TTB F 5000.30 Supplemental Information on Water Quality Considerations

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OMB No.1513-0023 (08/31/2011)

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

SUPPLEMENTAL INFORMATION ON WATER QUALITY CONSIDERATIONS
UNDER 33 U.S.C. 1341(a)
INSTRUCTIONS
COMPLETION . Answer all items in sufficient detail if applicable to your activity. If necessary, continue on a separate sheet. Your answers are evaluated to
determine if a certification or waiver by the applicable State Water Quality Agency is required under Section 21 of the Federal Water Pollution Control Act (33
U.S.C. 1341(a)).
FILING. Submit an original and one copy of this form with the related application or other document, to the Director, National Revenue Center, 550 Main St, Ste 8002,
Cincinnati, Ohio 45202-5215. This form must be completed and submitted even though three copies of the required certification or waiver have been sent
to the Director, National Revenue Center or are attached to this form.
DISPOSITION. After final action taken on the related application or other document, the copy of this form will be returned to the applicant.

1. FORM NUMBER

2. APPLICATION DATE

APPLICATION RELATED TO THIS RIDER
3. SERIAL NUMBER

4. NAME AND PRINCIPAL BUSINESS ADDRESS OF APPLICANT

5. PLANT ADDRESS (If different from address in item 4)

(Number, street, city, county, State, and ZIP code)

6. DESCRIBE ACTIVITY TO BE CONDUCTED IN WHICH THE ALCOHOL AND TOBACCO TAX AND TRADE BUREAU HAS AN INTEREST.

7. DESCRIBE ANY DIRECT OR INDIRECT DISCHARGE INTO NAVIGABLE WATERS WHICH MAY RESULT FROM THE CONDUCT OF THE
ACTIVITY DESCRIBED IN ITEM 6, INCLUDING THE BIOLOGICAL, CHEMICAL, THERMAL, OR OTHER CHARACTERISTIC OF THE DISCHARGE
AND THE LOCATIONS AT WHICH SUCH DISCHARGE MAY ENTER NAVIGABLE WATERS.

8. GIVE THE DATE OR DATES ON WHICH THE ACTIVITY WILL BEGIN AND END, IF KNOWN, AND ON WHICH THE DISCHARGE WILL TAKE PLACE.

9. DESCRIBE THE METHODS AND MEANS USED OR TO BE USED TO MONITOR THE QUALITY AND CHARACTERISTICS OF THE DISCHARGE
AND THE OPERATION OF EQUIPMENT OR FACILITIES EMPLOYED IN THE TREATMENT OR CONTROL OF WASTES OR OTHER EFFLUENTS.

I certify that I have examined this rider and, to the best of my knowledge and belief, it is true, correct, and complete and that copies of this rider may be
furnished to the applicable State Water Quality Agency and the Regional Administrator, Environmental Protection Agency.

10. APPLICANT

TTB F 5000.30 (10/2008)

11. BY (Signature and title)

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This information collection is used by TTB to determine whether a certification
from a State of multi-state authority is needed for discharge of effluent into navigable water of the U.S. This information is required to obtain a benefit.
The estimated average burden associated with this collection of information is .5 hour per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Reports
Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, Washington, DC 20220.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current, valid OMB control
number.

TTB F 5000.30 (10/2008)