather than the plant or site
manager.
2. Provide the telephone number of the facility operator.
3. Provide the email address of the facility operator.
4. Provide the mailing address of the operator (P.O. Box numbers
may be used). Include the city, state, and zip code. All
correspondence will be sent to this address.
EPA Form 3510-11 (09-08)
2. Enter the complete street address (if no street address exists,
provide a geographic description [e.g., Intersection of Routes 9
and 55]), city, county, state, and zip code. Do not use a P.O.
Box number.
3. Indicate whether the facility is located on Indian Lands.
5. Enter the latitude and longitude of the approximate center of
the facility or site in degrees/minutes/seconds. Latitude and
longitude can be obtained from United States Geological
Survey (USGS) quadrangle or topographic maps, by calling
1-(888) ASK-USGS, or by accessing the Census Bureau at:
www.census.gov/cgi-bin/gazetteer
Latitude and longitude for a facility in decimal form must be
converted to degrees (°), minutes ('), and seconds (") for proper
entry on the certification form. To convert decimal latitude or
longitude to degrees/minutes/seconds, follow the steps in the
following example.
Example: Convert decimal latitude 45.1234567 to degrees (°),
minutes ('), and seconds (").
a) The numbers to the left of the decimal point are the degrees:
45°.
b) To obtain minutes, multiply the first four numbers to the right
of the decimal point by 0.006: 1234 x 0.006 = 7.404.
c) The numbers to the left of the decimal point in the result
obtained in (b) are the minutes: 7'.
d) To obtain seconds, multiply the remaining three numbers to
the right of the decimal from the result obtained in (b) by
0.06: 404 x 0.06 = 24.24. Since the numbers to the right of
the decimal point are not used, the result is 24".
e) The conversion for 45.1234567 = 45° 7' 24".
6. Indicate whether the facility was previously covered under an
NPDES stormwater permit. If so, include the permit number or
permit tracking number.
7. Enter the 4-digit SIC code which identifies the facility’s primary
activity and second 4-digit SIC code identifying the facility’s
secondary activity, if applicable. SIC codes can be obtained
from the Standard Industrial Classification Manual, 1987.
8. Enter the total size of the site associated with industrial activity
in acres. Acreage may be determined by dividing square
footage by 43,560, as demonstrated in the following example.
Example: Convert 54,450 ft2 to acres
Divide 54,450 ft2 by 43,450 square feet per acre:
54, 450 ft2 ) 43,560 ft2/acre = 1.25 acres.
9. Check “Yes” or “No” as appropriate to indicate whether you have
paved or roofed over a formerly exposed, pervious area (i.e.,
lawn, meadow, dirt or gravel road/parking lot) in order to qualify
for no exposure. If yes, also indicate approximately how much
area was paved or roofed over and is now impervious area.
Page 3 of 4
Instructions for the NO EXPOSURE CERTIFICATION for Exclusion from NPDES Stormwater Permitting
Section C. Exposure Checklist
Check “Yes” or “No” as appropriate to describe the exposure
condition at your facility. If you answer “Yes” to ANY of the
questions (1) through (11) in this section, a potential for exposure
exists at your site and you cannot certify to a condition of no
exposure. You must obtain (or already have) coverage under an
NPDES stormwater permit. After obtaining permit coverage, you
can institute modifications to eliminate the potential for a discharge
of stormwater exposed to industrial activity, and then certify to a
condition of no exposure.
Section D. Certification Statement
Federal statutes provide for severe penalties for submitting false
information on this application form. Federal 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
EPA Form 3510-11 (09-08)
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.
Paperwork Reduction Act Notice
Public reporting burden for this certification is estimated to average
1.0 hour per certification, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of
information. Burden means the total time, effort, or financial
resources expended by persons to generate, maintain, retain, or
disclose to provide information to or for a Federal agency. This
includes the time needed to review instructions; develop, acquire,
install, and utilize technology and systems for the purposes of
collecting, validating, and verifying information, processing and
maintaining information, and disclosing and providing information;
adjust the existing ways to comply with any previously applicable
instructions and requirements; train personnel to be able to
respond to a collection of information; search data sources;
complete and review the collection of information; and transmit or
otherwise disclose the information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
Send comments regarding the burden estimate, any other aspect
of the collection of information, or suggestions for improving this
form, including any suggestions which may increase or reduce this
burden to: Director, OPPE Regulatory Information Division (2137),
USEPA, 401 M Street, SW, Washington, D.C. 20460. Include the
OMB control number of this form on any correspondence. Do not
send the completed No Exposure Certification form to this address.
Page 4 of 4
This Form Replaces Form 3517-7 (8-98)
Form Approved OMB Nos. 2040-0086 and 2040-0211
Refer to the Following Page for Instructions
United States Environmental Protection Agency
Washington, DC 20460
Notice of Termination (NOT) of Coverage Under an NPDES General Permit for
Stormwater Discharges Associated with Construction Activity
NPDES
FORM
Submission of this Notice of Termination constitutes notice that the party identified in Section II of this form is no longer authorized to
discharge stormwater associated with construction activity under the NPDES program from the site identified in Section III of this form. All
necessary information must be included on this form. Refer to the instructions at the end of this form.
I. Permit Information
NPDES Stormwater General Permit Tracking Number:
Reason for Termination (Check only one):
Final stabilization has been achieved on all portions of the site for which you are responsible.
Another operator has assumed control, according to Appendix G, Section 11.C of the CGP, over all areas of the site that have not been
finally stabilized.
Coverage under an alternative NPDES permit has been obtained.
For residential construction only, temporary stabilization has been completed and the residence has been transferred to the homeowner.
II. Operator Information
Name:
IRS Employer Identification Number (EIN):
–
Mailing Address:
Street:
City:
Phone:
-
-
Fax (optional):
-
State:
Zip Code:
-
State:
Zip Code:
-
-
E-mail:
III. Project/Site Information
Project/Site Name:
Project Street/Location:
City:
County or similar government subdivision:
IV. Certification Information
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.
Print Name: ______________________________________________________________________________________________________
Print Title: ________________________________________________________________________________________________________
Email: __________________________________________________________________________________________________________
Signature: _______________________________________________________________________________________________________
Date: ___________________________________________________________________________________________________________
EPA Form 3510-13 (Rev. 12/08)
Page 1 of 2
Instructions for Completing EPA Form 3510-13
Notice of Termination (NOT) of Coverage Under an NPDES General Permit for
Stormwater Discharges Associated with Construction Activity
NPDES Form
This Form Replaces Form 3517-7 (8-98)
Who May File an NOT Form
Permittees who are presently covered under the EPA-issued National
Pollutant Discharge Elimination System (NPDES) General Permit for
Stormwater Discharges Associated with Construction Activity may
submit an NOT form when final stabilization has been achieved on all
portions of the site for which you are responsible; another operator has
assumed control in accordance with Appendix G, Section 11.C of the
General Permit over all areas of the site that have not been finally
stabilized; coverage under an alternative NPDES permit has been
obtained; or for residential construction only, temporary stabilization
has been completed and the residence has been transferred to the
homeowner.
“Final stabilization” means that all soil disturbing activities at the site
have been completed and that a uniform perennial vegetative cover
with a density of at least 70% of the native background vegetative
cover for the area has been established on all unpaved areas and
areas not covered by permanent structures, or equivalent permanent
stabilization measures (such as the use of riprap, gabions, or
geotextiles) have been employed. See “final stabilization” definition in
Appendix A of the Construction General Permit for further guidance
where background native vegetation covers less than 100 percent of
the ground, in arid or semi-arid areas, for individual lots in residential
construction, and for construction projects on land used for agricultural
purposes.
Completing the 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. If
you have any questions about this form, refer to
www.epa.gov/npdes/stormwater/cgp or telephone the Stormwater
Notice Processing Center at (866) 352-7755. Please submit original
document with signature in ink - do not send a photocopied signature.
Section I. Permit Number
Enter the existing NPDES Stormwater General Permit Tracking
Number assigned to the project by EPA’s Stormwater Notice
Processing Center. If you do not know the permit tracking number,
refer to www.epa.gov/npdes/stormwater/cgp or contact the Stormwater
Notice Processing Center at (866) 352-7755.
Indicate your reason for submitting this Notice of Termination by
checking the appropriate box. Check only one:
Final stabilization has been achieved on all portions of the site for
which you are responsible.
Another operator has assumed control according to Appendix G,
Section 11.C over all areas of the site that have not been finally
stabilized.
Coverage under an alternative NPDES permit has been obtained.
For residential construction only, if temporary stabilization has
been completed and the residence has been transferred to the
homeowner.
Section II. Operator Information
Provide the legal name of the person, firm, public organization, or any
other entity that operates the project described in this application and
is covered by the permit tracking number identified in Section I. The
operator of the project is the legal entity that controls the site operation,
rather than the site manager. Provide the employer identification
number (EIN from the Internal Revenue Service; IRS). If the applicant
EPA Form 3510-13 (Rev. 12/08)
Form Approved OMB Nos. 2040-0086 and 2040-0211
does not have an EIN enter “NA” in the space provided. Enter the
complete mailing address, telephone number, and email address of
the operator. Optional: enter the fax number of the operator.
Section III. Project/Site Information
Enter the official or legal name and complete street address,
including city, state, zip code, and county or similar government
subdivision of the project or site. If the project or site lacks a street
address, indicate the general location of the site (e.g., Intersection of
State Highways 61 and 34). Complete site information must be
provided for termination of permit coverage to be valid.
Section IV. Certification Information
All applications, including NOIs, must be signed as follows:
For a corporation: By a responsible corporate officer. For the
purpose of this Part, a responsible corporate officer means: (i) a
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, respectively; or
For a municipality, state, federal, or other public agency: By either a
principal executive officer or ranking elected official. For purposes of
this Part, a principal executive officer of a federal agency includes (i)
the chief executive officer of the agency, or (ii) a senior executive
officer having responsibility for the overall operations of a principal
geographic unit of the agency (e.g., Regional Administrator of EPA).
Include the name, title, and email address of the person signing the
form and the date of signing. An unsigned or undated NOT form will
not be considered valid termination of permit coverage.
Paperwork Reduction Act Notice
Public reporting burden for this application is estimated to average
0.5 hours per notice, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding the burden
estimate, any other aspect of the collection of information, or
suggestions for improving this form including any suggestions which
may increase or reduce this burden to: Chief, Information Policy
Branch, 2136, U.S. Environmental Protection Agency, 1200
Pennsylvania Avenue, NW, Washington, DC 20460. Include the
OMB number on any correspondence. Do not send the completed
form to this address.
Visit this website for mailing instruction:
www.epa.gov/npdes/stormwater/mail
Visit this website for instructions on how to submit electronically:
www.epa.gov/npdes/stormwater/enoi
Page 2 of 2
APPENDIX J
NPDES COMPLIANCE INSPECTION REPORT
FORM 3560-3
Revised April 2006
This page intentionally left blank.
United States Environmental Protection Agency
Washington, D.C. 20460
Water Compliance Inspection Report
Section A: National Data System Coding (i.e., PCS)
Transaction Code
1
NPDES
2 5
yr/mo/day
3
11
Inspection Type
12
17
18
Inspector
Fac Type
19
20
Remarks
21
66
Inspection Work Days
67
!
Facility Self-Monitoring Evaluation Rating
69
BI
70
QA
71
72
-----------------------------Reserved--------------------------
73
74
75
80
Section B: Facility Data
Name and Location of Facility Inspected (For industrial users discharging to POTW, also
include POTW name and NPDES permit number)
Name(s) of On-Site Representative(s)/Title(s)/Phone and Fax Number(s)
Entry Time/Date
Permit Effective Date
Exit Time/Date
Permit Expiration Date
Other Facility Data (e.g., SIC NAICS, and other
descriptive information)
Name, Address of Responsible Official/Title/Phone and Fax Number
Co n t ac t e d
G Yes G No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit
Self-Monitoring Program
Pretreatment
Records/Reports
Compliance Schedules
Pollution Prevention
Facility Site Review
Laboratory
Storm Water
Effluent/Receiving Waters
Operations & Maintenance
Combined Sewer Overflow
Flow Measurement
Sludge Handling/Disposal
Sanitary Sewer Overflow
MS4
Section D: Summary of Findings/Comments
(Attach additional sheets of narrative and checklists, including Single Event Violation codes, as necessary)
SEV Codes
99999
99999
99999
99999
SEV Description
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Name(s) and Signature(s) of Inspector(s)
Agency/Office/Phone and Fax Numbers
Date
Signature of Management Q A Reviewer
Agency/Office/Phone and Fax Numbers
Date
EPA Form 3560-3 (Rev 4-06) Previous editions are obsolete.
INSTRUCTIONS
Section A: National Data System Coding (i.e., PCS)
Column 1: Transaction Code: Use N, C, or D for New, Change, or Delete. All inspections will be new unless there is an error in the data entered.
Columns 3-11: NPDES Permit No. Enter the facility's NPDES permit number - third character in permit number indicates permit type for U=unpermitted,
G=general permit, etc.. (Use the Remarks columns to record the State permit number, if necessary.)
Columns 12-17: Inspection Date. Insert the date entry was made into the facility. Use the year/month/day format (e.g., 04/10/01 = October 01, 2004).
Column 18: Inspection Type*. Use one of the codes listed below to describe the type of inspection:
A
B
C
D
F
G
I
J
M
N
O
P
R
S
Performance Audit
Compliance Biomonitoring
Compliance Evaluation (non-sampling)
Diagnostic
Pretreatment (Follow-up)
Pretreatment (Audit)
Industrial User (IU) Inspection
Complaints
Multimedia
Spill
Compliance Evaluation (Oversight)
Pretreatment Compliance Inspection
Reconnaissance
Compliance Sampling
U
X
Z
#
$
+
&
\
=
2
3
4
5
6
7
IU Inspection with Pretreatment Audit
Toxics Inspection
Sludge - Biosolids
Combined Sewer Overflow-Sampling
Combined Sewer Overflow-Non-Sampling
Sanitary Sewer Overflow-Sampling
Sanitary Sewer Overflow-Non-Sampling
CAFO-Sampling
CAFO-Non-Sampling
IU Sampling Inspection
IU Non-Sampling Inspection
IU Toxics Inspection
IU Sampling Inspection with Pretreatment
IU Non-Sampling Inspection with Pretreatment
IU Toxics with Pretreatment
!
Pretreatment Compliance (Oversight)
@
Follow-up (enforcement)
{
Storm Water-Construction-Sampling
}
Storm Water-Construction-Non-Sampling
:
Storm Water-Non-Construction-Sampling
~
<
>
Storm Water-Non-Construction
Non-Sampling
Storm Water-MS4-Sampling
Storm Water-MS4-Non-Sampling
Storm Water-MS4-Audit
Column 19: Inspector Code. Use one of the codes listed below to describe the lead agency in the inspection.
A—
B ---E—
J—
L ---N—
State (Contractor)
EPA (Contractor)
Corps of Engineers
Joint EPA/State Inspectors—EPA Lead
Local Health Department (State)
NEIC Inspectors
O— Other Inspectors, Federal/EPA (Specify in Remarks columns)
P— Other Inspectors, State (Specify in Remarks columns)
R — EPA Regional Inspector
S — State Inspector
T — Joint State/EPA Inspectors—State lead
Column 20: Facility Type. Use one of the codes below to describe the facility.
1—
2—
3—
4—
5—
Municipal. Publicly Owned Treatment Works (POTWs) with 1987 Standard Industrial Code (SIC) 4952.
Industrial. Other than municipal, agricultural, and Federal facilities.
Agricultural. Facilities classified with 1987 SIC 0111 to 0971.
Federal. Facilities identified as Federal by the EPA Regional Office.
Oil & Gas. Facilities classified with 1987 SIC 1311 to 1389.
Columns 21-66: Remarks. These columns are reserved for remarks at the discretion of the Region.
Columns 67-69: Inspection Work Days. Estimate the total work effort (to the nearest 0.1 work day), up to 99.9 days, that were used to complete the
inspection and submit a QA reviewed report of findings. This estimate includes the accumulative effort of all participating inspectors; any effort for laboratory
analyses, testing, and remote sensing; and the billed payroll time for travel and pre and post inspection preparation. This estimate does not require detailed
documentation.
Column 70: Facility Evaluation Rating. Use information gathered during the inspection (regardless of inspection type) to evaluate the quality of the facility
self-monitoring program. Grade the program using a scale of 1 to 5 with a score of 5 being used for very reliable self-monitoring programs, 3 being
satisfactory, and 1 being used for very unreliable programs.
Column 71: Biomonitoring Information. Enter D for static testing. Enter F for flow through testing. Enter N for no biomonitoring.
Column 72: Quality Assurance Data Inspection. Enter Q if the inspection was conducted as followup on quality assurance sample results. Enter N
otherwise.
Columns 73-80: These columns are reserved for regionally defined information.
Section B: Facility Data
This section is self-explanatory except for "Other Facility Data," which may include new information not in the permit or PCS (e.g., new outfalls, names of
receiving waters, new ownership, other updates to the record, SIC/NAICS Codes, Latitude/Longitude).
Section C: Areas Evaluated During Inspection
Check only those areas evaluated by marking the appropriate box. Use Section D and additional sheets as necessary. Support the findings, as necessary,
in a brief narrative report. Use the headings given on the report form (e.g., Permit, Records/Reports) when discussing the areas evaluated during the
inspection.
Section D: Summary of Findings/Comments
Briefly summarize the inspection findings. This summary should abstract the pertinent inspection findings, not replace the narrative report. Reference a
list of attachments, such as completed checklists taken from the NPDES Compliance Inspection Manuals and pretreatment guidance documents, including
effluent data when sampling has been done. Use extra sheets as necessary.
*Footnote: In addition to the inspection types listed above under column 18, a state may continue to use the following wet weather and CAFO inspection
types until the state is brought into ICIS-NPDES: K: CAFO, V: SSO, Y: CSO, W: Storm Water 9: MS4. States may also use the new wet weather, CAFO
and MS4 inspections types shown in column 18 of this form. The EPA regions are required to use the new wet weather, CAFO, and MS4 inspection types
for inspections with an inspection date (DTIN) on or after July 1, 2005.
Attachment 3
Single Event Violation Table
Single Event Violation Table Codes and Descriptions*
CODE
DESCRIPTION
CODE
Effluent Violations
DESCRIPTION
CSO
A0018
Approved Bypass
A0C18
Approved Bypass
A0013
Failed Toxicity Test
A0024
Dry weather overflow
Failure to Develop Adequate LTCP
A0023
Industrial Spill
B0030
A0017
Inspection sample above historic DMR range
B0031
Failure to Implement LTCP
A0022
Narrative Effluent Violation
B0029
Failure to Implement Nine Minimum Controls (NMCs)
A0012
Numeric effluent violation
BC291
Failure to implement required NMC #1(Proper operation and maintenance)
A0016
Reported Fish Kill
BC292
A0011
Unapproved Bypass
BC293
Failure to implement required NMC #2 (Maximum use of the collection
system)
Failure to implement required NMC #3 (Review pretreatment
requirements)
A0015
Unauthorized Discharge of Brine
BC294
Failure to implement required NMC #4 (Maximization of flow)
Management Practice Violations
BC295
Failure to implement required NMC #5 (Elimination of dry weather flow)
B0019
Best Management Practice Deficiencies
BC296
Failure to implement required NMC #6 (Control of solids)
B0024
Biosolids/Sewage Sludge Violation (Part 503)
BC297
Failure to implement required NMC #7 (Pollution prevention programs)
B0026
Failure to Allow Entry
BC298
Failure to implement required NMC #8 (Public notification)
B0012
Failure to Conduct Inspections
BC299
Failure to implement required NMC #9 (Monitoring)
B0027
Failure to Develop Adequate SPCC Plan
B0C41
Failure to Maintain Records or Meet Record Keeping Requirements
B0017
Failure to develop any or adequate SWPPP/SWMP
C0C11
Failure to monitor
B0011
Failure to Develop/Enforce Standards
E0C16
Failure to submit required report (non-DMR)
B0028
Failure to Implement SPCC Plan
E0C13
Improper/Incorrect reporting
B0018
Failure to Implement SWPPP/SWMP
B0044
LTCP implementation schedule milestone missed
B0041
Failure to Maintain Records
A0C22
Narrative effluent violation
B0040
Improper Chemical Handling
E0C14
Noncompliance with section 308 Information Request
B0023
Improper Land Application (non-503, non-CAFO)
A0C12
Numeric effluent violation
B0020
Improper Operation and Maintenance
A0C11
Related Unapproved Bypass
B0025
Inflow/Infiltration (I/I)
A0021
Unauthorized CSO Discharge to Waters/Wet Weather
B0021
Laboratory Not Certified
A0025
Unauthorized overflow to dry land or building backup
B0022
No Licensed/Certified Operator
B0045
Violation of a milestone in a permit
B0042
Violation of a milestone in an order
B0C42
Violation of a milestone in an order
Monitoring Violations
SSO
C0017
Analysis not Conducted
A0S18
Approved Bypass
C0011
Failure to Monitor for non-Toxicity Requirements
A0020
Discharge to Waters
C0021
Failure to Monitor for Toxicity Requirements
D0S11
Discharge without a valid permit (includes satellite systems)
C0015
Frequency of Sampling Violation
B0S41
Failure to Maintain Records or Meet Record Keeping Requirements
C0018
Improper Analysis or Lab Error
C0S11
Failure to monitor
C0014
Invalid/Unrepresentative Sample
E0018
Failure to report other violation
C0016
No Flow Measurement Device
E0019
Failure to report violation that may endanger public health 122.41(l)(7)
D0S12
Failure to submit required permit application info (includes satellite
systems)
Permitting Violations
D0014
Application Incomplete
B0S20
Improper Operation and Maintenance
D0011
Discharge Without a Valid Permit
A0S22
Narrative effluent violation
D0012
Failure to Apply for a Permit
E0S14
Noncompliance with section 308 Information Request
D0015
Failure to Pay Fees
A0S12
Numeric effluent violation
D0016
Failure to Submit Timely Permit Renewal Application
A0026
Overflow to Dry Land or Building Backup
D0013
Unapproved Operation
A0S11
Related Unapproved Bypass
D0017
Violation Specified in Comment
BS42A
Violation of milestone in an administrative order
BS42J
Violation of milestone in judicial decree
B0046
Violation of sewer moratorium or restriction
Reporting Violations
Storm Water Construction
E0017
D0R11
Failure to Notify
1
Discharge without a permit
E0012
Failure to Submit DMRs
D0R18
Failure to apply for a notice of termination
E0016
Failure to submit required report (non-DMR, non-pretreatment)
B0R12
Failure to Conduct Inspections
E0013
Improper/ Incorrect Reporting
B0C17
Failure to develop any or adequate SWPPP/SWMP
E0011
Late Submittal of DMRs
B0C18
Failure to Implement SWPPP/SWMP
E0014
Noncompliance with Section 308 Information Request
B0R41
Failure to Maintain Records
Pretreatment
C0R11
Failure to Monitor
C0012
Baseline Monitoring Report Violation
BR19A
Failure to properly install/implement BMPs
B0P12
Failure to Conduct Inspections
BR19B
Failure to properly operate and maintain BMPs
B0P11
Failure to Develop/Enforce Standards
D0R12
Failure to submit required permit application information
B0013
Failure to Enforce Against I/U
E0R16
Failure to submit required report (non-DMR)
B0015
Failure to Establish Local Limits
A0R22
Narrative effluent violation
C0013
Failure to Establish Self-Monitoring Requirements
E0R14
Noncompliance with section 308 Information Request
B0014
Failure to Issue SIU Permits
A0R12
Numeric Effluent Violation
B0016
Failure to Meet Inspection and Sampling Plan for SIUs
B0R42
Violation of a milestone in an order
E0015
Failure to submit required report (non-DMR)
Storm Water MS4
B0P40
Improper Chemical Handling
D0M11
Discharge without a permit
A0014
IU Violation of Pretreatment Standards
D0M18
Failure to apply for a notice of termination
B0M12
CAFO
B0A19
Best Management Practice Deficiencies
B0M17
Failure to Conduct Inspections
Failure to develop any or adequate SWPPP/SWMP
B0038
Direct Animal Contact with Waters of US
B0M18
Failure to Implement SWPPP/SWMP
D0A11
Discharge without a permit
B0M41
Failure to Maintain Records or Meet Record Keeping
B0A12
Failure to Conduct Inspections
C0M11
Failure to Monitor
B0032
Failure to Develop any or adequate NMP
BM19A
Failure to properly install/implement BMPs
B0033
Failure to Implement NMP
BM19B
Failure to properly operate and maintain BMPs
B0A41
Failure to Maintain Records or Meet Record Keeping
Requirements
D0M12
Failure to submit required permit application information
B0043
Failure to meet order final compliance date
E0M16
Failure to submit required report (non-DMR)
C0A11
Failure to Monitor
A0M22
Narrative effluent violation
D0A12
Failure to submit required permit application information
E0M14
Noncompliance with section 308 Information Request
C0019
Failure to Test Manure
A0M12
Numeric Effluent Violation
B0A40
Improper Chemical Handling
B0M42
Violation of a milestone in an order
B0A23
Improper Land Application
Storm Water Non-Construction
B0039
Improper Manure Handling (not including land application)
D0N11
Discharge without a permit
B0037
Improper Mortality Management
D0N18
Failure to apply for a notice of termination
B0036
Improper O&M of Storage Facility
B0N12
Failure to Conduct Inspections
E0A13
Improper/Incorrect reporting
B0N17
Failure to develop any or adequate SWPPP/SWMP
B0034
Insufficient Buffers/Setbacks
B0N18
Failure to Implement SWPPP/SWMP
B0035
Insufficient Storage Capacity
B0N41
Failure to Maintain Records
A0A22
Narrative effluent violation
C0N11
Failure to Monitor
E0A16
No Annual Report Submitted
BN19A
Failure to properly install/implement BMPs
C0020
No Depth Marker
BN19B
Failure to properly operate and maintain BMPs
E0A14
Noncompliance with section 308 Information Request
D0N12
Failure to submit required permit application information
A0A12
Numeric effluent violation
E0N16
Failure to submit required report (non-DMR)
A0019
Production Area Runoff
A0N22
Narrative effluent violation
B0A42
Violation of a milestone in an order
E0N14
Noncompliance with section 308 Information Request
A0N12
Numeric Effluent Violation
B0N42
Violation of a milestone in an order
* N. B. The codes and code names listed herein may change over time. Please consult ICIS-NPDES and PCS system
documentation for updated lists.
2
This page intentionally left blank.
See page three for instructions
Form Approved OMB No. 2040-0211
United States Environmental Protection Agency
Washington, DC 20460
NPDES
FORM
Low Erosivity Waiver Certification
This form provides notice to EPA that you, the project operator identified in Section I of this form, are certifying that construction
activity at the project site identified in Section II, will take place during a period when the rainfall erosivity factor is less than five
[40 CFR 122.26(b)(15)(i)(A)]. By submitting a complete and accurate form, the otherwise applicable NPDES permitting
requirements for stormwater discharges associated with construction activity, are waived. Based on your certification, a waiver is
granted for the period beginning on the date this Low Erosivity Waiver Form is mailed to EPA (i.e., postmark date), or the project
start date specified in Part III of this form, whichever shall occur last, and ending on the project completion date specified in
Part III. Refer to the instructions at the end of this form for more details.
I. Operator Information
Company
Name:
–
IRS Employer Identification Number (EIN):
Mailing Address:
Street:
State:
City:
Zip Code:
-
Zip Code:
-
Contact Name:
Phone:
-
-
-
Fax (optional):
-
Email:
II. Construction Project/Site Information
Project/Site Name:
Project Street/Location:
State:
City:
County or similar government subdivision:
Latitude and Longitude (Use one of three formats given, and specify the source)
°
΄
˝ N
2. Degrees, minutes with 2 decimal places (e.g., 76° 30.75΄)
°
.
3. Degrees, minutes with 4 decimal places (e.g., 76.5125°)
.
1. Degrees, minutes, seconds (e.g., 76°, 30΄, 45˝)
• Lat/Lon source?
USGS topographic map
Latitude:
EPA Web siting tool
GPS
°
΄
˝ W
΄ N
°
.
΄ W
°N
.
Longitude:
° W
Other (specify source):
• If you used a USGS topographic map, what is the scale?
• Horizontal Reference Datum?
NAD 27
• Is the project located on Indian country?
NAD 83 or WGS 84
Yes
Unknown
No If yes, enter Indian reservation name
• Is the project a federal facility or part of a federal facility?
Yes
No
• Is the project located in the State of Oklahoma and associated with oil and gas exploration, drilling, operations, and pipelines
Yes
No
(includes SIC Groups 13 and 46, and SIC codes 492 and 5171)?
• Is the project located in the State of Oklahoma and associated with agricultural production, services and silviculture
Yes
No
(includes SIC Groups 01, 02, 07, 08 and 09)?
• Is the project located in the State of Texas and associated with the exploration, development, or production of oil or gas or geothermal
Yes
No
resources, including transportation or crude oil or natural gas by pipeline?
Estimated Area to be Disturbed (to the nearest quarter acre):
EPA Form 7500-62 (Rev. 11/08)
-
III. Rainfall Erosivity Factor Calculation Data
/
Project Start Date:
Month
/
/
Project Completion Date:
Day
Year
Month
/
Day
Year
Are interim non-vegetative site stabilization measures used to establish the project completion date for
Yes
No
purposes of obtaining this waiver?
Rainfall erosivity factor (R factor):
.
Note: To qualify for this waiver, the construction activity must take place during a period when the R factor is less than five.
Rainfall erosivity factor was calculated by using:
Online calculator
EPA Fact Sheet 3-1
USDA Handbook 703
IV. Operator Certification
I certify under penalty of law that: (1) construction activity at the project or site specified in Part II shall disturb less than five acres
and shall take place during a period when the rainfall erosivity factor is less than five, (2) final stabilization will be completed as
defined in the Construction General Permit, and (3) 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. Further, if interim non-vegetative measures are used to establish the end of the construction
period for the purposes of obtaining this waiver, I commit to periodically inspect and properly maintain the area until the criteria for
final vegetative stabilization have been met.
Print Name:
Print Title:
Signature:
/
Date:
Month
Email:
EPA Form 7500-62 (Rev. 11/08)
/
Day
Year
Instructions for Completing EPA Form 7500-62 (Rev. 11/08)
Low Erosivity Waiver Certification
NPDES Form
Who May Qualify for a Low Erosivity Waiver
Under the National Pollutant Discharge Elimination System
(NPDES) Program, operators of construction projects that result
in land disturbances equal to or greater than one acre, including
sites that are less than one acre but are part of a larger common
plan of development or sale where there is a cumulative
disturbance of at least one acre, are required to obtain coverage
under an NPDES permit for stormwater discharges associated
with construction activity. EPA may waive the otherwise
applicable permit requirements for stormwater discharges from
construction activities that disturb less than five acres if the
construction activity will take place during a period when the
rainfall erosivity factor (R factor) is less than five. More
information on the low erosivity waiver is available on the web in
the Construction Rainfall Erosivity Waiver Fact Sheet at
www.epa.gov/npdes/pubs/fact3-1.pdf and can be accessed from
www.epa.gov/npdes/cgp. For questions related to completion of
this form, you may contact EPA’s Stormwater Notice Processing
Center toll free at 1-866-352-7755.
Completing the 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 the original form with a signature in
ink. EPA will not accept a photocopied signature.
Section I. Operator Information
Each legal entity that meets EPA’s definition of “operator” (see
definitions in Appendix A of EPA’s NPDES Construction General
Permit) and that meets the eligibility conditions for the low
erosivity waiver must file this form to have the permit
requirements waived. The operator is the legal entity that either
(1) has operational control over construction plans and
specifications, including the ability to make modifications to those
plans and specifications, or (2) has day-to-day operational control
of some or all of those activities. It is possible that there will be
more than one operator at a site and, in such cases, each entity
that meets the operator definition must complete a Low Erosivity
Waiver Certification. Provide the legal name of your firm, public
organization, or other entity that operates the project described in
this waiver certification. Usually this will be a company or
organization’s name but for construction activities undertaken by
you as an individual, this should be your name. Provide the
operator’s Internal Revenue Service (IRS) employer identification
number (EIN), commonly referred to as the “taxpayer ID.” If you
are completing this form as an individual (i.e., not representing a
company or organization), enter “NA” in the space provided for
EIN. Enter the operator’s complete mailing address and name of
contact person, telephone number and email who can answer
questions about the site (e.g., a project or site manager).
Optional: to facilitate communication, provide a fax number for the
contact person.
To determine whether EPA is the permitting authority for the
construction project, and thus has authority to waive the
otherwise applicable requirements of the Construction General
Permit, it is necessary to know whether the project is located in
Indian country, is a federal facility or part of a federal facility; and
to answer the other three questions on projects located in
Oklahoma and Texas.
EPA Form 7500-62 (Rev. 11/08)
Form Approved OMB No. 2040-0211
Section II. Construction Project/Site Information
Enter the official or legal name and complete street address,
including city, state, zip code, and county or similar government
subdivision of the project or site. If the project lacks a street
address, indicate the general location of the site (e.g., intersection
of State Highways 61 and 34).
The applicant must also provide the latitude and longitude of the
approximate center of the project/site using one of three formats
given in the form. The latitude and longitude of your facility can be
determined from several sources, including global positioning
system (GPS) receivers, U.S. Geological Survey (USGS)
topographic or quadrangle maps, and EPA's Web-based siting
tool, among others. Information on using these methods to find
your construction site’s latitude and longitude is available on the
web at www.epa.gov/npdes/cgp. This web page describes EPA’s
web-based siting tool, which combines interactive maps and
aerial photographs to help find your construction site’s latitude
and longitude. Specify which source you used to determine
latitude and longitude. If a USGS topographic map is used,
specify the scale of the map used.
Enter the horizontal reference datum for your latitude and
longitude. The 1927 North American Datum (NAD 27) is a set of
ellipsoid constants that describe the earth’s shape and are used
to calculate locations on the earth’s latitude-longitude grid. This
1927 datum provides the mathematical basis for latitude and
longitude coordinates on most USGS topographic maps.
However, this datum is being phased out. Latitude and longitude
on new or revised maps are now being calculated using the 1983
North American Datum (NAD 83), which is based on a newer
definition of the earth ellipsoid. The World Geodetic System
datum (WGS 84) was developed for the Department of Defense
(DOD), who wanted a new coordinate system for the entire earth
not just North America. DOD was willing to sacrifice a little
accuracy in North America to get a better world system. For our
purposes we don’t have to be concerned about WGS 84 to NAD
83 coordinate conversions because the differences are negligible.
The horizontal reference datum used on USGS topographic
maps is shown on the bottom left corner of USGS topographic
maps; it is also available for GPS receivers; but it is not provided
on EPA’s web-based siting tool. If you use EPA's web siting tool,
please check the “unknown” box. NAD 83 is the most accurate
reference datum and, as such, is preferred.
Enter the area (estimated to the nearest quarter acre) to be
disturbed including, but not limited to: grubbing, excavation,
grading, and utilities and infrastructure installation. Note: 1 acre =
43,560 sq. ft.
Section III. Rainfall Erosivity Factor Calculation Data
The construction period begins with the initial earth disturbance
and ends with final site stabilization. To qualify for this waiver, the
rainfall erosivity factor for the project must be less than five during
the entire construction period. Specify the construction period by
entering the project start date (date of initial earth disturbance)
and project completion date (date of final site stabilization). For
example, a grading contractor that is operating on-site for only
one week during a nine month construction project, must enter
the start date and completion date of the entire nine month
construction period.
Instructions for Completing EPA Form 7500-62 (Rev. 11/08)
Low Erosivity Waiver Certification
NPDES Form
EPA believes, where the environmental threat is low (i.e., in arid
and semi-arid climates), that “final stabilization” can include
techniques that employ re-vegetation combined with other
stabilization measures, consisting of temporary degradeable
rolled erosion control products, also known as “erosion control
blankets (ECBs). With proper selection, design, and installation of
the combination re-vegetation/ECB technique in arid or semi-arid
areas, an operator can be considered to have achieved final
stabilization upon completion of the installation process. Note that
if more than three years is required to establish 70 percent of the
natural vegetative cover, this technique cannot be used or cited
for fulfillment of the final stabilization requirement. If your waiver is
based on use of interim non-vegetative stabilization measures,
such as erosion control blankets, to establish the end of the
construction period, you must indicate so on this form. In doing
so, you must commit and certify (as a condition of waiver
eligibility) to periodically inspect and properly maintain the area
until the criteria for final stabilization, as defined in the
Construction General Permit, have been met.
The rainfall erosivity factor "R" is determined in accordance with
the U.S. Department of Agriculture Agriculture Handbook Number
703, Prediciting Soil Erosion by Water: A Guide to Conservation
Planning with the Revised Universal Soil Loss Equation (RUSLE),
Chapter 2 pages 21-64, dated January 1997. EPA's Construction
Rainfall Erosivity Waiver Fact Sheet (EPA 833-F-00-014),
available online at www.epa.gov/npdes/pubs/fact3-1.pdf, defines
rainfall erosivity and provides numerical examples showing how
to calculate your rainfall erosivity factor. You may use the fact
sheet approach or the online rainfall erosivity factor calculator
available at: http://ei.tamu.edu to calculate your rainfall erosivity
factor for your project.
If the R factor is five or greater during the project’s construction
period, you must have or obtain coverage under an NPDES
stormwater permit. If the project was eligible for the waiver during
the original construction period, but the construction activity will
extend past the project completion date specified in the Low
Erosivity Waiver Certification, the operator must recalculate the R
factor using the original start date and a new project completion
date. If the recalculated R factor is still less than five, a new
waiver certification form must be submitted before the end of the
original construction period. If the new R factor is five or greater,
the operator must submit a Notice of Intent to be covered by the
Construction General Permit before the original project
completion date. The Notice of Intent (NOI) form may be
submitted electronically using EPA’s eNOI system at
www.epa.gov/npdes/enoi or submitted by mailing the paper NOI
form (EPA Form 3510-9) available on the EPA website at
www.epa.gov/npdes/cgp.
Section IV. Operator Certification
All Low Erosivity Waiver Certification forms must be signed as
follows:
For a corporation: By a responsible corporate officer. For the
purpose of this Section, a responsible corporate officer 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
EPA Form 7500-62 (Rev. 11/08)
Form Approved OMB No. 2040-0211
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 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, respectively; or
For a municipality, state, federal, or other public facility: By either
a principal executive officer or ranking elected official. For
purposes of this Section, a principal executive officer of a federal
agency includes (i) the chief executive officer of the agency, or (ii)
a senior executive officer having responsibility for the overall
operations of a principal geographic unit of the agency (e.g.,
Regional Administrator of EPA).
Include the name, title, and email address of the person signing
the form and the signature date. An unsigned or undated Low
Erosivity Waiver Certification will not be considered valid.
Where to File This Form
Low Erosivity Waiver Certification forms must be sent to one of
the following two addresses.
Regular U.S. Mail Delivery
EPA Stormwater Notice
Processing Center
Mail Code 4203M
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Overnight/Express Mail Delivery
EPA Stormwater Notice
Processing Center
Room 7420
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Please submit the original form with a signature in ink. Do not
send a photocopied signature!
Paperwork Reduction Act Notice
Public reporting burden for this certification form is estimated to
average 1.0 hours. This estimate includes time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control
number. Send comments regarding the burden estimate, any
other aspect of the collection of information, or suggestions for
improving this form, including any suggestions which may
increase or reduce this burden to: Chief, Information Strategies
Branch (2822T), U.S. Environmental Protection, Agency, 1200
Pennsylvania Avenue, NW, Washington, D.C. 20460. Include the
OMB control number on any correspondence. Do not send the
completed form to this address.
STANDARD FORM 299 (1/2006)
Prescribed by DOI/USDA/DOT
P.L. 96487 and Federal
Register Notice 5-22-95
FORM APPROVED
OMB NO. 1004-0189
Expires: November 30, 2008
APPLICATION FOR TRANSPORTATION AND
UTILITY SYSTEMS AND FACILITIES
ON FEDERAL LANDS
NOTE: Before completing and filing the application, the applicant should completely review this package and schedule a
preapplication meeting with representatives of the agency responsible for processing the application. Each agency
may have specific and unique requirements to be met in preparing and processing the application. Many times, with
the help of the agency representative, the application can be completed at the preapplication meeting.
1. Name and address of applicant (include zip code)
2. Name, title, and address of authorized agent if different
from Item 1 (include zip code)
FOR AGENCY USE ONLY
Application Number
Date filed
3. TELEPHONE (area code)
Applicant
Authorized Agent
5. Specify what application is for: (check one)
4. As applicant are you? (check one)
a.
b.
c.
d.
e.
f.
Individual
Corporation*
Partnership/Association*
State Government/State Agency
Local Government
Federal Agency
* If checked, complete supplemental page
a.
b.
c.
d.
e.
f.
New authorization
Renewing existing authorization No.
Amend existing authorization No.
Assign existing authorization No.
Existing use for which no authorization has been received*
Other*
* If checked provide details under Item 7
6. If an individual, or partnership are you a citizen(s) of the United States?
Yes
No
7 . Project description [describe in detail): (a) Type of system or facility, (e.g., canal, pipeline, road); (b) related structures and facilities; (c) physical specifications
(length, width, grading, etc.); (d)
(d) term of years needed; (e) time of year of use or operation; (f) Volume or amount of product to be transported; (g) duration and
timing of construction; and (h) temporary work areas needed for construction (Attach additional sheets, if additional space is needed,)
8. Attach a map covering area and show location of project proposal
9. State or local government approval:
10. Nonreturnable application fee.
Attached
Attached
Applied for
Not required
Not required
11. Does project cross international boundary or affect international waterways?
Yes
No
(If "yes," indicate on map)
12. Give statement of your technical and financial capability to construct, operate, maintain, and terminate system for which authorization is being requested.
(Continued on page 2 )
This form is authorized for local reproduction.
13a. Describe other reasonable alternative routes and modes considered.
b. Why were these alternatives not selected?
c. Give explanation as to why it is necessary to cross Federal Lands
14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. (Specify number, date, code, or name)
15. Provide statement of need for project, including the economic feasibility and items such as: (a) cost of proposal (construction, operation, and maintenance); (b)
estimated cost of next best alternative; and (c) expected public benefits.
16.
Describe probable effects on the population in the area, including the social and economic aspects, and the rural lifestyles.
17. Describe likely environmental effects that the proposed project will have on: (a) air quality; (b) visual impact; (c) surface and ground water quality and quantity; (d)
the control or structural change on any stream or other body of water; (e) existing noise levels; and (f) the surface of the land, including vegetation, permafrost, soil,
and soil stability.
18. Describe the probable effects that the proposed project will have on (a) populations of fish, plantlife, wildlife, and marine life, including threatened and endangered
species; and (b) marine mammals, including hunting, capturing, collecting, or killing these animals.
19. State whether any hazardous material, as defined in this paragraph, will be used, produced, transported or stored on or within the right-of-way or any of the right-of-way
facilities, or used in the construction, operation, maintenance or termination of the right-of-way or any of its facilities. "Hazardous material" means any substance,
pollutant or contaminant that is listed as hazardous under the Comprehensive Environmental Response, Compensation, and Liability Act of 1980, as amended, 42 U.S.C.
9601 et seq., and its regulations. The definition of hazardous substances under CERCLA includes any "hazardous waste" as defined in the Resource Conservation and
Recovery Act of 1976 (RCRA), as amended, 42 U.S.C. 9601 et seq., and its regulations. The term hazardous materials also includes any nuclear or byproduct material
as defined by the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq. The term does not include petroleum, including crude oil or any fraction thereof that
is not otherwise specifically listed or designated as a hazardous substance under CERCLA Section 101(14), 42 U.S.C. 9601(14), nor does the term include natural gas.
20. Name all the Department(s)/Agency(ies) where this application is being filed.
I HEREBY CERTIFY, That I am of legal age and authorized to do business in the State and that I have personally examined the information contained in the application and
believe that the information submitted is correct to the best of my knowledge.
Date
Signature of Applicant
Title 18, U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 3 )
(SF -299, page 2)
APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS
AND FACILITIES ON FEDERAL LANDS
GENERAL INFORMATION
ALASKA NATIONAL INTEREST LANDS
This application will be used when applying for a right-of-way, permit,
license, lease, or certificate for the use of Federal lands which lie within
conservation system units and National Recreation or Conservation Areas
as defined in the Alaska National Interest Lands Conservation Act.
Conservation system units include the National Park System, National
Wildlife Refuge System, National Wild and Scenic Rivers System,
National Trails System, National Wilderness Preservation System, and
National Forest Monuments.
Transportation and utility systems and facility uses for which the
application may be used are:
1. Canals, ditches, flumes, laterals, pipes, pipelines, tunnels, and other
systems for the transportation of water.
2. Pipelines and other systems for the transportation of liquids other than
water, including oil, natural gas, synthetic liquid and gaseous fuels,
and any refined product produced therefrom.
3. Pipelines, slurry and emulsion systems, and conveyor belts for
transportation of solid materials.
4. Systems for the transmission and distribution of electric energy.
5. Systems for transmission or reception of radio, television, telephone,
telegraph, and other electronic signals, and other means of
communications.
6. Improved rights-of-way for snow machines, air cushion vehicles, and
all-terrain vehicles.
7. Roads, highways, railroads, tunnels, tramways, airports, landing
strips, docks, and other systems of general transportation.
This application must be filed simultaneously with each Federal
department or agency requiring authorization to establish and operate
your proposal.
In Alaska, the following agencies will help the applicant file an
application and identify the other agencies the applicant should contact
and possibly file with:
Department of Agriculture
Regional Forester, Forest Service (USFS)
Federal Office Building, P.O. Box 21628
Juneau, Alaska 99802-1628
Telephone: (907) 586-7847 (or a local Forest Service Office)
Department of the Interior
Bureau of Indian Affairs (BIA)
Juneau Area Office
9109 Mendenhall Mall Road, Suite 5, Federal Building Annex
Juneau, Alaska 99802
Telephone: (907) 586-7177
Bureau of Land Management (BLM)
222 West 7th Ave., Box 13
Anchorage, Alaska 99513-7599
Telephone: (907) 271-5477 (or a local BLM Office)
National Park Service (NPS)
Alaska Regional Office, 2525 Gambell St., Rm. 107
Anchorage, Alaska 99503-2892
Telephone: (907) 257-2585
U.S. Fish &Wildlife Service (FWS)
Office of the Regional Director
1011 East Tudor Road
Anchorage, Alaska 99503
Telephone: (907) 786-3440
Note-Filings with any Interior agency may be filed with any office noted
above or with the: Office of the Secretary of the Interior, Regional
Environmental Officer, Box 120, 1675 C Street, Anchorage, Alaska
99513.
(For supplemental, see page 4 )
Department of Transportation
Federal Aviation Administration
Alaska Region AAL- 4,222 West 7th Ave., Box 14
Anchorage, Alaska 99513-7587
Telephone: (907) 271-5285
NOTE - The Department of Transportation has established the above
central filing point for agencies within that Department. Affected
agencies are: Federal Aviation Administration (FAA), Coast Guard
(USCG), Federal Highway Administration (FHWA), Federal Railroad
Administration (FRA).
OTHER THAN ALASKA NATIONAL INTEREST LANDS
Use of this form is not limited to National Interest Conservation Lands of
Alaska.
Individual departments/agencies may authorize the use of this form by
applicants for transportation and utility systems and facilities on other
Federal lands outside those areas described above.
For proposals located outside of Alaska, applications will be filed at the
local agency office or at a location specified by the responsible Federal
agency.
SPECIFIC INSTRUCTIONS
(Items not listed are self-explanatory)
Item
7 Attach preliminary site and facility construction plans. The
responsible agency will provide instructions whenever specific
plans are required.
8 Generally, the map must show the section(s), township(s), and
ranges within which the project is to be located. Show the
proposed location of the project on the map as accurately as
possible. Some agencies require detailed survey maps. The
responsible agency will provide additional instructions.
9, 10, and 12 - The responsible agency will provide additional
instructions.
13 Providing information on alternate routes and modes in as much
detail as possible, discussing why certain routes or modes were
rejected and why it is necessary to cross Federal lands will assist
the agency(ies) in processing your application and reaching a
final decision. Include only reasonable alternate routes and
modes as related to current technology and economics.
14 The responsible agency will provide instructions.
15 Generally, a simple statement of the purpose of the proposal will
be sufficient. However, major proposals located in critical or
sensitive areas may require a full analysis with additional specific
information. The responsible agency will provide additional
instructions.
16 through 19 - Providing this information in as much detail as
possible will assist the Federal agency(ies) in processing the
application and reaching a decision. When completing these
items, you should use a sound judgment in furnishing relevant
information. For example, if the project is not near a stream or
other body of water, do not address this subject. The responsible
agency will provide additional instructions.
Application must be signed by the applicant or applicant's
authorized representative.
If additional space is needed to complete any item, please put the
information on a separate sheet of paper and identify it as
"Continuation of Item ".
(SF -299, page 3)
SUPPLEMENTAL
NOTE: The responsible agency(ies) will provide additional instructions
I - PRIVATE CORPORATIONS
CHECK APPROPRIATE
BLOCK
ATTACHED
FILED*
a. Articles of Incorporation
b. Corporation Bylaws
c. A certification from the State showing the corporation is in good standing and is entitled to operate within the State.
d. Copy of resolution authorizing filing
e. The name and address of each shareholder owning 3 percent or more of the shares, together with the number and percentage of any
class of voting shares of the entity which such shareholder is authorized to vote and the name and address of each affiliate of the entity
together with, in the case of an affiliate controlled by the entity, the number of shares and the percentage of any class of voting stock of
that affiliate owned, directly or indirectly, by that entity, and in the case of an affiliate which controls that entity, the number of shares
and the percentage of any class of voting stock of that entity owned, directly or indirectly, by the affiliate.
f. If application is for an oil or gas pipeline, describe any related right-of-way or temporary use permit applications, and identify
previous applications
g. If application is for an oil and gas pipeline, identify all Federal lands by agency impacted by proposal.
1 - PUBLIC CORPORATIONS
II
a. Copy of law forming corporation
b. Proof of organization
c. Copy of Bylaws
d. Copy of resolution authorizing filing
e. If application is for an oil or gas pipeline, provide information required by Item "I-f" and "I-g" above.
III - PARTNERSHIP OR OTHER UNINCORPORATED ENTITY
a. Articles of association, if any
b. If one partner is authorized to sign, resolution authorizing action is
c. Name and address of each participant, partner, association, or other
d. If application is for an oil or gas pipeline, provide information required by Item "I-f" and "I-g" above.
* If the required information is already filed with the agency processing this application and is current, check block entitled "Filed." Provide the file identification
information (e.g., number, date, code, name). If not on file or current, attach the requested information.
(Continued on page 5 )
(SF-299, page 4)
NOTICES
NOTE: This applies to the Department of the Interior/Bureau of Land Management (BLM).
The Privacy Act of 1974 provides that you be furnished with the following information in connection with the
information provided by this application for an authorization.
AUTHORITY: 16 U.S.C. 310 and 5 U.S.C. 301.
PRINCIPAL PURPOSE: The primary uses of the records are to facilitate the (1) processing of claims or
applications; (2) recordation of adjudicative actions; and (3) indexing of documentation in case files supporting
administrative actions.
ROUTINE USES: BLM and the Department of the Interior (DOI) may disclose your information on this form: (1) to
appropriate Federal agencies when concurrence or supporting information is required prior to granting or acquiring a
right or interest in lands or resources; (2) to members or the public who have a need for the information that is
maintained by BLM for public record; (3) to the U.S. Department of Justice, court, or other adjudicative body when
DOI determines the information is necessary and relevant to litigation; (4) to appropriate Federal, State, local, or
foreign agencies responsible for investigating, prosecuting violation, enforcing, or implementing this statute,
regulation, or order; and (5) to a congressional office when you request the assistance of the Member of Congress in
writing.
EFFECT OF NOT PROVIDING THE INFORMATION: Disclosing this information is necessary to receive or
maintain a benefit. Not disclosing it may result in rejecting the application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The Federal agencies collect this information from applicants requesting right-of-way, permit, license, lease, or
certifications for the use of Federal Lands.
Federal agencies use this information to evaluate your proposal.
No Federal agency may request or sponsor and you are not required to respond to a request for information which
does not contain a currently valid OMB Control Number.
BURDEN HOURS STATEMENT: The public burden for this form is estimated at 25 hours per response including
the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct
comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau
of Land Management (1004-0189), Bureau Information Collection Clearance Officer (WO-630) 1849 C Street,
N.W., Mail Stop 401 LS, Washington, D.C. 20240.
A reproducible copy of this form may be obtained from the Bureau of Land Management, Land and Realty Group,
1620 L Street, N.W., Rm. 1000 LS, Washington, D.C. 20036.
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
(SF – 299, page 5)
| File Type | application/pdf |
| File Title | NPDES Form 1 Application: General Information - Consolidated Permits Program |
| Subject | General information application. Must be submitted by all facilities applying for an individual NPDES permit, with the exception |
| Author | US EPA |
| File Modified | 2008-12-04 |
| File Created | 2008-12-04 |