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pdfAPPENDIX G
FORMS
Forms included:
Application Forms 1, 2A, 2B, 2C, 2D, 2E, 2F, 2S;
Construction General Permit NOI, NOT;
Pesticide General Permit NOI, NOT, PDEW, Adverse Incident, Annual
Report;
Multi Sector General Permit NOI, NOT, DMR, Annual Report, No
Exposure Certification Form;
Vessel General Permit NOI, NOT, PARI, Annual Report;
Small Vessel General Permit PARI, Annual Noncompliance, and
Uniform Federal Transportation/Utility System Application Form
Disclaimer
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United States
Environmental Protection
Agency
.
.a EPA
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.
1-10
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400 47' 30"
1000
0 Feet
USGS Map Central City, Ohio
Blue
Gap
750 37' 30"
Hamilton 9.4 miles
Location Map
Central Processing Co.
Central City, Ohio
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
15
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)
1
1
C
B. PHONE (area code & no.)
11111111111111111111111111111
111111111
2
15
16
45
46
48
49
51
52-
55
V. FACILTY MAILING ADDRESS
C
A. STREET OR P.O. BOX
11111111111111111111111111111
3
15
16
C
45
B. CITY OR TOWN
C. STATE
111111111111111111111111
D. ZIP CODE
1
4
15
16
40
41
42
47
51
VI. FACILITY LOCATION
A. STREET, ROUTE NO. OR OTHER SPECIFIC IDENTIFIER
1
C
11111111111111111111111111111
5
15
16
45
B. COUNTY NAME
111111111111111111111111
46
70
C. CITY OR TOWN
C
111111111111111111111111
6
15
D. STATE
16
EPA Form 3510-1 (8-90)
40
F. COUNTY CODE (if known)
E. ZIP CODE
1
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
1
111111111111111111111111111111111111111
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
111111111
A
56
15
6
-
18
19
-
21
22
-
26
E. STREET OR P.O. BOX
11111111111111111111111111111
26
55
F. CITY OR TOWN
C
I
I
I
I
I
I
I
I
I
I
I
I
I
I
G. STATE
I
I
I
I
I
I
I
I
I
H. ZIP CODE
I
YES
B
15
16
40 41
X. EXISTING ENVIRONMENTAL PERMITS
A. NPDES (Discharges to Surface Water)
C
T
I
16
17
18
30
C
T
9
P
15
16
I
T
I
111111111111
9 U
15
16
17
18
17
T
16
51
NO
52
C
T
I
16
17
30
9
18
30
I
111111111111
9 R
15
-
E. OTHER (specify)
111111111111
(specify)
15
18
C. RCRA (Hazardous Wastes)
C
47
111111111111
B. UIC (Underground Injection of Fluids)
C
42
D. PSD (Air Emissions from Proposed Sources)
111111111111
9 N
15
IX. INDIAN LAND
Is the facility located on Indian lands?
C
T
I
16
17
30
E. OTHER (specify)
111111111111
(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
EPA I.D. NUMBER (copy from Item 1 of Form 1)
FORM
EPA
2B
NPDES
U.S. ENVIRONMENTAL PROTECTION AGENCY
APPLICATIONS FOR PERMIT TO DISCHARGE WASTEWATER
CONCENTRATED ANIMAL FEEDING OPERATIONS AND AQUATIC ANIMAL PRODUCTION FACILITIES
Applying for: Individual Permit
I. GENERAL INFORMATION
Coverage Under General Permit
C. FACILITY OPERATION
STATUS
A. TYPE OF BUSINESS
B. CONTACT INFORMATION
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
B. MANURE, LITTER, AND/OR WASTEWATER
PRODUCTION AND USE
A. TYPE AND NUMBER OF ANIMALS
2. ANIMALS
1. TYPE
Mature Dairy Cows
Dairy Heifers
Veal Calves
Cattle (not dairy or veal
calves)
Swine (55 lbs. or over)
Swine (under 55 lbs.)
Horses
Sheep or Lambs
Turkeys
Chickens (Broilers)
Chickens (Layers)
Ducks
Other: Specify __________
3. TOTAL ANIMALS
EPA Form 3510-2B (Rev. 11-08)
NO. IN OPEN
CONFINEMENT
NO. HOUSED
UNDER ROOF
1. How much manure, litter, and wastewater is generated
annually by the facility? ________tons ________ gallons
2. If land applied how many acres of land under the control of
the applicant are available for applying the CAFOs
manure/litter/wastewater? _____________________acres
3. How many tons of manure or litter, or gallons of wastewater produced by the CAFO will be transferred annually
to other persons? ________tons ________gallons
Form Approved
OMB No. 2040-0250
C.
TOPOGRAPHIC MAP
D. TYPE OF CONTAINMENT, STORAGE AND CAPACITY
1. Type of Containment
Total Capacity (in gallons)
Lagoon
Holding Pond
Evaporation Pond
Other: Specify ___________________
2. Report the total number of acres contributing drainage: __________________ acres
Total Number of
Days
3. Type of Storage
Total Capacity
(gallons/tons)
Anaerobic Lagoon
Storage Lagoon
Evaporation Pond
Aboveground Storage Tanks
Belowground Storage Tanks
Roofed Storage Shed
Concrete Pad
Impervious Soil Pad
Other: Specify ___________________
E. NUTRIENT MANAGEMENT PLAN
Note: Effective February 27, 2009, a permit application is not complete until a nutrient management plan is submitted to the
Permitting Authority.
1. Please indicate whether a nutrient management plan has been included with this permit application.
Yes
No
2. If no, please explain:
3. Is a nutrient management plan being implemented for the facility?
Yes
No
4. The date of the last review or revision of the nutrient management plan. Date: _________________
5. If not land applying, describe alternative use(s) of manure, litter, and/or wastewater:
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
EPA Form 3510-2B (Rev. 11-08)
Conservation tillage
Constructed wetlands Infiltration field Grass filter
Terrace
Form Approved
OMB No. 2040-0250
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.
1. Outfall No.
2. Flow (gallons per day)
a. Maximum.
Daily
b. Maximum
30 Day
c. Long Term
Average
B. Indicate the total number of ponds, raceways, and similar
structures in your facility.
1. Ponds
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
a. Species
b. Harvestable Weight (pounds)
(1) Total Yearly
(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. Telephone ( _______ ) ____________________
C. Signature
D. Date Signed
EPA Form 3510-2B (Rev. 11-08)
Form Approved
OMB No. 2040-0250
INSTRUCTIONS
GENERAL
Item II-D
This form must be completed by all applicants who check “yes” to Item IIB in Form 1. Not all animal feeding operations or fish farms are required to
obtain NPDES permits. Exclusions are based on size and whether or not the
facility discharges proposed to discharge. See the description of these
exclusions in the CAFO regulations at 40 CFR 122.23.
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.
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.
Item II-E
Refer to the Form 1 instructions to determine where to file this form.
Provide information concerning the status of submitting a nutrient management
plan for the facility to complete the application. In those cases where the
nutrient management plan has not been submitted, provide an explanation. If
not land applying, describe the alternative uses of the manure, litter, and
wastewater (e.g., composting, pelletizing, energy generation, etc.).
Item I-A
Item II-F
See the note above to be sure that your facility is a “concentrated animal
feeding operation” (CAFO).
Check any of the identified conservation practices that are being implemented
at the facility to control runoff and protect water quality.
Item I-B
Item III
Use this space to give owner/operator contact information.
Supply all information in Item III if you checked (2) in Item I-A.
Item I-C
Item III-A
Check “proposed” if your facility is not now in operation or is expanding to
meet the definition of a CAFO in accordance with the CAFO regulations at 40
CFR 122.23.
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 I-D
Use this space to give a complete legal description of your facility’s location
including name, address, and latitude/longitude. Also, 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 entire
operation, including the production area and land under the operational control
of the CAFO operator where manure, litter, and/or wastewater are applied with
Form 1.
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.
EPA Form 3510-2B (Rev. 11-08)
Paper Reduction Act Notice
The public reporting and recordkeeping burden for this collection of
information is estimated to average 9.5 hours per response. The public
reporting and recordkeeping burden for development of the nutrient
management plan to be submitted with the form is estimated to average 58
hours per response. Send comments on the Agency's need for this
information, the accuracy of the provided burden estimates, and any
suggested methods for minimizing respondent burden, including through
the use of automated collection techniques to the Director, Collection
Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed form to
this address.
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
directly into the form, print it, and save the completed form.
Note: This form can be viewed and saved only using Adobe Acrobat Reader
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Instructions:
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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 3510-2D
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
2017 Construction General Permit (CGP)
Appendix J - Notice of Intent (NOI) Form and Instructions
Part 1.4.1 requires you to use the NPDES eReporting Tool, or “NeT” system, to prepare and submit
your NOI electronically. However, if the EPA Regional Office grants you a waiver to use a paper
NOI form, and you elect to use it, you must complete and submit the following form.
Page J-1 of 10
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF INTENT FOR THE 2017 NPDES CONSTRUCTION GENERAL PERMIT
NPDES
FORM
3510-9
Form Approved.
OMB No. 2040-0004
Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section III of this form requests authorization to discharge pursuant to
the NPDES Construction General Permit (CGP) permit number identified in Section II of this form. Submission of this NOI also constitutes notice that the operator
identified in Section III of this form meets the eligibility requirements of Part 1.1 CGP for the project identified in Section IV of this form. Permit coverage is
required prior to commencement of construction activity until you are eligible to terminate coverage as detailed in Part 8 of the CGP. To obtain authorization,
you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were never eligible for
permit coverage. Refer to the instructions at the end of this form.
I. Approval to Use Paper NOI Form
Have you been granted a waiver from electronic reporting from the Regional Office *?
YES
NO
If yes, check which waiver you have been granted, , the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as
under-served for broadband Internet access in the most recent report from the Federal Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
/
Date approval obtained:
/
* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you must
file this form electronically using the NPDES eReporting Tool (NeT).
II. Permit Information
NPDES ID (EPA Use Only):
Master Permit Number:
(see Appendix B of the CGP for the list of eligible permit numbers)
III. Operator Information
Operator Information
Operator
Name:
Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A?
YES
NO
Mailing Address:
Street:
City:
State:
ZIP Code:
-
County or Similar Government Division:
Phone:
-
-
Ext.
E-mail:
Operator Point of Contact Information:
First Name,
Middle Initial,
Last Name:
Title:
NOI Preparer (Complete if NOI was prepared by someone other than the certifier):
First Name,
Middle Initial,
Last Name:
Organization:
EPA Form 3510-9
Page 1 of 8
-
Phone:
-
Ext.
E-mail:
IV. Project/Site Information
Project/Site
Name:
Project/Site Address:
Street/Location:
City:
State:
-
ZIP Code:
County or Similar Government Subdivision:
For the project/site you are seeking permit coverage, provide the following information:
Latitude/Longitude (Use decimal degrees and specify method):
Latitude:
___ ___. ___ ___ ___ ___° N (decimal degrees)
Latitude/Longitude Data Source:
Map
GPS
Longitude:
___ ___ ___. ___ ___ ___ ___° W (decimal degrees)
Other_______________________
Horizontal Reference Datum:
NAD 27
Is your project/site located in Indian country lands, or located on a property of religious or cultural significance to an Indian tribe?
NAD 83
YES
WGS 84
NO
If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable), or if not in
Indian country, provide the name of the Indian tribe associated with the property:
___________________________________________________________________________________________________________________________________________________
Estimated Project Start Date:
/
/
Estimated Area to be Disturbed (to the nearest quarter acre):
Type of Construction Site (check all that apply):
/
Estimated Project Completion Date:
.
Single-Family Residential
Institutional
Multi-Family Residential
Highway or Road
Will there be demolition of any structure built or renovated before January 1, 1980?
Utility
YES
Commercial
NO
YES
Was the pre-development land use used for agriculture (see Appendix A for definition of “agricultural land”)?
YES
If yes, is your project an “emergency-related project” (see Appendix A)?
Industrial
Other ________________________________________________
If yes, do any of the structures being demolished have at least 10,000 square feet of floor space?
Have earth-disturbing activities commenced on your project/site?
/
NO
YES
NO
NO
YES
NO
Have stormwater discharges from your project/site been covered previously under an NPDES permit?
YES
NO
If yes, provide the NPDES ID ( if you had coverage under EPA’s 2012 CGP or the NPDES permit number if you had
coverage under an EPA individual permit:
V. Discharge Information
By indicating “Yes” below, I confirm that I understand that the CGP only authorizes the allowable stormwater discharges in Part 1.2.1 and the allowable nonstormwater discharges listed in Part 1.2.2. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability under CWA
section 402(k) by disclosure to EPA, state, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to be covered by
the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage other than the
allowable stormwater and non-stormwater discharges listed in Parts 1.2.1 and 1.2.2 will be discharged, they must be covered under another NPDES permit.
YES
Does your project/site discharge stormwater into a Municipal Separate Storm Sewer System (MS4)?
Are there any waters of the U.S. within 50 feet of your project’s earth disturbances?
EPA Form 3510-9
YES
YES
NO
NO
Page 2 of 9
Receiving Waters Information: (Attach a separate list if necessary)
List all of the stormwater points of
discharge from your site. Each point
of discharge must be identified by a
unique 3-digit ID (e.g., 001, 002). Also
provide the latitude and longitude
in decimal degrees for each point
of discharge. Note that latitude and
longitude does not need to be
updated if the points of discharge
change during the project.
Longitude
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Longitude
Longitude
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Longitude
EPA Form 3510-9
Pollutant(s) for which
there is a TMDL:
Pollutant(s) for which
there is a TMDL:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
TMDL Name and ID:
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Pollutant(s) for which
there is a TMDL:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
TMDL Name and ID:
Outfall ID
Latitude
If a TMDL been completed
for this receiving
waterbody, providing the
following information:
TMDL Name and ID:
Outfall ID
Latitude
If the receiving water is
impaired (on the CWA 303(d)
list), list the pollutants that are
causing the impairment:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
Outfall ID
Latitude
Provide the name of the first
water of the U.S. that receives
stormwater directly from the
point of discharge and/or from
the MS4 that the point of
discharge discharges to:
TMDL Name and ID:
Outfall ID
Latitude
For each point of discharge, provide the following receiving water information:
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Pollutant(s) for which
there is a TMDL:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
Page 3 of 9
TMDL Name and ID:
Outfall ID
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Latitude
Longitude
Pollutant(s) for which
there is a TMDL:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
TMDL Name and ID:
Outfall ID
___ ___. ___ ___ ___ ___
° N (decimal degrees)
Latitude
Longitude
Pollutant(s) for which
there is a TMDL:
___ ___ ___. ___ ___ ___ ___
° W (decimal degrees)
Provide the following Information about your point(s) of discharge latitude/longitude:
Latitude/Longitude Data Source:
Map
GPS
Other _________________________
Horizontal Reference Datum:
NAD 27
NAD 83
WGS 84
Are any of the waters of the U.S. to which you discharge 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) or as a Tier 3 water
(Outstanding National Resource Water)? (See Appendix F).
YES
NO
If yes, name(s) of receiving water(s) and its designation (Tier 2, Tier 2.5 or Tier 3):
VI. Chemical Treatment Information
Will you use polymers, flocculants, or other treatment chemicals at your construction site?
If yes, will you use cationic treatment chemicals at your construction site*?
YES
YES
NO
NO
If yes, have you been authorized to use cationic treatment chemicals by your applicable EPA Regional Office in advance of filing your NOI*?
YES
NO
If you have been authorized to use cationic treatment chemicals by your applicable EPA Regional Office, attach a copy of your authorization letter and
include documentation of the appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals
will not lead to a violation of water quality standards.
Please indicate the treatment chemicals that you will use: ____________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
* Note: You are ineligible for coverage under this permit unless you notify your applicable EPA Regional Office in advance and the EPA office authorizes
coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic
treatment chemicals will not lead to a violation of water quality standards.
EPA Form 3510-9
Page 4 of 9
VII. Stormwater Pollution Prevention Plan (SWPPP) Information
Has the SWPPP been prepared in advance of filing this NOI, as required?
YES
NO
SWPPP Contact Information:
First Name,
Middle Initial
Last Name:
Professional
Title:
-
Phone:
-
Ext.
E-mail:
VIII. Endangered Species Protection
Using the instructions in Appendix D of the CGP, under which criterion listed below are you eligible for coverage under this permit? Check only 1 box, include
the required information and provide a sound basis for supporting the criterion selected. You must consider Endangered Species Act listed threatened or
endangered species (ESA-listed) and/or designated critical habitat(s) under the jurisdiction of both the U.S. Fish and Wildlife Service (USFWS) and National
Marine Fisheries Service (NMFS) and select the most conservative criterion that applies.
A
No ESA-listed species and/or designated critical habitat present in action area. Using the process outlined in Appendix D of this permit, you certify
that ESA-listed species and designated critical habitat(s) under the jurisdiction of the USFWS or NMFS are not likely to occur in your site’s “action area”
as defined in Appendix A of this permit. [Basis statement content: A basis statement supporting the selection of this criterion should identify the USFWS
and NMFS information sources used. Attaching aerial image(s) of the site to this NOI is helpful to EPA, USFWS, and NMFS in confirming eligibility under
this criterion. Please Note: NMFS’ jurisdiction includes ESA-listed marine and estuarine species that spawn in inland rivers.]
B
Eligibility requirements met by another operator under the 2017 CGP. The construction site’s discharges and discharge-related activities were already
addressed in another operator’s valid certification of eligibility for your “action area” under eligibility Criterion A, C, D, E, or F of the 2017 CGP and you
have confirmed that no additional ESA-listed species and/or designated critical habitat under the jurisdiction of USFWS and/or NMFS not considered
in the that certification may be present or located in the “action area.” To certify your eligibility under this criterion, there must be no lapse of NPDES
permit coverage in the other CGP operator’s certification. By certifying eligibility under this criterion, you agree to comply with any conditions upon
which the other CGP operator's certification was based. You must include in your NOI the NPDES ID from the other 2017CGP operator’s notification of
authorization under this permit. If your certification is based on another 2017 CGP operator’s certification under criterion C, you must provide EPA with
the relevant supporting information required of existing dischargers in criterion C in your NOI form. [Basis statement content: A basis statement
supporting the selection of this criterion should identify the eligibility criterion of the other CGP NOI, the authorization date, and confirmation that the
authorization is effective.]
If you select criterion B, provide the NPDES ID from the other operator’s notification of authorization under this permit: __ __ __ __ __ __ __ __ __
C
Discharges not likely to adversely affect ESA-listed species and/or designated critical habitat. ESA-listed species and/or designated critical habitat(s)
under the jurisdiction of the USFWS and/or NMFS are likely to occur in or near your site’s “action area,” and you certify to EPA that your site’s
discharges and discharge-related activities are not likely to adversely affect ESA-listed threatened or endangered species and/or designated critical
habitat. This certification may include consideration of any stormwater controls and/or management practices you will adopt to ensure that your
discharges and discharge-related activities are not likely to adversely affect ESA-listed species and/or designated critical habitat. To certify your
eligibility under this criterion, indicate 1) the ESA-listed species and/or designated habitat located in your “action area” using the process outlined in
Appendix D of this permit; 2) the distance between the site and the listed species and/or designated critical habitat in the action area (in miles); and
3) a rationale describing specifically how adverse effects to ESA-listed species will be avoided from the discharges and discharge-related activities.
You must also include a copy of your site map from your SWPPP showing the upland and in-water extent of your “action area” with this NOI. [Basis
statement content: A basis statement supporting the selection of this criterion should identify the information resources and expertise (e.g., state or
federal biologists) used to arrive at this conclusion. Any supporting documentation should explicitly state that both ESA-listed species and designated
critical habitat under the jurisdiction of the USFWS and/or NMFS were considered in the evaluation.]
What ESA-listed species and/or designated critical habitat are located in your “action area”:
____________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Distance between your site and the ESA-listed species and/or designated critical habitat within the action area (in miles, state “on site” if the ESAlisted species and/or designated critical habitat is within the area to be disturbed):
____________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
D
Coordination with USFWS and/or NMFS has successfully concluded. Coordination between you and the USFWS and/or NMFS has concluded. The
coordination must have addressed the effects of your site’s discharges and discharge-related activities on ESA-listed species and/or designated
critical habitat under the jurisdiction of USFWS and/or NMFS, and resulted in a written concurrence from USFWS and/or NMFS that your site’s
discharges and discharge-related activities are not likely to adversely affect listed species and/or critical habitat. You must include copies of the
correspondence with the participating agencies in your SWPPP and this NOI. [Basis statement content: A basis statement supporting the selection of
this criterion should identify whether USFWS or NMFS or both agencies participated in coordination, the field office/regional office(s) providing that
coordination, and the date that coordination concluded.]
EPA Form 3510-9
Page 5 of 9
E
ESA Section 7 consultation has successfully concluded. Consultation between a Federal Agency and the USFWS and/or NMFS under section 7 of the
ESA has concluded. The consultation must have addressed the effects of the construction site’s discharges and discharge-related activities on ESAlisted species and/or designated critical habitat under the jurisdiction of USFWS and/or NMFS. To certify eligibility under this criterion, Indicate the
result of the consultation:
biological opinion from USFWS and/or NMFS that concludes that the action in question (taking into account the effects of your site’s
discharges and discharge-related activities) is not likely to jeopardize the continued existence of listed species, nor the destruction or adverse
modification of critical habitat; or
written concurrence from USFWS and/or NMFS with a finding that the site’s discharges and discharge-related activities are not likely to
adversely affect ESA-listed species and/or designated critical habitat.
You must include copies of the correspondence between yourself and the USFWS and/or NMFS in your SWPPP and this NOI. [Basis statement
content: A basis statement supporting the selection of this criterion should identify the federal action agencie(s) involved, the field office/regional
office(s) providing that consultation, any tracking numbers of identifiers associated with that consultation (e.g., IPaC number, PCTS number), and the
date the consultation was completed.]
F
Issuance of section 10 permit. Potential take is authorized through the issuance of a permit under section 10 of the ESA by the USFWS and/or NMFS,
and this authorization addresses the effects of the site’s discharges and discharge-related activities on ESA-listed species and designated critical
habitat. You must include copies of the correspondence between yourself and the participating agencies in your SWPPP and your NOI. [Basis
statement content: A basis statement supporting the selection of this criterion should identify whether USFWS or NMFS or both agencies provided a
section 10 permit, the field office/regional office(s) providing permit(s), any tracking numbers of identifiers associated with that consultation (e.g.,
IPaC number, PCTS number), and the date the permit was granted.]
Provide a brief summary of the basis for criterion selection listed above [the necessary content for a supportive basis statement is provided under the criterion
you selected.].
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
IX. Historic Preservation
Are you installing any stormwater controls as described in Appendix E that require subsurface earth disturbance? (Appendix E, Step 1)
YES
NO
If yes, have prior surveys or evaluations conducted on the site have already determined historic properties do not exist, or that prior disturbances have
precluded the existence of historic properties? (Appendix E, Step 2)
YES
NO
If no, have you determined that your installation of subsurface earth-disturbing stormwater controls will have no effect on historic properties?
(Appendix E, Step 3)
YES
NO
If no, did the SHPO, THPO, or other tribal representative (whichever applies) respond to you within the 15 calendar days to indicate whether the
subsurface earth disturbances caused by the installation of stormwater controls affect historic properties? (Appendix E, Step 4)
YES
NO
If yes, describe the nature of their response:
Written indication that no historic properties will be affected by the installation of stormwater controls.
Written indication that adverse effects to historic properties from the installation of stormwater controls can be mitigated by
agreed upon actions.
No agreement has been reached regarding measures to mitigate effects to historic properties from the installation of
stormwater controls.
Other:
X. 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 have no personal knowledge that the information submitted is other than 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.
First Name,
Middle Initial,
Last Name:
Title:
Signature:
__________________________________________________________________________________________
Date:
/
/
Email:
EPA Form 3510-9
Page 6 of 9
Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)
This Form Replaces Form 3510-9 (02/12)
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 stormwater
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. Operators 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
obtain coverage under an NPDES general permit. For coverage
under the 2017 CGP, each person, firm, public organization, or
any other entity that meets either of the following criteria must file
a Notice of Intent 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 the permit
conditions. If you have questions about whether you need a
NPDES stormwater permit, or if you need information to determine
whether EPA or your state agency is the permitting authority,
contact your EPA Regional Office.
Completing the Form
Obtain and read a copy of the 2017 CGP, viewable at
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#cgp. 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, telephone EPA’s NOI Processing Center
at (866) 352-7755. Please submit the original document with
signature in ink - do not send a photocopied signature.
Section I. Approval to Use Paper NOI Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper NOI form unless the EPA
Regional Office has approved its use. Where you have obtained
approval to use this form, indicate the waiver that you have been
granted, the name of the EPA staff person who granted the
waiver, and the date that approval was provided.
See https://www.epa.gov/npdes/contact-usstormwater#regional
for a list of EPA Regional Office contacts.
Section II. Permit Number
Provide the master permit number of the permit under which you
are applying for coverage (see Appendix B of the general permit
for the list of eligible master permit numbers)
Section III. Operator Information
Provide the legal name of the person, firm, public organization, or
any other entity that operates the project described in this NOI.
Refer to Appendix A of the permit for the definition of “operator”.
Indicate whether you are seeking coverage under this permit as
a “federal operator” as defined in Appendix A.
EPA Form 3510-9
Form Approved OMB No. 2040-0004
Also provide a point of contact, the operator’s mailing address,
county, telephone number, 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.
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 full name,
organization, phone number, and email address of the NOI
preparer.
Section IV. 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.
Provide the latitude and longitude of your facility in decimal
degrees 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 web-based
siting tools, among others. For consistency, EPA requests that
measurements be taken from the approximate center of the
construction site. For linear construction sites, the measurement
should be taken midpoint of the site. If known, enter the horizontal
reference datum for your latitude and longitude. The horizontal
reference datum is shown on the bottom left corner of USGS
topographic maps; it is also available for GPS receivers.
Indicate whether the project is in Indian country lands or located
on a property of religious or cultural significance to an Indian tribe,
and if so, provide the name of the Indian tribe associated with the
area of Indian country (including name of Indian reservation, if
applicable), or if not in Indian country, provide the name of the
Indian tribe associated with the property.
Enter the estimated construction start and completion dates using
four digits for the year (i.e., 10/06/2012). Indicate to the nearest
quarter acre the estimated area to be disturbed.
Indicate the type of construction site, if demolition is occurring,
and if so, if the structure has at least 10,000 square feet of floor
space. Indicate whether the pre-development land use of the site
was used for agriculture Appendix A defines “agricultural land” as
cropland, grassland, rangeland, pasture, and other agricultural
land, on which agricultural and forest-related products or
livestock are produced and resource concerns may be
addressed. Agricultural lands include cropped woodland,
marshes, incidental areas included in the agricultural operation,
and other types of agricultural land used for the production of
livestock.
Indicate whether earth-disturbing activities have already
commenced on your project/site. If earth-disturbing activities
have commenced on your site because stormwater discharges
from the site have been previously covered under a NPDES permit,
you must provide the 2012 CGP NPDES ID or the NPDES permit
number if coverage was under an individual permit.
Section V. Discharge Information
You must confirm that you understand that the CGP only
authorizes the allowable stormwater discharges listed in Part 1.2.1
and the allowable non-stormwater discharges listed in Part 1.2.2.
Page 7 of 9
Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)
This Form Replaces Form 3510-9 (02/12)
Any discharges not expressly authorized under the CGP are not
covered by the CGP or the permit shield provision of the CWA
Section 402(k) and they cannot become authorized or shielded
by disclosure to EPA, state, or local authorities via the NOI to be
covered by the permit or by any other means (e.g., in the SWPPP
or during an inspection). If any discharges requiring NPDES permit
coverage other than the allowable stormwater and nonstormwater discharges listed in Parts 1.2.1 and 1.2.2 will be
discharged, they must either be eliminated or covered under
another NPDES permit.
Indicate whether discharges from the site will enter into a
municipal separate storm sewer system (MS4), as defined in
Appendix A.
Also, indicate whether any waters of the U.S. exist within 50 feet from
your site. Note that if “yes”, you are required to comply with the
requirement in Part 2.2.1 of the permit to provide natural buffers or
equivalent erosion and sediment controls.
For each unique point of discharge you list, you must specify the
name of the first water of the U.S. that receives stormwater directly
from the point of discharge and/or from the MS4 that the point of
discharge discharges to. You must specify whether any waters of
the U.S. that you discharge to are listed as ”impaired” as defined in
Appendix A, and the pollutants for which the water is impaired. You
must identify any Total Maximum Daily Loads (TMDL) that have
been completed for any of the waters of the U.S. that you discharge
to.
Indicate whether discharges from the site will enter into a water of
the U.S. that is designated as a Tier 2, Tier 2.5, or Tier 3 water. A list
of Tier 2, 2.5, and 3 waters is provided as Appendix F. If the answer
is “yes”, name all waters designated as Tier 2, Tier 2.5, or Tier 3 to
which the site will discharge.
Section VI. Chemical Treatment Information
Indicate whether the site will use polymers, flocculants, or other
treatment chemicals. Indicate whether the site will employ
cationic treatment chemicals. If the answer is “yes” to either
question, indicate which chemical(s) you will use. Note that you
are not eligible for coverage under this permit to use cationic
treatment chemicals unless you notify your applicable EPA
Regional Office in advance and the EPA office authorizes
coverage under this permit after you have included appropriate
controls and implementation procedures designed to ensure that
your use of cationic treatment chemicals will not lead to a
violation of water quality standards. If you have been authorized
to use cationic treatment chemicals by your applicable EPA
Regional Office, attach a copy of your authorization letter and
include documentation of the appropriate controls and
implementation procedures designed to ensure that your use of
cationic treatment chemicals will not lead to a violation of water
quality standards. Examples of cationic treatment chemicals
include, but are not limited to, cationic polyacrylamide (C-PAM),
PolyDADMAC (POLYDIALLYLDIMETHYLAMMONIUM CHLORIDE),
and chitosan.
Section VII. Stormwater Pollution Prevention Plan (SWPPP)
Information
All sites eligible for coverage under this permit are required to
prepare a SWPPP in advance of filing the NOI, in accordance with
Part 7. Indicate whether the SWPPP has been prepared in
advance of filing the NOI.
EPA Form 3510-9
Form Approved OMB No. 2040-0004
Indicate the street, city, state, and ZIP code where the SWPPP can
be found. Indicate the contact information (name, organization,
phone, and email) for the person who developed the SWPPP for
this project.
Section VIII. Endangered Species Information
Using the instructions in Appendix D, indicate under which
criterion (i.e., A, B, C, D, E, or F) of the permit the applicant is
eligible with regard to protection of ESA-listed endangered and
threatened species and designated critical habitat. A description
of the basis for the criterion selected must also be provided.
If criterion B is selected, provide the NPDES Number for the other
operator who had previously certified their eligibility for the CGP
under criterion A, C, D, E, or F. The Tracking Number was assigned
when the operator received coverage under this permit, and is
included in the notice of authorization.
If criterion C is selected, you must attach copies of your site map.
See Part 7.2.4 of the permit for information about what is required
to be in your site map. You must also specify the federally-listed
species and/or federally-designated critical habitat that are
located in the “action area” of the project, and provide the
distance between the construction site and any listed
endangered species and/or their designated critical habitat.
If criterion D, E, or F is selected, attach copies of any
communications between you and the U.S. Fish and Wildlife
Service and National Marine Fisheries Service and identify the
participating agencies and Field Offices/Regional Offices you
worked with in the basis statement of this NOI.
Section IX. Historic Preservation
Use the instructions in Appendix E to complete the questions on
the NOI form regarding historic preservation.
Section X. Certification Information
The NOI 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 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
Page 8 of 9
Instructions for Completing EPA Form 3510-9
Notice of Intent for the 2017 NPDES Construction General Permit
NPDES Form Date (2/17)
This Form Replaces Form 3510-9 (02/12)
(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 and title 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.
Modifying Your NOI
If you have been granted a waiver from your Regional Office
from electronic reporting, and if after submitting your NOI you
need to correct or update any fields on this NOI form, you may
do so by indicating changes on this same form. Paperwork
Reduction Act Notice
Public reporting burden for this NOI is estimated to average 3.95
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
EPA Form 3510-9
Form Approved OMB No. 2040-0004
any correspondence. Do not send the completed form to this
address.
Submitting Your Form
Submit your NOI form by mail to one of the following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2017 CGP
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2017 CGP
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#ereporting
Page 9 of 9
2017 Construction General Permit (CGP)
Appendix K - Notice of Termination (NOT) Form and Instructions
Part 8.3 requires you to use the NPDES eReporting Tool, or “NeT” system, to prepare and submit
your NOT electronically. However, if you are given a waiver by the EPA Regional Office to use a
paper NOT form, and you elect to use it, you must complete and submit the following form.
Page K -1 of 3
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF TERMINATION (NOT) FOR THE 2017 NPDES CONSTRUCTION GENERAL PERMIT
NPDES
FORM
3510-13
Form
Approved.
OMB No.
2040-0004
Submission of this Notice of Termination constitutes notice that the operator identified in Section III of this form is no longer authorized discharge pursuant to
the NPDES Construction General Permit (CGP) from the site identified in Section IV of this form. All necessary information must be included on this form. Refer
to the instructions at the end of this form.
I. Approval to Use Paper NOT Form
Have you been granted a waiver from electronic reporting from the Regional Office *?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract)
that is identified as under-served for broadband Internet access in the most recent report from the Federal
Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
/
Date approval obtained:
/
* Note: You must have been given approval by the Regional Office prior to using this paper NOT form. If you have not obtained a waiver, you must file this
form electronically using the NDPES eReporting Tool (NeT).
II. Permit Information
NPDES ID:
Reason for Termination (Check only one):
You have completed all construction activities at your site, and you have met all other requirements in Part 8.2.1.
Another operator has assumed control over all areas of the site and that operator has submitted an NOI and obtained coverage under the CGP.
You have obtained coverage under an individual permit or another general NPDES permit addressing stormwater discharges from the
construction site.
III. Operator Information
Operator
Name:
Mailing Address:
Street:
City:
State:
ZIP Code:
-
State:
ZIP Code:
-
County or Similar Government Division:
Phone:
-
-
Ext.
E-mail:
IV. Project/Site Information
Project/Site Name:
Project/Site Address:
Street/Location:
City:
County or Similar Government Division:
V. Certification Information
EPA Form 3510-13
Page 1 of 2
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.
First
Name,
Middle
Initial, Last
Name:
Title:
Signature:
____________________________________________________________________________________
Date:
/
/
Email:
EPA Form 3510-13
Page 2 of 2
Instructions for Completing EPA Form 3510-13
Notice of Termination for the 2017 NPDES
Construction General Permit
NPDES Form Date (2/17)
This Form Replaces Form 3510-13 (02/12)
Who May File an NOT Form
Permittees who are presently covered under the EPA-issued 2017
Construction General Permit (CGP) for Stormwater Discharges
Associated with Construction Activity may submit an NOT form
when: (1) earth-disturbing activities at the site are completed and
the conditions in Parts 8.2.1.a through 8.2.1.b are met; or (2) the
permittee has transferred all areas under its control to another
operator, and that operator has submitted and obtained
coverage under this permit; or (3) the permittee has obtained
coverage under a different NPDES permit for the same discharges.
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
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#cgp or telephone EPA’s NOI Processing
Center at (866) 352-7755. Please submit original document with
signature in ink - do not send a photocopied signature.
Section I. Approval to Use Paper NOT Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper NOT form unless the EPA
Regional Office has approved its use. Where you have obtained
approval to use this form, indicate the waiver that you have been
granted, the name of the EPA staff person who granted the
waiver, and the date that approval was provided.
Seehttps://www.epa.gov/npdes/contact-us-stormwater#regional
for a list of EPA Regional Office contacts.
Section II. Permit Information
Enter the existing NPDES ID assigned to the project . If you do not
know the permit tracking number, or contact EPA’s NOI Processing
Center at (866) 352-7755.
Indicate your reason for submitting this Notice of Termination by
checking the appropriate box. Check only one.
Section III. Operator Information
Provide the legal name of the person, firm, public organization, or
any other entity that operates the project described in this NOT
and is covered by the NPDES ID identified in Section II. Enter the
complete mailing address, telephone number, and email address
of the operator.
Section IV. 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 V. Certification Information
The NOT, 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,
EPA Form 3510-13
Form Approved OMB No. 2040-0004
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 NOT 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.
Submitting Your Form:
Submit your NOT form by mail to one of the following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2017 CGP
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2017 CGP
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
https://www.epa.gov/npdes/stormwater-dischargesconstruction-activities#ereporting
Page 3 of 2
United States Environmental Protection Agency
2016 NPDES Pesticide General Permit
Appendix D.
Notice of Intent Form
Part 7.8 requires you to use the NPDES eNOI System to prepare and submit your NOI unless the
electronic system is unavailable. If you are given a waiver by the EPA Regional Office to use a
paper NOI form, and you elect to use it, you must complete and submit the following form.
D-1
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF INTENT (NOI) OF COVERAGE UNDER THE PESTICIDE
GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE APPLICATION
OF PESTICIDES
Form Approved
OMB No.
2040-0284
Submission of this completed Notice of Intent (NOI) constitutes notice that the Operator identified in Section B intends to be authorized to discharge pollutants
to waters of the United States within the pest management area identified in Section C under EPA’s Pesticide General Permit. Submission of this NOI
constitutes notice that the party identified in Section B of this form has read, understands, and meets the eligibility conditions of Part 1 of the permit; agrees to
comply with all applicable terms and conditions of the permit; and understands that continued authorization under the permit is contingent on maintaining
eligibility for coverage. To be granted coverage, all information required on this form must be completed. Please read and make sure you comply with all permit
requirements, including the requirement for large entities to prepare a Pesticide Discharge Management Plan (PDMP) prior to NOI submittal. Refer to the
instructions at the end of this form to complete your NOI.
Approval to Use Paper NOI Form (Electronic Submission Waiver)
Has the EPA Regional Office granted you a waiver from electronic reporting*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the
date of approval:
Waiver granted:
The Decision-maker is physically located in a geographical area (i.e., ZIP code or census tract) that is identified as
under-served for broadband Internet access in the most recent report from the Federal Communications
Commission.
The Decision-maker has limitations regarding available computer access or computer capability.
Name of EPA staff person
who granted the waiver:
/
Date approval obtained:
/
*Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOI form. If you
have not obtained a waiver, you must file this form electronically using the NPDES eNOI system at
https://www.epa.gov/npdes/pesticide-permitting.
A. Notice of Intent Status
1. Mark whether this is the first time you are requesting coverage under the 2016 PGP, or if this is a change of information for a discharge
already covered under the 2016 PGP. If this is a change of information, supply the NPDES permit tracking number for the discharge.
a.
Original NOI Submission
b.
NOI Change of Information:
(NPDES Permit Tracking Number)
Please note: When selecting A.1.b please fill out Section B (Operator Name and Mailing Address) and the fields of the NOI that need to be modified.
B. Operator Information
1. Operator Name:
2. Operator Type (check one):
a.
Federal government
b.
State government
c.
Local government
d.
Mosquito control district (or similar)
e.
Irrigation control district (or similar)
f.
Weed control district (or similar)
g.
Other: If other, provide brief description of
type of Operator:
3. Are you a large entity as defined in Appendix A of the permit? (check one):
Yes
No
Please note: If you answer “Yes” to question 3 you are required to develop a Pesticide Discharge Management Plan (PDMP) and submit an Annual
Report reflecting all pesticide uses for which you are requesting permit coverage under this NOI.
4. In which state are your pest management areas located? Please specify only one state per NOI:
5. Mailing Address:
a. Street:
b. City:
e. Telephone:
c. State:
–
–
Ext
f. Fax:
–
d. ZIP Code:
–
–
g. Contact Name:
h. E-mail:
EPA FORM 6100-22 (Revised October 24, 2016)
Page 1 of 7
C. Pest Management Areas: Complete Section C for each Pest Management Area for which coverage under EPA’s Pesticide
General Permit is desired. Copy this section for additional Pest Management Areas.
Pest Management Area #___ of ##___
1. Pest Management Area Name:__________________________________________________________________________________________________
Provide a map of the location of the Pest Management Area or describe the location of the Pest Management Area in detail.
2. Are any of your activities for which you are requesting coverage under this NOI occurring on Indian Country?
Yes
No
If yes, identify the reservation or otherwise describe those areas:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
3. Are any of your activities (in this pest management area) for which you are requesting coverage under this NOI occurring on areas considered “federal
facilities” as defined by the permit?
Yes
No
4. Mailing address and contact information of the pesticide Applicator (or check here
if same as provided in Section B):
a. Street:
b. City:
c. State:
e. Telephone:
–
–
Ext
–
d. ZIP Code:
f. Fax:
–
–
g. Contact Name:
h. E-mail:
5. Pesticide Use Patterns to be included in this Pest Management Area (check all that apply):
a.
Mosquito and Other Flying Insect Pest Control
c.
Animal Pest Control
b.
Weed and Algae Pest Control
d.
Forest Canopy Pest Control
6. Receiving Waters (check one):
a.
Coverage requested for all waters of the United States within the Pest Management Area identified above.
b.
Coverage requested specifically for the following waters of the United States within the Pest Management Area identified above.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
c.
Coverage requested for all waters of the United States within the Pest Management Area identified above except for:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
7. Tier 3 Waters
Is coverage requested for discharge to a Tier 3 water (Outstanding National Resource Water) of the United States?
If yes, answer a and b:
Yes
No
a. Name of Tier 3 water(s): _________________________________________________________________________________________________
b. Provide rationale for determination that pesticide discharge is necessary to protect water quality, the environment, and/or public health and that
any such discharge will not degrade water quality or will degrade water quality only on a short-term or temporary basis:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
8. Water Quality, Impaired Waters
Operators are not eligible for coverage under this permit for any discharges from a pesticide application to waters of the United States if the waters are
identified as impaired by a substance which is either an active ingredient of the pesticide designated for use or is a degradate of such an active
ingredient. See Part 1.1.2.1 of the permit. Check one:
a.
Waters are NOT impaired by any substance which is either an active ingredient of a pesticide to be discharged or a degradate of such an active
ingredient
b.
Waters are on a current state list as being impaired by a substance which is either an active ingredient of a pesticide to be discharged or a
degradate of such an active ingredient; however, evidence is attached documenting that the waters are no longer impaired.
EPA FORM 6100-22 (Revised October 24, 2016)
Page 2 of 7
D. Endangered Species Protection: Complete Section D for each Pest Management Area for which coverage under EPA’s
Pesticide General Permit is desired. Copy this section for additional Pest Management Areas.
Pest Management Area #___ of ##___
1. Identify the criterion for which you are eligible for permit coverage as it applies to Federally Listed Threatened or Endangered Species (i.e., Species)
and/or Federally Designated Critical Habitat (i.e., Habitat). Check one:
a.
Pesticide application activities will not result in a point source discharge to one or more waters of the United States containing National Marine
Fisheries Service (NMFS) Listed Resources of Concern, as defined in Appendix A, of the PGP.
b.
Pesticide application activities for which permit coverage is being requested will discharge to one or more waters of the United States containing
NMFS Listed Resources of Concern, as defined in Appendix A of the PGP, but consultation with NMFS under Section 7 of the Endangered Species
Act (ESA) has been concluded for pesticide application activities covered under the PGP. Consultations can be either formal or informal, and would
have occurred only as a result of a separate federal action. The consultation addressed the effects of pesticide discharges and discharge-related
activities on federally-listed threatened or endangered species and federally-designated critical habitat, and must have resulted in either:
i. A biological opinion from NMFS finding no jeopardy to federally-listed species and no destruction/adverse modification of federally-designated
critical habitat; or
ii. Written concurrence from NMFS with a finding that the pesticide discharges and discharge-related activities are not likely to adversely affect
federally-listed species or federally-designated critical habitat.
c.
Pesticide application activities for which permit coverage is being requested will discharge to one or more waters of the United States containing
NMFS Listed Resources of Concern, as defined in Appendix A of the PGP, but all “take” of these resources associated with such pesticide
application activities has been authorized through NMFS’ issuance of a permit under section 10 of the ESA, and such authorization addresses the
effects of the pesticide discharges and discharge-related activities on federally-listed species and federally-designated critical habitat. (The term
“take” means to harass, pursue, hunt, shoot, wound, kill, trap, capture, or collect, or to attempt to engage in any such conduct. See Section 3 of the
Endangered Species Act, 16 U.S.C. § 1532 (19).)
d.
Pesticide application activities were, or will be, discharged to one or more waters of the United States containing NMFS Listed Resources of
Concern, as defined in Appendix A of the PGP, but only in response to a Declared Pest Emergency Situation.
e.
Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more waters of the United States
containing NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those where the Decision-maker
includes in the NOI written correspondence from NMFS that pesticide application activities performed consistent with appropriate measures will
avoid or eliminate the likelihood of adverse effects to NMFS Listed Resources of Concern.
f.
Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more waters of the United States
containing NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those from pesticide application
activities that are demonstrated by the Decision-maker as not likely to adversely affect NMFS Listed Resources of Concern or that the pest poses a
greater threat to the NMFS Listed Resources of Concern than does the discharge of the pesticide.
2. If you checked criterion d or criterion f above, provide the following information for all discharges to waters of the United States containing NMFS Listed
Resources of Concern identified within the pest management area for which permit coverage is being requested. For discharges pursuant to criterion d,
Declared Pest Emergency Situations, information for items a through g should also include any discharges that have already occurred prior to NOI
submission as well as the activities you performed in the 15 day period before submission of this NOI was required. In some cases, implementation of
pest management measures as specified in the permit involves a degree of “adaptive management” such that exact timing and quantities of applications
cannot be determined in advance for the duration of the permit. In such cases, the permittee must provide the required information to the extent feasible
and consistent with the implementation of the selected pest management measures.
a.
Describe the location of the pest management area in detail or provide a map of the location
b.
Pest(s) to be controlled:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
c.
Pesticide product(s) to be discharged and method of application: _________________________________________________________________
d.
Planned quantity and rate of discharge(s) for each method of application: __________________________________________________________
e.
Number of planned discharges: ____________
f.
Approximate date(s) of planned discharge(s): ________________________________________________________________________________
g.
Your rationale supporting your determination that you meet the criterion for which you are submitting this NOI, for example, the specific BMPs
applied, visual monitoring, equipment and/or site inspections, and other appropriate measures that will be undertaken to avoid or eliminate the
likelihood of adverse effects. For certifications pursuant to criterion d, indicate whether the discharge is likely to adversely affect NMFS Listed
Resources of Concern in response to a pest emergency and, if so, any feasible measures to avoid or eliminate such adverse effects; for example, it
is not sufficient to state that “integrated pest management procedures will be applied” without describing the specific measures to be taken (attach
additional pages as necessary):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
EPA FORM 6100-22 (Revised October 24, 2016)
Page 3 of 7
E. 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. On the basis of 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.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:
Date:
/
/
Date:
/
/
NOI Preparer (Complete if NOI was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:
–
–
Ext
E-Mail:
EPA FORM 6100-22 (Revised October 24, 2016)
Page 4 of 7
Instructions for Completing the Notice of Intent (NOI) for Coverage Under the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides
Who Must File a NOI with EPA?
Any Operator, as described in Part 1.2.2 of the permit and meeting the eligibility
requirements identified in Part 1.1 of the permit and Table 1-1 below must submit a
complete and accurate NOI. As required in the permit, only certain Operators who are
also Decision-makers must submit NOIs.
Table 1-1. Decision-Makers Required to Submit NOIs
PGP Part/
Which Decision-Makers Must
For Which Pesticide
Pesticide Use
Submit NOIs?
Application Activities?
All four use
Any Decision-maker with an eligible Activities resulting in a
patterns
discharge to a Tier 3 water
discharge to a Tier 3 water
identified in
(Outstanding National Resource
Part 1.1.1
Water) consistent with Part 1.1.2.2
All four use
Any Decision-maker with an eligible Activities resulting in a
patterns
discharge to waters of the United
discharge to waters of the
identified in
States containing NMFS Listed
United States containing
Part 1.1.1
Resources of Concern, as defined in NMFS Listed Resources of
Appendix A
Concern, as defined in
Appendix A
1.1.1(a) Any Agency for which pest
All activities resulting in a
Mosquito and management for land resource
discharge for which the
Other Flying
stewardship is an integral part of the Federal or State agency is
Insect Pest
organization’s operations.
responsible for pest control
Control
Mosquito control districts, or similar All activities resulting in a
pest control districts
discharge for which the
Decision-maker is
responsible for pest control
1.1.1(b) Weed and
Algae Pest
Control
1.1.1(c) Animal Pest
Control
Local governments or other entities
who exceed the annual treatment
area threshold identified here
Adulticide treatment if more
than 6,400 acres during a
calendar year
Any Agency for which pest
management for land resource
stewardship is an integral part of the
organization’s operations.
All activities resulting in a
discharge for which the
Federal or State agency is
responsible for pest control
Irrigation and weed control districts,
or similar pest control districts
All activities resulting in a
discharge for which the
Decision-maker is
responsible for pest control
Local governments or other entities
who exceed the annual treatment
area threshold identified here
Treatment during a calendar
year if more than either:
20 linear miles
OR
80 acres of water (i.e.,
surface area)
Any Agency for which pest
management for land resource
stewardship is an integral part of the
organization’s operations.
All activities resulting in a
discharge for which the
Federal or State agency is
responsible for pest control
Local governments or other entities
who exceed the annual treatment
area threshold identified here
Treatment during a calendar
year if more than either:
20 linear miles
OR
80 acres of water (i.e.,
surface area)
1.1.1.(d) Any Agency for which pest
Forest Canopy management for land resource
Pest Control
stewardship is an integral part of the
organization’s operations.
Local governments or other entities
who exceed the annual treatment
area threshold identified here
All activities resulting in a
discharge for which the
Federal or State agency is
responsible for pest control
Treatment if more than 6,400
acres during a calendar year
If you have questions about whether you need to file an NOI or questions about
completing the form, see https://www.epa.gov/npdes/pesticide-permitting or contact
the NOI Center toll free at 866-352-7755.
One NOI can be submitted for multiple pest management areas in a state for which
you are seeking permit coverage; however, no more than one state can be included on
any single NOI form.
EPA FORM 6100-22 (Revised October 24, 2016)
When to File the NOI?
Do not file your NOI until you have obtained and thoroughly read a copy of the permit.
A copy of the permit is on EPA’s website (https://www.epa.gov/npdes/pesticidepermitting).The permit describes procedures to ensure your eligibility, prepare your
Pesticide Discharge Management Plan (PDMP), and complete the NOI form
questions—all of which must be done before you sign the NOI certification statement
attesting to the accuracy and completeness of your NOI. You will also need a copy of
the permit once you have obtained coverage so that you can comply with the
implementation requirements of the permit. Note: PDMP is not required for 1) any
application made in response to a Declared Pest Emergency Situation, as defined in
Appendix A of the permit; and 2) any Decision-maker who is required to submit an NOI
solely because their application results in a point source discharge to waters of the
United States containing NMFS Listed Resources of Concern, as defined in Appendix
A of the permit.
Approval to Use Paper NOI Form: Note that you are not authorized to use this paper
NOI form unless the EPA Regional Office has approved its use. Where you have
obtained approval to use this form, indicate the waiver that you have been granted, the
name of the EPA staff person who granted the waiver, and the date that approval was
provided.
For any discharges after October 31, 2016: All eligible discharges are authorized for
permit coverage through January 12, 2017 without submission of an NOI. For any
discharges after January 12, 2017, Decision-makers meeting the eligibility
requirements identified in the Part 1.1 of the permit and Table 1-1 must submit a
complete and accurate NOI according to Table 1-2 and Table 1-3 and consistent with
the requirements of Part 1.2 of the permit. Note: NOIs submitted under the 2011 PGP
are automatically terminated on October 31, 2016. Decision-makers who are required
to submit an NOI must submit a new NOI by January 12, 2017 to obtain coverage
under the 2016 PGP.
Table 1-2. NOI Submittal Deadlines and Discharge Authorization Dates for
Discharges from the Application of Pesticides 1
After January 12, 2017, any eligible discharge for which an NOI is required must
submit an NOI consistent with the earliest due date identified below. If EPA receives
an NOI on or before January 2, 2017 (or on or before December 12, 2016, for
discharges to waters of the United States containing NMFS Listed Resources of
Concern), uninterrupted coverage continues. NOI due dates for any discharges
occurring on or after January 12, 2017 are as follows:
NOI Submission
Discharge Authorization
Operator Type
Deadline
Date2
Any Decision-maker with any
At least 30 days before No earlier than 30 days
discharge to waters of the
any discharge to
after EPA posts on the
United States containing NMFS waters of the United
Internet a receipt of a
Listed Resources of Concern,
States containing
complete and accurate
except for those discharges in NMFS Listed
NOI.3, 5
response to a Declared Pest
Resources of Concern,
Emergency Situation, as
as defined in Appendix
defined in Appendix A.
A. 5
Any Decision-maker with a
discharge in response to a
Declared Pest Emergency
Situation for which that activity
triggers the NOI requirement
identified in Part 1.2.2, except
for any discharges to waters of
the United States containing
NMFS Listed Resources of
Concern.
No later than 30 days
after beginning
discharge.
Immediately upon
beginning to discharge for
activities conducted in
response to a Declared
Pest Emergency
Situation.
Any Decision-maker with any
discharge to waters of the
United States containing NMFS
Listed Resources of Concern, in
response to a Declared Pest
Emergency Situation, as
defined in Appendix A.
No later than 15 days
after beginning to
discharge in response
to a Declared Pest
Emergency Situation.
Immediately upon
beginning to discharge for
activities conducted in
response to a Declared
Pest Emergency Situation
for a period of at least 60
days. 4
Any Decision-maker who
exceeds any annual treatment
area threshold.
At least 10 days before
exceeding an annual
treatment area
threshold.
No earlier than 10 days
after EPA posts on the
Internet receipt of a
complete and accurate
NOI.
Page 5 of 7
Operator Type
Any Decision-maker otherwise
required to submit an NOI as
identified in Table 1-1
1
2
3
4
5
NOI Submission
Deadline
At least 10 days before
any discharge for
which an NOI is
required
Discharge Authorization
Date2
No earlier than 10 days
after EPA posts on the
Internet receipt of a
complete and accurate
NOI.
State, territory and tribal specific requirements in addition to the requirements in this
table are provided in Part 9 of the permit.
On the basis of a review of an NOI or other information, EPA may delay
authorization to discharge beyond any timeframe identified in Table 1-2, determine
that additional technology-based and/or water quality-based effluent limitations or
other conditions are necessary, or deny coverage under this permit and require
submission of an application for an individual NPDES permit, as detailed in Part 1.3
of the permit.
Within 30 days after EPA posts on the Internet receipt of a complete and accurate
NOI, for those areas with NMFS Listed Resources of Concern, as defined in
Appendix A of the permit, NMFS will provide EPA with a determination as to
whether it believes the eligibility criterion of “not likely to adversely affect listed
species or designated critical habitat” has been met, could be met with conditions
that NMFS identifies, or has not been met. EPA expects to rely on NMFS’
determination in deciding whether to withhold authorization. If NMFS does not
provide EPA with this information within 30 days of EPA posting on the Internet
receipt of a complete and accurate NOI, the discharges will be authorized 30 days
after EPA posts on the Internet receipt of a complete NOI.
In any Declared Pest Emergency Situation in areas with waters of the United States
containing NMFS Listed Resources of Concern, NMFS will have 30 days after
submission of an NOI to provide EPA with a determination as to whether the
eligibility criteria of “not likely to adversely affect listed species or designated critical
habitat” has been met, could be met with conditions that NMFS identifies, or has
not been met. EPA expects to rely on NMFS’ determination in deciding whether to
allow continued permit coverage and if additional conditions are necessary. If
NMFS does not provide EPA with a recommendation within 30 days of EPA posting
on the Internet receipt of a complete and accurate NOI, authorization for these
discharges will continue. If EPA identifies additional permit conditions, or includes
additional permit conditions recommended by NMFS, as necessary to qualify
discharges as eligible for coverage beyond 60 days under the PGP, those
conditions remain in effect for the life of the permit.
EPA may authorize certain discharges in less than 30 days, but no fewer than 10
days, for any discharges authorized under Criterion B, C, or E of Part 1.1.2.4 (for
which NMFS has already evaluated the effects of these discharges).
Table 1-3. NOI Change of Information Submittal Deadlines and Discharge
Authorization Dates
NOI Submission
Discharge Authorization
Operator Type
Deadline
Date
Any Decision-maker requiring
At least 10 days
No earlier than 10 days
permit coverage for a pest
before beginning to after EPA posts on the
management area not identified discharge in that
Internet the receipt of a
on a previously submitted NOI newly identified area complete and accurate NOI
for this permit, except for
unless discharges
unless discharges are in
discharges to any; (1) Tier 3
are in response to a response to a Declared
water, or (2) waters of the
Declared Pest
Pest Emergency Situation
United States containing NMFS Emergency Situation in which case coverage is
Listed Resources of Concern.
in which case not
available immediately upon
Except for such waters,
later than 30 days
beginning to discharge
changes other than
after beginning
from activities conducted in
identification of a new pest
discharge.
response to Declared Pest
management area or a new
Emergency Situation.
pesticide use pattern do not
require a revised NOI submittal.
Any Decision-maker discharging
to a Tier 3 water not identified
by name on a previously
submitted NOI for this permit,
except for Tier 3 waters
containing NMFS Listed
Resources of Concern
At least 10 days
before beginning to
discharge in that
newly identified area
unless discharges
are in response to a
Declared Pest
Emergency Situation
in which case not
later than 30 days
after beginning
discharge.
EPA FORM 6100-22 (Revised October 24, 2016)
No earlier than 10 days
after EPA posts on the
Internet the receipt of a
complete and accurate NOI
unless discharges are in
response to a Declared
Pest Emergency Situation
in which case coverage is
available immediately upon
beginning to discharge
from activities conducted in
response to Declared Pest
Emergency Situation.
Operator Type
Any Decision-maker with any
discharge to waters of the
United States containing NMFS
Listed Resources of Concern,
as defined in Appendix A, not
identified on a previously
submitted NOI for this permit.
This includes changes in any
treatment area, pesticide
product, method or rate of
application, or approximate
dates of applications.
NOI Submission
Deadline
At least 30 days
before beginning to
discharge in that
newly identified
treatment area
unless discharges
are in response to a
Declared Pest
Emergency Situation
in which case not
later than 15 days
after beginning
discharge.
Discharge Authorization
Date
No earlier than 30 days
after EPA posts on the
Internet receipt of a
complete and accurate NOI
unless discharges are in
response to a Declared
Pest Emergency Situation
in which case coverage is
available immediately upon
beginning to discharge
from activities conducted in
response to Declared Pest
Emergency Situation.
Where to File the NOI
The Decision-maker must prepare and submit the NOI using EPA’s electronic Notice
of Intent system (eNOI) available on EPA’s website
(https://www.epa.gov/npdes/pesticide-permitting) unless the Decision-maker is granted
a waiver from the requirement to use eNOI for submission of the NOI. See Part 8 of
the PGP for EPA Regional contacts. The Electronic Submission Waiver is at the top of
this form.
EPA will immediately post on the pesticides eNOI Website all NOIs received. Late
NOIs will be accepted, but authorization to discharge will not be retroactive.
If you are granted a waiver from using eNOI; you must send the NOI form to one of the
addresses listed below.
Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you have questions, contact EPA’s Pesticides Notice Processing Center toll free at
866-352-7755.
If you file a paper NOI, submit the original with a signature in ink. Do not send
copies. Also, faxed copies will not be accepted.
If you are required to develop a PDMP, that document does not need to be
submitted for review unless specifically requested by EPA. You must keep a
copy of your PDMP 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 Pesticides eNOI System.
Section A. NOI Status
1. Indicate if this is the first time you are requesting coverage under the permit or if
this is a change of information.
a. Check this box if this is the first time you are requesting coverage under the permit
for these discharges. If this is the first time you are requesting coverage, refer to
Table 1-2 for NOI submittal deadlines and discharge authorization dates.
b. Check this box if this is a change of information for a discharge already covered
under the permit. If this is a change of information, supply the NPDES permit
tracking number that you received in your confirmation letter or e-mail from EPA’s
Pesticide Notice Processing Center. You can find the tracking number assigned to
your previous NOI using EPA’s eNOI System
(https://www.epa.gov/npdes/pesticide-permitting). For additional details regarding a
change of information, see Table 1-3. Also fill out Section B of this form (Operator
Name and Mailing Address) and the associated fields of information that need to be
modified on the NOI.
Page 6 of 7
Section B. Operator Information
1. Provide the legal name of the person, firm, public organization or any other public
entity who is the Decision-maker for the pesticides applications described in this
notice. A Decision-maker is an Operator who has control over the decision to
perform pesticide applications including the ability to modify those decisions that
result in a discharge to waters of the United States.
2. Indicate the type of Operator: federal government, state government, local
government, mosquito control district (or similar), irrigation control district (or
similar), weed control district (or similar), or other. If other, provide brief description
of type of Operator in the space provided.
3. Indicate whether or not you are a “large entity” as defined in Appendix A of the
permit. Note that if you are a large entity, you are required to develop a Pesticide
Discharge Management Plan (PDMP) and submit future Annual Reports reflecting
all pesticide uses for which you are requesting permit coverage under this NOI.
4. Indicate which state your pest management areas are located. Specify only one
state per NOI. If there is more than one state, additional NOIs must be submitted.
5. Provide the Decision-maker’s mailing address, telephone number, fax number
(optional), name, and e-mail address. Correspondence will be sent to this address.
Section C. Pest Management Area: Information for each Pest Management Area
for which coverage under EPA’s Pesticide General Permit is desired.
1. Indicate whether you are submitting an NOI for multiple pest management areas. A
pest management area is the area of land, including any water, for which you have
responsibility and are authorized to conduct pest management activities as covered
by this permit (e.g., if you are a mosquito control district, your pest management
area is the total area of the district). You must complete a Section C for each pest
management area. If you are submitting an NOI for only one area, enter “1” of “1.” If
you are submitting NOIs for multiple pest management areas, enter the number for
the NOI for which you are requesting coverage followed by the total number of pest
management areas for which you are requesting coverage. Enter the name of the
pest management area. Attach a map of the pest management area or describe the
location of the pest management area in the space provided. A mapping tool is
available at https://www.epa.gov/npdes/pesticide-permitting-PGP-eNOI.
2. Indicate whether pesticide application will occur on Indian Country, and if so,
provide the name of the reservation, if applicable.
3. Indicate whether pesticide application will occur on a Federal Facility, as defined in
Appendix A of the permit.
4. Enter the mailing address of the contact person for the pest management area. If
this address is the same as the Decision-maker’s mailing address, indicate that by
checking the box. If it is a different address, enter the mailing address, telephone
number, fax number (optional), contact name, and e-mail address.
5. Indicate the pesticide use patterns for the pest management area for which the NOI
is required. For additional information regarding pesticide use patterns, see Part
1.1.1 of the permit. Check all the use patterns that apply to the pest management
area.
6. Indicate if permit coverage is being requested for all waters of the United States
within the pest management area or if permit coverage is being requested to
specific waters of the United States within the pest management area. If specific
waters are being requested, write the names of the waterbodies. If permit coverage
is being requested for all waters of the United States within the pest management
area except for specific waterbodies, name those specific waterbodies in the space
provided. EPA’s Water Locator Tool can help you identify the closest receiving
water to your facility (http://www.epa.gov/waterdata/waters-tools).
7. Indicate if permit coverage is being requested to discharge to a Tier 3 (Outstanding
National Resource Water) water of the United States. If yes, write the name(s) of
the Tier 3 water(s) in the space provided. Describe and demonstrate why it is
necessary to apply the pesticide discharge to protect the water quality,
environment, and/or public health and that any such discharge will not degrade
water quality or will degrade water quality only on a short-term or temporary basis.
8. Verify that waters within the pest management area are either not impaired by
substances which are either active ingredients in the pesticide planned for use or
degradates of such active ingredients, OR that evidence shows that the target
waters in question are no longer impaired. See Part 1.1.2.1 of the permit for more
information on discharges to Water Quality Impaired Waters.
Section D. Endangered Species Protection. Complete Section D for each Pest
Management Area for which coverage under EPA’s PGP is desired.
specific criteria for determining eligibility. To demonstrate eligibility, you must meet one
or more of the six criteria (a-f) for the entire term of coverage under the permit.
2. If you checked criterion d or criterion f, you are required to provide a description of
the location of the pest management area or a map of the location of the pest
management area, the pest(s) to be controlled, pesticide product(s) to be discharged
and method of application, planned quantity and rate of discharge(s) for each
application method, number of planned discharges, approximate date(s) of planned
discharge(s), and the rational supporting your determination that you meet the criterion
for which the Decision-maker is submitting this NOI and documentation demonstrating
the finding of “not likely to adversely affect.” If you certify under criteria f and do not
hear from EPA within 30 days, you may assume your discharge is authorized. For
certifications pursuant to criterion d, indicate whether the discharge is likely to
adversely affect NMFS Listed Resources of Concern and, if so, any feasible measures
to avoid or eliminate such adverse effects. If you are certifying under criterion d (which
allows you to discharge 15 days before you even submit your NOI), your NOI should
describe both the pest emergency activities you plan to do after you submit your NOI
as well as the activities you performed in that 15 day period before you had to submit
the NOI. See Part 1.1.2.4 of the permit for more information regarding Endangered
and Threatened Species and Critical Habitat Protection. If you certify under criterion d
and do not hear from EPA, you may assume that permit authorization continues
unless notified otherwise. EPA may authorize certain discharges in less than 30 days,
but no fewer than 10 days, for any discharges authorized under criterion b, c, or e (for
which NMFS has already evaluated the effects of these discharges). If you certify
under one of these criteria and do not hear from EPA within 30 days, you may assume
your discharge is authorized.
Section E. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by 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 that govern the
operation of the regulated activity 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 PDMP contact or a consultant for the certifier’s signature), include
the name, organization, phone number and e-mail address of the NOI preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 2.5 hours or 150 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the Director,
Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in
any correspondence. Do not send the completed NOI form to that address.
Identify the Pest Management Areas, corresponding to those in Part C.
1. Coverage under the permit is available only for discharges and discharge-related
activities, as defined in Appendix A of the permit, that are not likely to jeopardize the
continued existence of any species that are federally- listed as endangered or
threatened (“listed”) under the Endangered Species Act (ESA) and not likely to result
in the adverse modification or destruction of habitat that is federally-designated as
critical under the ESA (“critical habitat”) except as provided in criterion b, c, and for at
least 60 days, d, below. For a subset of listed species and critical habitat, identified as
NMFS Listed Resources of Concern and defined in Appendix A of the permit, there are
EPA FORM 6100-22 (Revised October 24, 2016)
Page 7 of 7
United States Environmental Protection Agency
2016 NPDES Pesticide General Permit
Appendix E.
Notice of Termination Form
Part 7.8 requires you to use the NPDES eNOI System to prepare and submit your NOT unless
the electronic system is unavailable. If you are given a waiver by the EPA Regional Office to use
a paper NOT form, and you elect to use it, you must complete and submit the following form.
E-1
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT
(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES
Form Approved
OMB No.
2040-0284
Approval to Use Paper NOT Form (Electronic Submission Waiver)
Has the EPA Regional Office granted you a waiver from electronic reporting*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:
The Decision-maker is physically located in a geographical area (i.e., ZIP code or census tract) that is identified as underserved for broadband Internet access in the most recent report from the Federal Communications Commission.
The Decision-maker has limitations regarding available computer access or computer capability.
Name of EPA staff person
who granted the waiver:
Date approval obtained:
/
/
*Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOT form. If you have not
obtained a waiver, you must file this form electronically using the NPDES eNOI system at https://www.epa.gov/npdes/pesticidepermitting.
A. Permit Information
1. NPDES Permit Tracking Number:
2. Reason for termination (check one only):
a. You have ceased all discharges from the application of pesticides for which you obtained permit coverage and you do not expect
to discharge during the remainder of the permit term.
b. You have obtained permit coverage under an NPDES individual permit or alternative NPDES general permit for all pesticide
discharges requiring NPDES permit coverage.
c. A new Operator has taken over decision-making responsibility for the pest
control activities covered under an existing NOI. Provide the transfer date and
the new Operator information.
Date of transfer:
/
/
New Operator Name:
Street:
City:
State:
Telephone:
–
ZIP Code:
–
–
Ext.
E-mail:
B. Operator Information
1. Operator Name:
2. Mailing Address:
Street:
City:
State:
Telephone:
–
ZIP Code:
–
–
Ext.
3. Contact Name:
E-mail:
EPA FORM 6100-0023 (Revised October 24, 2016)
Page 1 of 3
C. Certification
I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A above. I understand that by
submitting this Notice of Termination, I am no longer authorized to discharge pesticides to waters of the United States. This document and all
attachments were prepared under my direction and supervision in accordance with a system designed to ensure that qualified personnel properly
gather and evaluate the information submitted. On the basis of 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 or imprisonment. Additionally, I understand
that the submittal of this Notice of Termination does not release a pesticide Operator from liability for any violations of the Clean Water Act.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:
Date:
/
/
Date:
/
/
NOT Preparer (Complete if NOT was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:
–
–
Ext.
E-Mail:
EPA FORM 6100-0023 (Revised October 24, 2016)
Page 2 of 3
INSTRUCTIONS FOR COMPLETING THE NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT (PGP) FOR
DISCHARGES FROM THE APPLICATION OF PESTICIDES
Who Must File an NOT with EPA?
Any Operator required to submit a Notice of Intent (NOI) is required to submit a
Notice of Termination (NOT) to end coverage under this permit. However, if EPA
notifies the Operator to apply for an NPDES individual permit or alternative general
permit, coverage under this permit terminates automatically. Dischargers
automatically covered under this permit as identified in Part 1.2.3 of the permit are
likewise automatically terminated upon permanent cessation of discharge consistent
with any of the criteria identified in Part 1.2.5.3 of the permit. As required in the
permit, only certain Operators who are also Decision-makers must submit NOIs.
Note: NOIs submitted under the 2011 PGP are automatically terminated on
October 31, 2016. Decision-maker who are required to submit an NOI must submit a
new NOI to obtain coverage under the 2016 PGP.
If you have questions about whether you need to file an NOT or questions about
completing the form, see https://www.epa.gov/npdes/pesticide-permitting or contact
the NOI Center toll free at 866-352-7755.
When to File the NOT?
Approval to Use Paper NOT Form: Note that you are not authorized to use this
paper NOT form unless the EPA Regional Office has approved its use. Where you
have obtained approval to use this form, indicate the waiver that you have been
granted, the name of the EPA staff person who granted the waiver, and the date
that approval was provided.
Operators must file the NOT form within 30 days after one or more of the conditions
in Part 1.2.5.2 of the permit have been met.
Where to File the NOT?
Consistent with Part 1.2.5.1 of the permit, the Operator must submit the NOT using
EPA’s electronic Notice of Intent (eNOI) System available on EPA’s website
(https://www.epa.gov/npdes/pesticide-permitting) unless the Operator is granted a
waiver from the requirement to use eNOI for submission of the NOT. See Part 8 of
the PGP for EPA Regional contacts. The Electronic Submission Waiver is at the top
of this NOT form.
Filing electronically is the fastest way to terminate permit coverage and help ensure
that your NOT is complete.
If you are granted a waiver from using eNOI; you must send the NOT form to one of
the addresses listed below.
Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you file a paper NOT, submit the original form with a signature in ink. Do not send
copies. Also, faxed copies will not be accepted.
Completing the NOT Form
To complete this form, type or print in uppercase letters in the appropriate areas
only. 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
can also use this paper form as a checklist for the information you will need when
filing an NOT electronically via EPA’s Pesticides eNOI system.
b. Select this box if you have obtained NPDES individual permit coverage or
alternative NPDES permit coverage.
c. Select this box if a new Operator has taken over decision-making
responsibility of pest control activities covered under an existing NOI and you
are no longer the Operator. Provide the date of transfer and the name and
contact information of the new Operator.
Section B. Operator Information
1. Provide the full legal name of the person, firm, public organization, or other entity
that is the Operator who is the Decision-maker for the pesticide application
described in this application.
2. Provide the Operator’s mailing address and telephone number. Correspondence
will be sent to this address.
3. Provide a contact person’s full legal name and e-mail address. This person will
be contacted regarding any NOT communication.
Section C. Certification
Carefully read the certification statement. By completing and submitting the NOT,
the Operator certifies that the Operator is no longer authorized to discharge
pesticides to waters of the United States. Provide the printed full legal name, title
and email address of the certifier. Sign and date the form. (CAUTION: An unsigned
or undated NOT form will prevent the termination 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 that govern
the operation of the regulated activity 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 NOT was prepared by someone other than the certifier (for example, if the
NOT was prepared by the PDMP contact or a consultant for the certifier’s
signature), include the name, organization, phone number and e-mail address of the
NOT preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 0.5 hours or 30 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed NOT form to that
address.
Section A. Permit Information
1. Enter the existing NPDES Permit Tracking Number assigned by eNOI or the EPA’s
Pesticides Processing Center. You can find the tracking number assigned to your
previous NOI using EPA’s eNOI System (https://www.epa.gov/npdes/pesticidepermitting).
2. Select the appropriate box to indicate why you are submitting an NOT to end
permit coverage. Select one of the three termination options:
a. Select this box if you have ceased all discharges from the application of
pesticides for which you obtained permit coverage and you do not expect to
discharge during the remainder of the permit term.
EPA FORM 6100-0023 (Revised October 24, 2016)
Page 3 of 3
United States Environmental Protection Agency
2016 NPDES Pesticide General Permit
Appendix F.
Pesticide Discharge Evaluation Worksheet
F-1
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
PESTICIDE DISCHARGE EVALUATION WORKSHEET FOR THE
PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE
APPLICATION OF PESTICIDES
Form Approved
OMB No.
2040-0284
This worksheet is for any Operator who is also a Decision-maker required to submit a Notice of Intent (NOI) and is a small entity, as defined in Appendix
A of the Pesticide General Permit (PGP). The information on this worksheet must be retained for each pesticide application activity.
A. General Information
1. Operator Name:
NPDES Permit Tracking
Number:
2. Worksheet Preparer Name:
3. Pest Management Area: # __ of ## ____
4. Pest Management Area Name: ________________________________________________________________________________________
5. Indicate the pesticide use pattern for the Pest Management Area:
a.
Mosquito and Other Flying Insect Pests
b.
Weed and Algae Pests
c.
Animal Pests
d.
Forest Canopy Pests
6. For each treatment area (use additional pages for each treatment area):
a. Provide a description of the treatment area within this Pest Management Area, including location description:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
b. Size of treatment area (in acres or linear feet): _____ acres or ______ linear feet.
c. Name or location of any waters of the United States to which discharges occurred:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
B. Pest Evaluation
1. Identify the target pest(s) and explain why pest control is needed:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Describe Pest Management Measure(s) implemented before the first pesticide application:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
C. Pesticide Application
1. Name and contact information for pesticide Applicator(s):
Company Name:
Street:
City:
State:
Zip Code:
-
Contact Name:
Phone:
–
–
Ext.
E-mail:
EPA FORM 6100-0026 (REVISED October 24, 2016)
Page 1 of 3
/
2. Pesticide application start date:
/
/
Pesticide application end date:
/
3. Name of each pesticide product used, EPA registration number, and quantity of pesticide applied (as packaged or as formulated): Circle lbs or gallons.
Product Name
Product Name
Product Name
EPA Reg. No.
EPA Reg. No.
EPA Reg. No.
Quantity
(lbs or gallons)
Quantity
(lbs or gallons)
Quantity
(lbs or gallons)
Application
method:
Application
method:
Application
method:
____________________________
____________________________
4. Was visual monitoring conducted during pesticide application and/or post-application?
Yes.
___________________________
No. If no, describe why not?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. Were any adverse effects identified during visual monitoring?
Yes.
No. If yes, describe.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
D. 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. On the basis of my inquiry of the person or persons
who manage the system, or those persons directly responsible for gathering the information, the information contained is, to the best of my knowledge
and belief, true, accurate, and complete. I am aware that there are significant penalties for recording false information, including the possibility of fine
and imprisonment for knowing violations.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:
/
Date:
/
Pesticide Discharge Evaluation Worksheet Preparer (Complete if worksheet was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:
–
–
Ext.
Date:
/
/
E-Mail:
EPA FORM 6100-0026 (REVISED October 24, 2016)
Page 2 of 3
Instructions for Completing the Pesticide Discharge Evaluation Worksheet (PDEW) for the PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE
APPLICATION OF PESTICIDES
Who Must Complete a PDEW?
Any Operator, who is a Decision-maker required to submit a Notice of Intent (NOI)
and is a small entity as defined in Appendix A of the permit may complete this
Pesticide Discharge Evaluation Worksheet (PDEW) to meet the requirements of
Part 7.4 of the PGP.
Pest management area, as defined in Appendix A of the permit, can be a large
area (e.g., an entire town) or a very specific well-defined management area (e.g., a
lake). Thus, a pest management area can have one or more treatment areas.
Operators required to retain the information contained on this worksheet must do
so for each treatment area. For treatment areas with the same or similar pests, the
Operator can use one worksheet to document pest management activities for
those multiple treatment areas.
When to Complete a PDEW?
Before any pesticide application, any Operator using this form to meet its
obligations under the PGP must complete Section B of this worksheet. Section C,
except for the pesticide application end date and total quantity of pesticide applied,
must be completed as soon as possible but no later than 14 days after the first
pesticide application. The total quantity of pesticide applied and the pesticide
application end date must be completed as soon as possible but no later than 14
days after completion of pesticide application for this project.
Any Operator using this form to meet its obligations under the PGP must retain this
worksheet for at least 3 years from the date that coverage is granted under the
PGP or when the permit expires or is terminated. These Operators must make this
worksheet available to EPA, including an authorized representative of EPA, upon
request.
Completing the PDEW
To complete this form, type or print in uppercase letters in the approriate areas
only. Make sure you complete all questions.
Section A. General Information
1. Enter the Operator’s full legal name and the existing NPDES Permit Tracking
Number assigned by eNOI or the EPA’s Pesticides Processing Center. You can
find the tracking number assigned to your previous NOI using EPA’s eNOI
System (https://www.epa.gov/npdes/pesticide-permitting).
2. Enter the full legal name of the person completing the form.
3. Section A should be completed for each Pest Management Area. Indicate which
Pest Management Area out of the total number of Pest Management Areas for
which the section is being completed (i.e., Pest Management Area 1 of 10 total
Pest Management Areas).
4. Enter the name of the Pest Management Area.
5. Identify the pesticide use pattern(s) for the Pest Management Area.
6. For each treatment area, provide a brief description and location description of
the treatment area within the Pest Management Area; size of the treatment
area in acres or linear feet, and name or location of any waters of the United
States to which discharges occur.
5. Indicate if there were any adverse effects identifed during visual monitoring.
Provide a brief decription of any adverse effects that were identified.
Section D. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by 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 that govern
the operation of the regulated activity 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 PDEW was prepared by someone other than the certifier (for example, if the
PDEW was prepared by a consultant for the certifier’s signature), include the
name, organization, phone number and e-mail address of the PDEW preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 1 hour or 60 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Pesticide
Discharge Evaluation Worksheet to this address.
Section B. Pest Evaluation
1. Identify the target pest(s) and provide a brief description of why pest control is
needed.
2. Provide a brief description of any Pest Management Measure(s) implemented
before pesticide application. For example, identify if you have performed
physical control techniques such as pulling weeds, removing breeding habitat,
or trapping animals.
Section C. Pesticide Application
1. Provide the company name and contact information of the pesticide Applicator.
2. Enter the date that the pesticide application began and ended.
3. Enter the name of each pesticide product used including the EPA Pesticide
Registraion Number, the quanity of pesticide applied, and the method used to
apply the pesticide (e.g., fixed wing aircraft, backpack sprayer).
4. Indicate if visual monitoring was conducted during the pesticide application
and/or post-application. If visual monitoring was not performed, provide a brief
description of why visual monitoring was not conducted.
EPA FORM 6100-0026 (REVISED October 24, 2016)
Page 3 of 3
United States Environmental Protection Agency
2016 NPDES Pesticide General Permit
Appendix G.
Annual Report Template
Part 7.8 requires you to use the NPDES eNOI System to prepare and submit your Annual Report
unless the electronic system is unavailable. If you are given a waiver by the EPA Regional
Office to use a paper Annual Report form, and you elect to use it, you must complete and submit
the following form.
G-1
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR
DISCHARGES FROM THE APPLICATION OF PESTICIDES
Form Approved
OMB No.
2040-0284
This form is for any Operator who is a Decision-maker required to submit an NOI. The annual report must be submitted no later than February 15 of the following year for all
pesticide activities covered under the permit occurring during the previous calendar year as detailed in Part 7 of the permit.
Approval to Use Paper Annual Report Form (Electronic Submission Waiver)
Has the EPA Regional Office granted you a waiver from electronic reporting*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:
The Decision-maker is physically located in a geographical area (i.e., ZIP code or census tract) that is identified as under-served for broadband
Internet access in the most recent report from the Federal Communications Commission.
The Decision-maker has limitations regarding available computer access or computer capability.
Name of EPA staff person who granted
the waiver:
/
Date approval obtained:
/
*Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper annual reporting form. If you have not obtained a
waiver, you must file this form electronically using the NPDES eNOI system at https://www.epa.gov/npdes/pesticide-permitting.
A. General Information - For pesticides activities in calendar year:
1. NPDES Permit Tracking Number:
2. Operator Name:
3. Operator Contact Information:
a. Street:
b. City:
c. State:
–
e. Telephone:
–
Ext
f. Fax:
d. ZIP Code:
–
–
–
4. Contact Information:
a. Contact Name:
b. Title:
c. E-mail:
B. Adverse Incidents and Corrective Actions
1. Was an adverse incident observed and/or corrective actions taken for any Pest Management Area for which you have coverage under the permit?
a.
No adverse incidents were observed or no corrective action was taken. (Proceed to Section C)
b.
Yes, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-6 for each Pest Management Area in which adverse
incidents were observed or corrective actions were taken. Copy this section for additional Pest Management Areas).
Pest Management Area #____ of ##____
2. Pest Management Area Name: ___________________________________________________________________________________________________
3. If applicable, provide the date for any adverse incidents as a result of those treatment(s), as described in Part 6.4 of the permit (use additional pages, if needed):
Date of adverse incident observation:
/
/
4. Date and time the Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, and any instructions received from EPA.
a.
Date:
b.
Time: ___________________________________________
/
/
c.
Who the Operator spoke with at EPA: ________________________________________
d.
Instructions received from EPA:
________________________________________________________________________
________________________________________________________________________
5. Date of submission of Thirty (30)-Day Adverse Incident Written Report:
/
/
6. Describe any corrective action(s), including spill responses, resulting from pesticide application activities and the rationale for such action(s), subsequent to those steps
described in the Thirty (30)-Day Adverse Incident Written Report:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
EPA FORM 6100-25 (Revised October 24, 2016)
NOTE: Copy this page and attach additional pages as necessary
Page 1 of 5
C. Pest Management Area(s) (use additional pages for each Pest Management Area)
Pest Management Area
#
of ##
1. Have any discharges from pest control activities occurred in this calendar year?
a.
No discharge from pest control activities this calendar year. Note: Checking this box completes Section C if you had no discharge from pest control activities this
year. Proceed to section D.
b.
Yes. Proceed to question 2.
For each treatment area (use additional pages for each treatment area):
2. Indicate the pesticide use pattern for the treatment area:
a.
Mosquito and Other Flying Insect Pest Control
b.
Weed and Algae Pest Control
c.
Animal Pest Control
d.
Forest Canopy Pest Control
3. Description of treatment area:
a. Provide a map or description of the treatment area within this Pest Management Area, including location description _____________________________________
______________________________________________________________________________________________________________________________
b.
Size of treatment area (in acres or linear feet): _____ acres or ______ linear feet.
c.
Name or location of any waters of the United States to which discharges occurred:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
d.
Target Pest(s): ___________________________________________________________________________________________________________________
e.
Did any pesticide application activities result in a discharge to waters of the United States containing NMFS Listed Resources of Concern as defined in
Appendix A of the permit?
Yes
No
If yes, approximate date(s) of any discharges: ___________________________________________________________________________
4. Name and contact information of pesticide Applicator(s) (or check here if same as provided in Section A):
Company Name:
Street:
City:
State:
Contact Name:
Zip Code:
-
Title:
–
Phone:
–
Ext
E-mail:
5. Was this pest control activity addressed in your Pesticide Discharge Monitoring Plan (PDMP) before pesticide application:
Yes
No
Not Applicable
6. Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Pesticide Registration Number(s) and by application method.
Circle if quantity indicated is in lbs or gallons, or briquettes, if applicable. Use additional pages if necessary.
Product Name ___________________________
Product Name __________________________
EPA Pesticide Registration Number :
EPA Pesticide Registration Number :
Application method:
Quantity Applied (lbs or
gallons of product):
Application method:
Aerially by fixed-wing
______ lbs or gallons
a.
b.
Aerially by rotary aircraft
______ lbs or gallons
c.
Land-based sprayer (includes backpack, land
vehicle mounted sprayers, high pressure
canopy sprayer)
______ lbs or gallons
d.
Aquatic vehicle mounted sprayer
e.
Quantity Applied (lbs or
gallons of product):
Aerially by fixed-wing
______ lbs or gallons
b.
Aerially by rotary aircraft
______ lbs or gallons
c.
Land-based sprayer (includes backpack, land
vehicle mounted sprayers, high pressure
canopy sprayer)
______ lbs or gallons
______ lbs or gallons
d.
Aquatic vehicle mounted sprayer
______ lbs or gallons
Direct mixture (includes metering, subsurface
applications)
______ lbs or gallons
e.
Direct mixture (includes metering, subsurface
applications)
______ lbs or gallons
f.
Chemigation
______ lbs or gallons
f.
Chemigation
______ lbs or gallons
g.
Other (specify): _____________________
______ lbs or gallons or
briquettes
g.
Other (specify): ___________________
______ lbs or gallons or
briquettes
a.
EPA FORM 6100-25 (Revised October 24, 2016)
NOTE: Copy this page and attach additional pages as necessary
Page 2 of 5
D. Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. On the basis of 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.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:
Date:
/
/
/
/
Annual Report Preparer (Complete if the Annual Report was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:
–
–
Ext
Date:
E-Mail:
EPA FORM 6100-25 (Revised October 24, 2016)
NOTE: Copy this page and attach additional pages as necessary
Page 3 of 5
Instructions for Completing the Annual Reporting Form for the Pesticide General Permit (PGP) for
Discharges from the Application of Pesticides
Who Must File an Annual Report with EPA?
Any Operator who is a Decision-maker required to submit a Notice of Intent (NOI)
and is a large entity as defined in Appendix A of the permit and any Decision-maker
required to submit an NOI solely because of their application results in a discharge
to waters of the United States containing NMFS Listed Resources of Concern, must
submit an annual report to EPA each calendar year. Once required to submit an
annual report for one year, an annual report must be filed each subsequent year of
this permit whether or not you have discharges from the application of pesticides in
accordance with Section 7.6 of the permit.
When to File an Annual Report?
Any Operator required to file an annual report must submit the annual report no later
than February 15 of the following year for all pesticide activities covered under this
permit occurring during the previous calendar year. If the Operator is required to
submit an NOI based on an annual treatment area threshold, the annual report must
include information for the calendar year, with the first annual report required to
include activities for the portion of the calendar year after the point at which the
Operator exceeded the annual treatment area threshold. If the Operator first
exceeds an annual treatment area threshold after December 1 in a calendar year,
an annual report is not required for that first partial year but annual reports are
required thereafter, with the first annual report submitted also including information
from the first partial year.
When Operator terminates permit coverage, as specified in Part 1.2.5 of the permit,
an annual report must be submitted for the portion of the year up through the date of
termination. The annual report is due no later than February 15 of the following year.
Where to File the Annual Report?
The Operator must prepare and submit the Annual Report using EPA’s electronic
Notice of Intent (eNOI) system available on EPA’s website
(https://www.epa.gov/npdes/pesticide-permitting) unless the Operator is granted a
waiver from the requirement to use eNOI for submitting the Annual Report. See Part
8 of the PGP for EPA Regional contacts. The Electronic Submission Waiver is at the
top of this form.
If you are granted a waiver from using eNOI; you must send the Annual Report to
one of the addresses listed below.
Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you have questions, contact EPA’s Pesticides Notice Processing Center toll free
at (866) 352-7755.
Section A. General Information
1. Enter your permit tracking number that you received in your NOI confirmation
letter or e-mail from EPA’s Pesticide Notice Processing Center. You can find the
tracking number assigned to your NOI by using EPA’s eNOI System
(https://www.epa.gov/npdes/pesticide-permitting).
2. Provide the legal name of the person, firm, public organization or any other
public entity who is the Decision-maker for the pesticides applications described
in this report. A Decision-maker is an Operator who has control over the decision
to perform pesticide applications including the ability to modify those decisions
that result in a discharge to waters of the United States.
3. Enter the address, telephone number, and fax number of the Operator.
4. Provide the full legal name, title and e-mail address of a contact person for the
Annual Report.
Section B. Adverse Incidents and Corrective Actions
1. Identify if an adverse incident was observed and corrective actions were taken
for any Pest Management Area for which you have coverage under the permit. If
no, proceed to Section C. If yes, complete Section B for each Pest Management
Area for which an adverse incident was observed or corrective action was taken.
2. Enter the name of the Pest Management Area.
3. If applicable, enter the date of any adverse incidents resulting from the
treatments, as described in Part 6.4 of the permit. Use additional pages if there
are multiple dates to be described.
4. Enter the date and time the Operator contacted EPA to notify the Agency of the
adverse incident, pursuant to Part 6.4.1.1 of the permit.
a. Indicate the date of the contact.
b. Indicate the time of the contact.
c. Indicate who the Operator spoke with at EPA.
d. Indicate any instructions received from EPA.
5. Enter the date that the Thirty (30)-Day Adverse Incident Written Report was
submitted, pursuant to Part 6.4.2 of the permit.
6. Provide a description of any corrective action(s) resulting from pesticide
application activities and the rationale for the action(s), performed subsequently
to or in addition to any actions described in the Thirty (30)-Day Adverse Incident
Written Report.
Section C. Pest Management Area(s)
Section C should be completed for each Pest Management Area. Indicate which
Pest Management Area out of the total number of Pest Management Areas for
which the section is being completed (i.e., Pest Management Area 1 of 10 total Pest
Management Areas).
1. Identify if you had a discharge from pest control activities this calendar year.
Check yes if you had discharge from pest control activities this calendar year.
Check no if you had no discharge from pest control activities this calendar year.
Note: Checking the no box completes Section C
2. Select the box for the type of pesticide use pattern for the treatment area (use
additional pages for each treatment area).
3. Provide a description of the treatment area.
If you file a paper Annual Report, please submit the original with a signature in ink.
Do not send copies. Also, faxed copies will not be accepted.
a. Provide a map or description of the treatment area, including a description of
the location.
Completing the Annual Report Form
To complete this form, type or print in uppercase letters in the appropriate areas
only. 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 Annual Report electronically via EPA’s Pesticides eNOI system.
b. Provide the size of the treatment area in acres or linear feet.
Approval to Use Paper Annual Reporting Form: You must indicate whether you
have been granted a waiver from electronic reporting from the EPA Regional Office.
Note that you are not authorized to use this paper Annual Reporting form unless the
EPA Regional Office has approved its use. Where you have obtained approval to
use this form, indicate the waiver that you have been granted, the name of the EPA
staff person who granted the waiver, and the date that approval was provided.
EPA FORM 6100-25 (Revised October 24, 2016)
c. Provide the name or location of any waters of the United States to which
discharges occur.
d. Provide a description of the target pest(s).
e. Indicate whether any pesticide application activities resulted in a discharge to
waters of the United States containing NMFS Listed Resources of Concern,
as defined in Appendix A of the permit. If yes, provide approximate date(s) of
the discharge. Additional information on NMFS Listed Resources of Concern
is available on EPA’s website at https://www.epa.gov/npdes/pesticidepermitting.
Page 4 of 5
4. Provide the company name(s), mailing address, a contact person, contact
person’s title, telephone number and e-mail address of the pesticide
Applicator(s). If the information is the same as Section A, check the appropriate
box and proceed to the next question.
5. Indicate if the pest control activity was addressed in your PDMP before pesticide
application.
6. Enter the total amount of each pesticide product applied for the reporting year by
the product name, EPA Pesticide Registration Number(s) and by application
method. Circle whether the quantity applied is in pounds or gallons or briquettes,
if applicable. Copy and attach additional pages, as necessary.
Section D. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by 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
govern the operation of the regulated activity 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 Annual Report was prepared by someone other than the certifier (for example,
if the Annual Report was prepared by the PDMP contact or a consultant for the
certifier’s signature), include the name, organization, phone number and e-mail
address of the Annual Report preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 8 hours or 480 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Annual Report
Form to this address.
EPA FORM 6100-25 (Revised October 24, 2016)
Page 5 of 5
United States Environmental Protection Agency
2016 NPDES Pesticide General Permit
Appendix H.
Adverse Incident Report Template
H-1
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
THIRTY (30)-DAY ADVERSE INCIDENT WRITTEN REPORT FOR
THE PESTICIDE GENERAL PERMIT (PGP)
FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES
Form Approved
OMB No.
2040-0284
This form is for Operators required to submit a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state
lead agency for pesticide regulation. Where multiple Operators are authorized for a discharge that results in an adverse incident, reporting by any one of
the Operators constitutes compliance for all of the Operators, provided a copy of this report is also provided to all of the other authorized Operators
within 30 days of the reportable adverse incident.
A. Reportable Adverse Incident
Is the adverse incident reportable? Reporting of adverse incidents is not required under the PGP in the following situations: (a) An Operator is aware
of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application; (b) An Operator has been
notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents; (c) An Operator
receives information of an adverse incident, but that information is clearly erroneous; or (d) An adverse incident occurs to pests that are similar in kind to
potential target pests identified on the FIFRA label.
Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation.
No. STOP. You are not required to complete this report. However, you may consider using this form to document the incident and your rationale
for why reporting of the adverse incident is not required. This information may be useful to support your rationale should you be questioned on
such.
B. Information from the 24-Hour Adverse Incident Notification
When an Operator observes or is otherwise made aware of an adverse incident, which may have resulted from a discharge from a pesticide application,
the Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at https://www.epa.gov/npdes/pesticide-permitting.
This notification must be made by telephone within 24 hours of the Operator becoming aware of the adverse incident. Operators must include in the
written report the information provided to EPA in the 24-hour adverse incident notification (PGP Part 6.4.1.1). Attach additional information if necessary.
1. Caller’s Contact Information:
a. Name:
–
b. Telephone Number:
–
Ext
2. Operator Information:
a. Operator Name:
b. Mailing Address:
Street:
State:
City:
ZIP Code:
–
(Enter “NA” if not applicable)
3. NOI NPDES Permit Tracking Number:
4. Contact person, if different than the person providing the 24-hour notice under item 1 above:
a. Name:
b. Telephone Number:
–
–
Ext
5. Describe how and when the Operator became aware of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Describe the location of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
EPA FORM 6100-0024 (REVISED October 24, 2016)
Page 1 of 6
7. Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7a below, for each product
applied in the area of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
a. EPA Pesticide Registration Number:
EPA Pesticide Registration Number:
8. Describe any steps the Operator has taken or will take to correct, repair, remedy, clean up, or otherwise address any adverse effects:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
9. Identify any other Operators authorized for coverage under this permit for discharges from the pesticide application activities that resulted in the
adverse incident and if so, provide details of your notification of those other Operator(s):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
C. Date and Time the Operator Notified EPA of the Adverse Incident
1. Date EPA was contacted:
/
/
2. Time EPA was contacted: ______________________________
3. Name and/or title of the person the Operator spoke with at EPA:
a. Name:
b. Title:
4. Instructions received from EPA:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
EPA FORM 6100-0024 (REVISED October 24, 2016)
Page 2 of 6
D. Other Information Required in the Thirty (30) Day Adverse Incident Report
Please attach additional information if necessary.
1. Location of incident, including the names of any waters affected and appearance of those waters (sheen, color, clarity, etc.):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
2. Describe the circumstances of the adverse incident including species affected, estimated number of affected individuals, and approximate size of
dead or distressed organisms:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3. Describe the magnitude and scope of the affected area (e.g. aquatic square area or total stream distance affected):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
4. Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name
of pesticide product and EPA pesticide registration number (EPA Reg. No.).
Pesticide
application rate:
Pesticide
application rate:
Intended use site:
Intended use site:
Method of application:
Method of application:
Pesticide Product:
Pesticide Product:
EPA Reg. No.:
EPA Reg. No.:
5. Describe the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for
pesticides applied):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Provide an indication of which laboratory test(s), if any, were performed, and when. (Note: A summary of the test results must be provided within
5 days after they become available, if not available at the time of submission of this report.):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
7. Describe the actions to be taken to prevent recurrence of adverse incidents:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
EPA FORM 6100-0024 (REVISED October 24, 2016)
Page 3 of 6
E. Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. On the basis of 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.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:
/
Date:
/
Adverse Incident Report Preparer (Complete if Adverse Incident Report was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:
–
–
Ext
Date:
/
/
E-Mail:
EPA FORM 6100-0024 (REVISED October 24, 2016)
Page 4 of 6
Instructions for Completing and Submitting the Thirty (30) Day Adverse Incident Written Report for the Pesticide
General Permit (PGP) for Discharges from the Application of Pesticides
Who Must Submit a 30-day Adverse Incident Report?
Section B. Information from the 24-hour Adverse Incident Notification
All Operators who observe or are otherwise made aware of a reportable adverse
incident pursuant to Part 6.4 of the permit must submit on adverse incident report.
1. Provide contact information for the person who called EPA to report the adverse
incident.
a. Enter the legal name of the caller.
b. Enter the phone number of the caller.
2. Provide the Operator’s contact information.
a. Enter the legal name of the Operator.
b. Enter the mailing address of the Operator.
3. If an NOI was filed as required in Part 1.2 of the permit, enter the NPDES Permit
Tracking Number assigned by eNOI or the EPA’s Pesticides Processing Center.
You can find the tracking number assigned to your NOI using EPA’s eNOI
System (https://www.epa.gov/npdes/pesticide-permitting). If no NOI submitted,
enter “NA” for not applicable.
4. Provide information for a contact person, if different than the person who called
EPA to report the adverse incident.
a. Enter the legal name of the contact person.
b. Enter the phone number of the contact person.
5. Provide a description of how and when the Operator became aware of the
adverse incident.
6. Provide a description of the location of the adverse incident.
7. Provide a description of the adverse incident and the pesticide product used in
the adverse incident. Include the EPA pesticide registration number for each
product applied in the area of the adverse incident. Attach additional pages if
necessary.
8. Provide a description of any steps the Operator has taken to correct, repair,
remedy, clean up or otherwise address the adverse effects of the incident.
9. Identify any other Operators authorized for coverage under the permit for
discharges from the pesticide application activities that resulted in the adverse
incident. If other Operators are authorized under this permit, provide details of
your notification of those other Operator(s).
However, even for those identified adverse incidents for which the Operator is not
required to report, EPA recommends that Operators consider using this form to
document the incident and the rationale for why reporting of the adverse incident is
not required. This information may be useful to support a rationale should this
determination be questioned.
An adverse incident, as defined in the Appendix A of the permit, is an unusual or
unexpected incident that an Operator has observed upon inspection or of which the
Operator otherwise became aware, in which: (1) there is evidence that a person or
non-target organism has likely been exposed to a pesticide residue, and (2) the
person or non-target organism suffered a toxic or adverse effect. See Appendix A of
the permit, for the complete definition of adverse incident.
Where multiple Operators are authorized for a discharge that results in an adverse
incident, notification and reporting by any one of the Operators constitutes
compliance for all of the Operators, provided a copy of the written report required in
Part 6.4.2 of the permit is also provided to all of the other authorized Operators
within 30 days of the reportable adverse incident.
When to File the Adverse Incident Report
Operators must provide a written report of any reportable adverse incidents to the
appropriate EPA Regional office and to the state lead agency for pesticide
regulation within 30 days of the adverse incident pursuant to Part 6.4.1.1 of the
permit.
Where to File the 30-day Adverse Incident Report
The Operator must immediately notify the appropriate EPA Incident Reporting
Contact, as identified at https://www.epa.gov/npdes/pesticide-permitting, of the
adverse incident within 24 hours. The Operator(s) must provide a written report of
the adverse incident to the appropriate EPA Regional office at the address listed in
Part 8 of the permit and to the state lead agency for pesticide regulation (see
http://npic.orst.edu/state1.htm).
If an Operator becomes aware of an adverse incident affecting a federally listed
threatened or endangered species or federally designated critical habitats which
may have resulted from a discharge from the Operator’s pesticide application, the
Operator must immediately notify the National Marine Fisheries Service (NMFS) in
the case of an anadromous or marine species, (see http://www.nmfs.noaa.gov) or
the United States Fish and Wildlife Service (FWS) in the case of a terrestrial or
freshwater species (see http://www.fws.gov).
Completing the 30-day Adverse Incident Report
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
appropriate EPA Regional office.
Section A. Reportable Adverse Incident
The Operator is required to submit this Adverse Incident Report if the adverse
incident is reportable. Check yes if the adverse incident is reportable. If an Adverse
Incident Report is not required, check no. No further action is needed on this form.
Reporting of adverse incidents is not required under the PGP in the following
situations:
a. An Operator is aware of facts that indicate that the adverse incident was not
related to toxic effects or exposure from the pesticide application;
b. An Operator has been notified by EPA, and retains such notification, that the
reporting requirement has been waived for this incident or category of incidents;
c. An Operator receives information notifying the Operator of an adverse incident,
but that information is clearly erroneous; or
d. An adverse incident occurs to pests that are similar in kind to potential target
pests identified on the FIFRA label.
EPA FORM 6100-0024 (REVISED October 24, 2016)
Section C. Date and Time the Operator Notified EPA of the Adverse Incident
1.
2.
3.
4.
Enter the date that EPA was contacted to report the adverse incident.
Enter the time EPA was contacted to report the adverse incident.
Provide the legal name and title of the person contacted at EPA.
Provide a description of the instructions received by EPA.
Section D. Other Information Required in the Thirty (30) Day Adverse Incident
Report
1. Enter the location of the adverse incident and include the names of any waters
affected. Please include the appearance of those waters (sheen, color, clarity,
etc.).
2. Provide a description of the circumstances of the adverse incident including
species affected, estimated number of affected individuals and approximate size
of dead or distressed organisms.
3. Provide a description of the magnitude and scope of the affected area. Include
aquatic square area or total stream distance affected, if possible.
4. Provide the pesticide application rate, intended use site (e.g., on the bank, above
waters, or directly to water), method of application, and the name of pesticide
product and EPA pesticide registration number.
5. Provide a description of the habitat and the circumstances under which the
adverse incident occurred (including any available ambient water data for
pesticides applied).
6. Indicate which laboratory test(s) were performed and when, if laboratory tests
were performed. The summary of the test results must be provided within 5 days
after they become available, if not available at the time of submission of this
report.
7. Provide a description of the actions to be taken to prevent recurrence of adverse
incidents.
Page 5 of 6
Section E. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. 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 that govern
the operation of the regulated activity 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 report was prepared by someone other than the certifier (for example, if the
report was prepared by a consultant for the certifier’s signature), include the name,
organization, phone number and e-mail address of the report preparer and the date
that the report was prepared.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 4 hours or 240 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Adverse Incident
Report to this address.
EPA FORM 6100-0024 (REVISED October 24, 2016)
Page 6 of 6
Multi-Sector General Permit (MSGP)
G-1
Appendix G - Notice of Intent (NOI) Form
Part 7.1 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your
NOI. However, if you are given a waiver by the EPA Regional Office to use a paper NOI form,
and you elect to use it, you must complete and submit the following form.
Page G-1 of 11
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. 2040-0004
Submission of this Notice of Intent (NOI) constitutes notice that the operator identified in Section C of this form requests authorization to discharge pursuant to
the NPDES Stormwater Multi-Sector General Permit (MSGP) permit number identified in Section B of this form. Submission of this NOI also constitutes notice that
the operator identified in Section C of this form meets the eligibility conditions of Part 1.1 of the MSGP for the facility identified in Section D of this form. To
obtain authorization, you must submit a complete and accurate NOI form. Discharges are not authorized if your NOI is incomplete or inaccurate or if you were
never eligible for permit coverage. Refer to the instructions at the end of this form to complete your NOI.
A. Approval to Use Paper NOI Form
1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified
as under-served for broadband Internet access in the most recent report from the Federal Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
/
Date approval obtained:
/
* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOI form. If you have not obtained a waiver, you
must file this form electronically using the NPDES eReporting Tool (NeT) at http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOI-System-forEPAs-MultiSector-General-Permit.cfm
B. Permit Information
NPDES ID (EPA Use Only):
1. Master Permit Number:
(see Appendix C of the MSGP for the list of eligible master permit numbers)
2. Are you a new discharger or a new source as defined in Appendix A?
YES
NO (If yes, skip to Part C of this form).
3. If you are not a new discharger or a new source, have stormwater discharges from your facility been covered previously under an NPDES permit?
YES
NO
If yes, provide the NPDES ID if you had coverage under EPA’s 2008 MSGP or the NPDES ID if you had coverage under an EPA
individual permit:
C. Facility Operator Information
1. Operator Information:
Operator Name:
Mailing Address:
Street:
City:
State:
ZIP Code:
-
County or Similar Government Subdivision:
Phone:
-
-
Ext.
E-mail:
2. Operator Point of Contact Information:
First Name, Middle Initial, Last Name:
Title:
3. NOI Preparer Information (Complete if NOI was prepared by someone other than the certifier):
First Name, Middle Initial, Last Name:
Organization:
Phone:
-
-
Ext.
E-mail:
EPA FORM 3510-6 (Revised 6-2015)
Page 1 of 10
D. Facility Information
1. Facility Name:
2. Facility Address:
Street/Location:
City:
State:
-
ZIP Code:
County or Similar Government Subdivision:
3. Latitude/Longitude for the facility:
Latitude:
Longitude:
___ ___. ___ ___ ___ ___° N (decimal degrees)
Latitude/Longitude Data Source:
Map
___ ___ ___. ___ ___ ___ ___° W (decimal degrees)
GPS
Other
If you used a USGS topographic map, what was the scale? ___________________________________________________________________________________________
Horizontal Reference Datum:
NAD 27
NAD 83
4. Is your facility located on Indian Country lands?
WGS 84
YES
NO
If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable):
____________________________________________________________________________
5. Are you requesting coverage under this NOI as a “federal operator” as defined in Appendix A?
6. What is the ownership type of the
facility?
Corporation
Federal Facility (U.S. Government)
State Government
Mixed Ownership (e.g.
Public/Private)
District
YES
NO
Privately Owned Facility
Municipality
County Government
Tribal Government
School District
Municipal or Water
District
7. Estimated area of industrial activity at your facility exposed to stormwater:
(to the nearest quarter acre)
8. Sector-Specific Information
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 the MSGP, and the applicable sector and subsector of your primary industrial activity (See Appendix D):
Primary SIC Code:
Sector:
OR
Primary Activity Code:
Subsector:
Identify the applicable sector(s) and subsector(s) of any co-located industrial activity for which you are requesting permit coverage:
Sector:
Subsector:
Sector:
Subsector:
Sector:
Subsector:
Sector:
Subsector:
Sector:
Subsector:
Sector:
Subsector:
If you are a Sector S (Air Transportation) facility, do you anticipate using more than 100,000 gallons of pure glycol in glycol-based deicing fluids and/or 100
tons or more of urea on an average annual basis?
YES
NO
If you are a Sector G (Metal Mining) facility, do you have discharges from waste rock and overburden piles?
Check the type of ore you mine at your facility:
Mercury Ore
Iron Ore
Tungsten Ore
Platinum Ore
9. Is your facility presently inactive and unstaffed?*
YES
Titanium Ore
YES
Nickel Ore
Vanadium Ore
NO
Aluminum Ore
Molybdenum
Uranium, Radium,
and/or Vanadium Ore
NO
* Note that if your facility becomes inactive and unstaffed during the permit term, you must submit an NOI modification to reflect the change.
E. Discharge Information
1. By indicating “Yes” below, I confirm that I understand that the MSGP only authorizes the allowable stormwater discharges in Part 1.1.2 and the allowable
non-stormwater discharges listed in Part 1.1.3. Any discharges not expressly authorized in this permit cannot become authorized or shielded from liability
under CWA section 402(k) by disclosure to EPA, state, or local authorities after issuance of this permit via any means, including the Notice of Intent (NOI) to
be covered by the permit, the Stormwater Pollution Prevention Plan (SWPPP), during an inspection, etc. If any discharges requiring NPDES permit coverage
other than the allowable stormwater and non-stormwater discharges listed in Parts 1.1.2 and 1.1.3 will be discharged, they must be covered under another
NPDES permit.
YES
2. Federal Effluent Limitation Guidelines
Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines?
EPA FORM 3510-6 (Revised 6-2015)
YES
NO
Page 2 of 10
If yes, which effluent limitation guidelines apply to your stormwater discharges?
40 CFR Part/Subpart
Affected MSGP Sector
New Source Date
Part 411, Subpart C
Runoff from material storage piles at cement
manufacturing facilities
Eligible Discharges
E
2/20/1974
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
4/8/1974
Part 423
Coal pile runoff at steam electric generating facilities
O
11/19/1982
10/8/19741
Part 429, Subpart I
Discharges resulting from spray down or intentional wetting
of logs at wet deck storage areas
A
1/26/1981
Part 436, Subpart B, C, or
D
Mine dewatering discharges at crushed stone mines,
construction sand and gravel mines, or industrial sand
mines
J
N/A
Part 443, Subpart A
Runoff from asphalt emulsion facilities
D
7/28/1975
Part 445, Subparts A & B
Runoff from hazardous waste and non-hazardous waste
landfills
K, L
2/2/2000
Part 449
Runoff containing urea from airfield pavement deicing at
existing and new primary airports with 1,000 or more annual
non-propeller aircraft departures
S
6/15/2012
Check if Applicable
1NSPS
promulgated in 1974 were not removed via the 1982 regulation; therefore wastewaters generated by Part 423-applicable sources that were New
Sources under the 1974 regulations are subject to the 1974 NSPS.
3. Receiving Waters Information: (Attach a separate list if necessary)
List all of the stormwater outfalls
from your facility. Each outfall
must be identified by a unique
3-digit ID (e.g., 001, 002). Also
provide the latitude and
longitude in degrees decimal for
each outfall.
For each outfall, provide the following receiving water information:
Provide the name of the first water of
the U.S. that receives stormwater
directly from the outfall and/or from
the MS4 that the outfall discharges
to:
If the receiving water is
impaired (on the CWA 303(d)
list), list the pollutants that are
causing the impairment:
Outfall ID
Latitude
If a TMDL been completed
for this receiving
waterbody, providing the
following information:
TMDL Name and ID:
Pollutant(s) for which
there is a TMDL:
Longitude
Outfall ID
Latitude
TMDL Name and ID:
Pollutant(s) for which
there is a TMDL:
Longitude
If substantially identical to other outfall, list identical outfall ID: ________________
EPA FORM 3510-6 (Revised 6-2015)
Page 3 of 10
TMDL Name and ID:
Outfall ID
Latitude
Pollutant(s) for which
there is a TMDL:
Longitude
If substantially identical to other outfall, list identical outfall ID: ________________
TMDL Name and ID:
Outfall ID
Latitude
Pollutant(s) for which
there is a TMDL:
Longitude
If substantially identical to other outfall, list identical outfall ID: ________________
TMDL Name and ID:
Outfall ID
Latitude
Pollutant(s) for which
there is a TMDL:
Longitude
If substantially identical to other outfall, list identical outfall ID: ________________
TMDL Name and ID:
Outfall ID
Latitude
Pollutant(s) for which
there is a TMDL:
Longitude
If substantially identical to other outfall, list identical outfall ID: ________________
EPA FORM 3510-6 (Revised 6-2015)
Page 4 of 10
4. Provide the following Information about your outfall latitude longitude:
Latitude/Longitude Data Source:
Map
GPS
Other
If you used a USGS topographic map, what was the scale? ___________________________________________________________________________________________
Horizontal Reference Datum:
NAD 27
NAD 83
WGS 84
5. Does your facility discharge into a Muncipal Separate Storm Sewer System (MS4)?
YES
NO
If yes, provide the name of the MS4 operator:
6. Check if you discharge to any of the waters of the U.S. that are 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) or as a Tier 3
water (Outstanding National Resource Water)? (See Appendix L).
Tier 2/2.5. Provide the name(s) of receiving water(s):
Tier 3 (Outstanding National Resource Waters)*
* Note: You are ineligible for coverage if you are a new discharger or new source to waters designated as Tier 3 (outstanding national resource waters) for
antidegradation purposes under 40 CFR 131.13(a)(3).
7. If you are subject to benchmark monitoring requirements for a hardness-dependent metal, what is the hardness of your receiving water(s) (see Appendix J)?
_________________ (mg/L)
8. If you are subject to benchmark monitoring requirements for a hardness-dependent metal, does your facility discharge into any saltwater receiving waters?
YES
NO
9. Does your facility discharge to a federal CERCLA site listed in Appendix P?
YES
NO
If yes, did you notify the EPA Regional Office in advance of filing your NOI, and did the EPA Regional Office determine that you are eligible for permit
coverage pursuant to Part 1.1.4.10*?
YES
NO
* Note: If you discharge to a federal CERCLA site listed in Appendix P, you are ineligible for coverage under this permit unless you notify the EPA Regional
Office in advance and the EPA Regional Office determines you are eligible coverage under this permit. In determining your eligibility for coverage under this
Part, the EPA Regional Office may evaluate whether you have included adequate controls and/or procedures to ensure that your discharges will not lead to
recontamination of aquatic media at the CERCLA Site such that it will to cause or contribute to an exceedance of a water quality standard.
F. Stormwater Pollution Prevention Plan (SWPPP) Information
1. Has the SWPPP been prepared in advance of filing this NOI, as required?
YES
NO
2. SWPPP Contact Information:
First Name, Middle Initial, Last Name:
Professional Title:
Phone:
-
-
Ext.
E-mail:
3. SWPPP Availability:
Your current SWPPP or certain information from your SWPPP must be made available through one of the following two options. Select one of the options and
provide the required information*:
* Note: You are not required to post any confidential business information (CBI) or restricted information (as defined in Appendix A) (such information may be
redacted), but you must clearly identify those portions of the SWPPP that are being withheld from public access.
Option 1: Maintain a current copy of your SWPPP on an Internet page (Universal Resource Locator or URL).
Provide the web address URL:
Option 2: Provide the following information from your SWPPP:
A. Describe your onsite industrial activities exposed to stormwater (e.g., material storage; equipment fueling, maintenance, and cleaning; cutting steel beams),
and potential spill and leak areas:
EPA FORM 3510-6 (Revised 6-2015)
Page 5 of 10
B. List the pollutant(s) or pollutant constituent(s) associated with each industrial activity exposed to stormwater that could be discharged in stormwater and any
authorized non-stormwater discharges listed in Part 1.1.3:
C. Describe the control measures you will employ to comply with the non-numeric technology-based effluent limits required in Part 2.1.2 and Part 8, and any
other measures taken to comply with the requirements in Part 2.2 Water Quality-Based Effluent Limitations (see Part 5.2.4):
D. Provide a schedule for good housekeeping and maintenance (see Part 5.2.5.1) and a schedule for all inspections required in Part 4 (see Part 5.2.5.2):
G. Endangered Species Protection
1. Using the instructions in Appendix E of the MSGP, under which endangered species criterion listed in Part 1.1.4.5 are you eligible for coverage under this
permit (only check 1 box)?*
A
B
C
D
E
* Note: After you submit your NOI and before your NOI is authorized, EPA may notify you if any additional controls are necessary to ensure your discharges
have no likely adverse affects on listed species and critical habitat.
2. Provide a brief summary of the basis for the criterion selected in Appendix E (e.g., communication with U.S. Fish and Wildlife Service or National Marine
Fisheries Service to determine no species in action area; implementation of controls approved by EPA and the Services):
_____________________________________________________________________________________________________________________________________________________
3. If you select criterion B, provide the NPDES ID from the other operator’s NOI authorized under this permit:
4. If you select criterion C, you must answer the following questions:
a. What federally-listed species or designated critical habitat are located in your “action area”:
_________________________________________________________________________________________________________________________________________________
b. Using the Appendix E worksheet, check which of the following is applicable to your facility and answer any corresponding questions:
I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and agree to implement any additional measures
that were determined by EPA to be necessary to ensure that my discharges and/or discharge-related activities will not have likely adverse affects on
listed species and critical habitat.
Date your Criterion C Eligibilty Form was sent to EPA:
/
/
Describe any EPA-approved measures you will implement to ensure no likely adverse affects on listed species and critical habitat:
_______________________________________________________________________________________________________________________________________________
I submitted my completed Criterion C Eligibility Form to EPA at least 30 days prior to submitting this NOI and have not been notified of any additional
measures necessary to ensure no likely adverse affects on listed species and critical habitat.
Date your Criterion C Eligibility Form was sent to EPA:
/
/
5. If you select criterion D or E, you must attach copies of any letters or other communications with the U.S. Fish and Wildlife Service or National Marine Fisheries
Service.
EPA FORM 3510-6 (Revised 6-2015)
Page 6 of 10
H. Historic Preservation
1. If your facility is not located on Indian country lands, is your facility located on a property of religious or cultural significance to an Indian tribe?
YES
NO
If yes, provide the name of the Indian tribe associated with the property: _____
2. Using the instructions in Appendix F of the MSGP, under which historic properties preservation criterion listed in Part 1.1.4.6 are you eligible for coverage
under this permit (only check 1 box)?
A
B
C
D
I. 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.
First Name, Middle Initial, Last Name:
Title:
Signature:
Date:
/
/
E-mail:
EPA FORM 3510-6 (Revised 6-2015)
Page 7 of 10
Instructions for Completing EPA Form 3510-6
Notice of Intent (NOI) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-6 (09/08)
Form Approved OMB No. 2040-0004
Who Must File an NOI Form
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 Notice of Intent (NOI) if you are an operator a facility:
and e-mail. Correspondence for the NOI will be sent to this address. Also
provide the name and title for the operator point of contact (note that
the point of contact name may be the same as the operator name).
• 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 has developed 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 and Part 8 to meet numeric and non-numeric effluent
limits.
Section D. Facility Information
Enter the official or legal name and complete address, including city,
state, ZIP code, and county or similar government subdivision of the
facility. If the facility lacks a street address, indicate the general location
of the facility (e.g., Intersection of State Highways 61 and 34). Complete
facility information must be provided for permit coverage to be
granted.
Completing the Form
Obtain and read a copy of the 2015 MSGP, viewable at
http://water.epa.gov/polwaste/npdes/stormwater/EPA-MultiSector-General-Permit-MSGP.cfm. To complete this form, type or
print, using uppercase letters, in the appropriate areas only. Please
place each character between the marks. Abbreviate if necessary
to stay within the number of characters allowed for each item. Use
only one space for breaks between words, but not for punctuation
marks unless they are needed to clarify your response. Please submit
original document with signature in ink - do not send a photocopied
signature.
Section A. Approval to Use Paper NOI Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you are
not authorized to use this paper NOI form unless the EPA Regional
Office has approved its use. Where you have obtained approval to
use this form, indicate the waiver that you have been granted, the
name of the EPA staff person who granted the waiver, and the date
that approval was provided.
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 full name,
organization, phone number, and email address of the NOI preparer.
Provide the latitude and longitude of your facility in decimal degrees 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. Refer to http://transition.fcc.gov/mb/audio/bickel/DDDMMSSdecimal.html/ for assistance in providing the proper latitude/longitude
format. For consistency, EPA requests that measurements be taken from the
approximate center of the facility. Specify which method you used to
determine latitude and longitude. If a U.S.G.S. topographic map is used,
specify the scale of the map used. Enter the horizontal reference datum for
your latitude and longitude. 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.
Indicate whether the facility is on Indian country lands, and if so, provide
the name of the Indian tribe associated with the area of Indian country
(including name of Indian reservation, if applicable).
Indicate whether you are seeking coverage under this permit as a
“federal operator” as defined in Appendix A. Also check the ownership
type for the facility (e.g., Federal Facility, Privately Owned Facility,
Municipality, County Government, Corporation, State Government,
Tribal Government, School District, District, Mixed Ownership [e.g.,
public/private], Municipal or Water District).
See http://water.epa.gov/polwaste/npdes/stormwater/StormwaterEnter the estimated area of industrial activity at your facility exposed to
Contacts.cfm for a list of EPA Regional Office contacts.
stormwaterto the nearest quarter acre.
Section B. Permit Information
Provide the master permit number of the permit under which you are List the four-digit Standard Industrial Classification (SIC) code or two
applying for coverage (see Appendix C of the general permit for the character activity code that best describes the primary industrial
activities performed by your facility under which you are required to
list of eligible master permit numbers).
obtain permit coverage. Your primary industrial activity includes any
You must indicate whether you are a new discharger or a new source activities performed on-site which are (1) identified by the facility’s
(see Appendix A for the definitions). If you are not a new discharger primary SIC code and included in the descriptions of 40 CFR
or a new source, you must indicate whether stormwater discharges 122.26(b)(14)(ii), (iii), (vi), or (viii); or (2) included in the narrative
from your facility have been previously covered under another descriptions of 40 CFR 122.26(b)(14)(i), (iv), (v), (vii), or (ix). See Appendix
NPDES permit. If yes, you must provide the unique NPDES ID (i.e., D of the MSGP for a complete list of SIC codes and activities codes
permit tracking number) for the previous permit your facility was covered under the MSGP. Also provide the applicable sector and
covered under.
subsector associated with the SIC code or activity code for your primary
industrial activities. For a complete list of sector and subsector codes,
Section C. Facility Operator Information
see Appendix D of the MSGP.
Provide the legal name of the person, firm, public organization, or any
other entity that operates the facility described in this NOI. An If your facility has co-located industrial activities that are not identified
operator of a facility is the legal entity that controls the operation of as your primary industrial activity, identify the sector and subsector
the facility. Refer to Appendix A of the permit for the definition of codes that describe these other industrial activities.
“operator”. Provide the operator’s mailing address, phone number,
EPA FORM 3510-6 (Revised 6-2015)
Page 8 of 10
Instructions for Completing EPA Form 3510-6
Notice of Intent (NOI) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-6 (09/08)
For Sector S facilities (Air Transportation), indicate whether you
anticipate that the entire airport facility will use more than 100,000
gallons of pure glycol in glycol-based deicing fluids 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.S
of the permit).
Form Approved OMB No. 2040-0004
If you are subject to any benchmark monitoring requirements for metals
(see the requirements applicable to your Sector(s) in Part 8 of the
permit), indicate the hardness for your receiving water(s). See Appendix
J of the permit for information about determining waterbody hardness.
If you are subject to benchmark monitoring requirements for hardnessdependent metals you must also answer whether your facility
For Sector G facilities (Metal Mining), check the type of ore(s) mined discharges into any saltwater receiving waters.
at the facility.
Indicate whether your facility will discharge to a federal CERCLA site
Indicate whether your facility is currently inactive and unstaffed. Note listed in Appendix P. Note that if your facility will discharge into a federal
that if your facility becomes inactive and unstaffed during the permit CERCLA site listed in Appendix P, you are not eligible for coverage under
term, you must submit an NOI modification to reflect the change.
this permit unless you notify the EPA Regional Office in advance and the
EPA Regional Office authorizes overage under this permit after you have
Section E. Discharge Information
included adequate controls and/or procedures designed to ensure that
You must confirm that you understand that the MSGP only authorizes discharges will not lead to recontamination of aquatic media at the
the allowable stormwater discharges listed in Part 1.1.2 and the CERCLA site such that your discharge will cause or contribute to an
allowable non-stormwater discharges listed in Part 1.1.3. Any exceedance of a water quality standard.
discharges not expressly authorized under the MSGP are not covered
by the MSGP or the permit shield provision of the CWA Section 402(k) Section F. Stormwater Pollution Prevention Plan (SWPPP) Information
and they cannot become authorized or shielded by disclosure to All facilities eligible for coverage under this permit are required to
EPA, state, or local authorities via the NOI to be covered by the permit prepare a SWPPP in advance of filing the NOI, in accordance with Part
or by any other means (e.g., in the SWPPP or during an inspection). If 5. Indicate whether the SWPPP has been prepared in advance of filing
any discharges requiring NPDES permit coverage other than the the NOI.
allowable stormwater and non-stormwater discharges listed in Parts
1.1.2 and 1.1.3 will be discharged, they must either be eliminated or Indicate the contact information (name, phone, and email) for the
person who developed the SWPPP for this facility.
covered under another NPDES permit.
Depending on your industrial activities, your facility may be subject to You identify how your SWPPP information will be made available,
federal effluent limitation guidelines which include additional effluent consistent with Part 5.4 and 7.3 of the permit. If you are making your
limits and monitoring requirements for your facility. Please review SWPPP publicly available on a web site, check Option 1 and provide the
these requirements, described in Part 2.1.3 of the MSGP, and check appropriate Internet URL address. If you are not providing a URL, check
Option 2 and provide the selected SWPPP information on this NOI form.
any appropriate boxes on the NOI form.
You may copy and paste this information directly from your SWPPP.
You must identify all the outfalls from your facility that discharge
stormwater. Each outfall must be assigned a unique 3-digit ID (e.g., 001, Section G. Endangered Species Protection
002, 003). You must also provide the latitude and longitude for each Using the instructions in Appendix E, indicate the Part 1.1.4.5 criterion
outfall from your facility. Indicate whether any outfalls are substantially (i.e., A, B, C, D, or E) you are eligible under with regard to the protection
identical to an outfall already listed, and identify the outfall it is identical of federally listed endangered and threatened species and designated
to. For each unique outfall you list, you must specify the name of the critical habitat. A description of the basis for the criterion selected must
first water of the U.S. that receives stormwater directly from the outfall also be provided.
and/or from the MS4 that the outfall discharges to. You must specify
If criterion B is selected, provide the NPDES ID (i.e., permit tracking
whether any receiving waters that you discharge to are listed as
number) for the other operator who has certified their eligibility under
”impaired” as defined in Appendix A, and the pollutants for which the
this permit. The NPDES ID was assigned when the operator received
water is impaired. You must also check identify any Total Maximum
coverage under this permit.
Daily Loads (TMDL) that have been completed for any of the waters of
the U.S. that you discharge to. You must also provide information about If criterion C is selected, you must specify the federally-listed species or
the outfall latitude/longitude, including data source, the scale (if designated critical habitat that are located in the “action area” of the
applicable), and the horizontal reference datum. See the instructions facility. You must also indicate under which scenario you determined
in Section D for more information about determining the latitude and you were eligible to submit your NOI under criterion C using Appendix E,
longitude.
and answer any corresponding questions.
Identify whether your facility discharges into a Municipal Separate If criterion D or E is selected, attach copies of any communications
Storm Sewer System (MS4). If yes, provide the name of the MS4 between you and the U.S. Fish and Wildlife Service and National Marine
operator. If you are uncertain of the MS4 operator, contact your local Fisheries Service to this NOI.
government for that information.
Section H. Historic Preservation
Indicate whether discharges from the facility will enter into a water of If the project is not located in Indian country lands, indicate whether the
the U.S that is designated as a Tier 2, Tier 2.5, or Tier 3 water. A list of project is located on a property of religious or cultural significance to an
Tier 2, 2.5, and 3 waters is provided as Appendix L. If the answer is Indian tribe, and if so, provide the name of the Indian tribe associated
“yes”, name all waters designated as Tier 2, Tier 2.5, or Tier 3 to which with the property. Use the instructions in Appendix F to complete the
the facility will discharge. Note that you are ineligible for coverage if questions on the NOI form regarding historic preservation.
you are a new discharger or a new source to waters designated as
Tier 3 (outstanding national resource waters) for antidegradation
purposes under 40 CFR 131.13(a)(3).
EPA FORM 3510-6 (Revised 6-2015)
Page 9 of 10
Instructions for Completing EPA Form 3510-6
Notice of Intent (NOI) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-6 (09/08)
Section I. 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) 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.
Form Approved OMB No. 2040-0004
Paperwork Reduction Act Notice
Public reporting burden for this NOI is estimated to average 3.7 hours,
plus an additional 2 hours for certain respondents required to gather
hardness data. 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: Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number on any
correspondence. Do not send the completed form to this address.
Submitting Your Form
If you have been granted a waiver from your Regional Office to submit
a paper NOI form, you must send your NOI by mail to one of the
following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2015 MSGP Reports
U.S. EPA
1200 Pennsylvania Avenue, NW
For a partnership or sole proprietorship: By a general partner or the Washington, DC 20460
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 and title of the person signing the form and the
date of signing.
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2015 MSGP Reports
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOIAn unsigned or undated NOI form will not be considered eligible for System-for-EPAs-MultiSector-General-Permit.cfm
permit coverage.
Modifying Your NOI
If you have been granted a waiver from your Regional Office from
electronic reporting, and if after submitting your NOI you need to
correct or update any fields on this NOI form, you may do so by
indicating changes on this same form.
EPA FORM 3510-6 (Revised 6-2015)
Page 10 of 10
Multi-Sector General Permit (MSGP)
H-1
Appendix H - Notice of Termination (NOT) Form
Part 7.1 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your
Notice of Termination (NOT). However, if you are given a waiver by the EPA Regional Office to
use a paper NOT form, and you elect to use it, you must complete and submit the following
form.
H-1 of 5
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF TERMINATION (NOT) FOR STORMWATER DISCHARGES ASSOCIATED
WITH INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT
NPDES
FORM
3510-7
Form Approved.
OMB No. 2040-0004
Submission of this Notice of Termination constitutes notice that the operator identified in Section C of this form is no longer authorized to discharge
pursuant to the NPDES Multi-Sector General Permit (MSGP) from the facility identified in Section D of this form. All necessary information must be included
on this form. Refer to the instructions at the end of this form.
A. Approval to use Paper NOT Form
1. Have you been granted a waiver from electronic reporting from the Regional Office*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is
identified as under-served for broadband Internet access in the most recent report from the Federal Communications
Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
Date approval obtained:
/
/
* Note: You are required to obtain approval from the applicable Regional Office prior to using this paper NOT form. If you have not obtained a waiver, you
must file this form electronically using the NPDES eReporting Tool (NeT) at http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOI-System-forEPAs-MultiSector-General-Permit.cfm
B. Permit Information
1. NPDES ID:
2. Reason for Termination (check one only):
A new owner or operator has taken over responsibility for the facility.
You have ceased operations at the facility, 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.
You obtained coverage under an individual or alternative general permit for all discharges required to be covered by an NPDES permit.
C. Facility Operator Information
1. Operator Name:
2. Mailing Address:
Street:
City:
3. Phone:
State:
-
-
ZIP Code:
-
ZIP Code:
-
Ext.
4. E-mail:
D. Facility Information
1. Facility Name:
2. Facility Address:
Street:
City:
State:
County or similar government subdivision:
EPA FORM 3510-7 (Revised 06-2015)
Page 1 of 4
E. 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.
First Name, Middle
Initial, Last Name:
Title:
Signature:
_____________________________________________________________________________________
Date:
/
/
E-mail:
EPA FORM 3510-7 (Revised 06-2015)
Page 2 of 4
Instructions for Completing EPA Form 3510-7
Notice of Termination for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-7 (09/08)
Who May File Notice of Termination (NOT) Form
Permittees currently covered by EPA’s NPDES Stormwater MultiSector General must submit a Notice of Termination (NOT) within
30 days after one or more of the following conditions have been
met:
• A new owner or operator has assumed responsibility for the
facility;
• 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 per
Part 2.1.2.5;
• You are a Sector G, H, or J facility and you have met the
applicable termination requirements; or
• You obtained coverage under an individual or alternative
general permit for all discharges required to be covered by
an NPDES permit.
See the MSGP Part 1.3.3 for more information.
Completing the Form
To complete this form, type or print, using uppercase letters, in the
appropriate areas only. Please place each character between
the marks. Abbreviate if necessary to stay within the number of
characters allowed for each item. Use only one space for breaks
between words, but not for punctuation marks unless they are
needed to clarify your response. Please submit original document
with signature in ink - do not send a photocopied signature.
Section A. Approval to Use Paper NOT Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper NOT form unless the EPA
Regional Office has approved its use. Where you have obtained
approval to use this form, indicate the waiver that you have been
granted, the name of the EPA Regional Office staff person who
granted the waiver, and the date that approval was provided.
See
http://water.epa.gov/polwaste/npdes/stormwater/StormwaterContacts.cfm for a list of EPA Regional Office contacts.
Section B. Permit Information
Enter the existing NPDES ID (i.e., NOI tracking number) assigned to
your permit authorization.
Indicate your reason for submitting this Notice of Termination by
checking the appropriate box. Check only one box (see MSGP
Part 1.3.3 for more information).
Section C. Facility Operator Information
Provide the legal name of the person, firm, public organization,
or any other entity that operates the facility described in this NOT.
An operator of a facility is the legal entity that controls the
operation of the facility. Refer to Appendix A of the permit for the
definition of “operator”. Provide the operator’s mailing address,
phone number, and e-mail.
EPA FORM 3510-7 (Revised 06-2015)
Form Approved OMB No. 2040-0004
Section D. Facility Information
Enter the official or legal name and complete street address,
including city, state, ZIP code, and county or similar government
subdivision of the facility. If the facility lacks a street address,
indicate the general location of the facility (e.g., Intersection of
State Highways 61 and 34). Complete facility information must be
provided for termination of permit coverage to be valid.
Section E. Certification Information
All NOTs 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 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 and title of the
person signing the form and the date of signing.
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 Notice of Termination is estimated
to average 0.5 hours, 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, Collection Strategies
Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number of this form on any correspondence. Do not send
the completed NOT form to this address.
Page 3 of 4
Instructions for Completing EPA Form 3510-7
Notice of Termination for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-7 (09/08)
Submitting Your Form
If you have been granted a waiver from your Regional Office to
submit a paper NOT form, you must send your NOT by mail to one
of the following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2015 MSGP Reports
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
EPA FORM 3510-7 (Revised 06-2015)
Form Approved OMB No. 2040-0004
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2015 MSGP Reports
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
http://water.epa.gov/polwaste/npdes/stormwater/StormwatereNOI-System-for-EPAs-MultiSector-General-Permit.cfm
Page 4 of 4
Multi-Sector General Permit (MSGP)
M-1
Appendix M - Discharge Monitoring Report (DMR) Form
Part 7.1 requires you to use the electronic NetDMR system to prepare and submit your Discharge
Monitoring Report (DMR) form. However, if you are given approval by the EPA Regional Office to
use a paper DMR form, and you elect to use it, you must complete and submit the following
form.
Page M-1 of 8
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
MSGP INDUSTRIAL DISCHARGE MONITORING REPORT (DMR) FORM
NPDES
FORM
6100-29
Form Approved.
OMB No. 2040-0004
A. Approval to Use Paper DMR Form
1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is identified as
under-served for broadband Internet access in the most recent report from the Federal Communications Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
/
Date approval obtained:
/
* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper DMR form. If you have not obtained a waiver, you
must file this form electronically using the NetDMR at http://www.epa.gov/netdmr/
B. Permit Information
1. NPDES ID:
2. Reason(s) for Submission (Check all that apply):
Submitting monitoring data (Fill in all Sections).
Reporting no discharge for all outfalls for this monitoring period (Fill in Sections A, B, C, D, E.1, and G).
Reporting that your site status has changed to inactive and unstaffed (Fill in Sections A, B, C, D, and F and include date of status change in comment field
in Section F.4).
Reporting that your site status has changed to active (Fill in all Sections and include date of status change in comment field in Section F.4).
Reporting that no further pollutant reductions are achievable for all outffalls and for all pollutants via Part 6.2.1.2 of the MSGP (Fill in Sections A, B, C, D,
and G).
C. Facility Operator Information
1. Operator Information
Operator Name:
Mailing Address:
Street:
City:
State:
-
Phone:
-
ZIP Code:
-
Ext.
E-mail:
2. DMR Preparer (Complete if DMR was prepared by someone other than the certifier):
First Name, Middle Initial, Last Name:
Organization:
Phone:
-
-
Ext.
E-mail:
EPA FORM 6100-29
Page 1 of 7
D. Facility Information
1. Facility Name:
2. Facility Address:
Street/Location:
City:
State:
-
ZIP Code:
County or Similar Government Subdivision:
E. Discharge Information
1. Identify monitoring period:
Check here if proposing alternative monitoring periods due to irregular stormwater runoff. Identify alternative
monitoring schedule and indicate for which alternative monitoring period you are reporting monitoring data:
Quarter 1 (January 1 – March 31)
Quarter 1: From
/
To
/
Quarter 2 (April 1 – June 30)
Quarter 2: From
/
To
/
Quarter 3 (July 1 – September 30)
Quarter 3: From
/
To
/
Quarter 4 (October 1 – December 31)
Quarter 4: From
/
To
/
2. Are you required to monitor for cadmium, copper, chromium, lead, nickel, silver, or zinc in freshwater?
3. What is the hardness level of the receiving water?
4. Does your facility discharge into any saltwater receiving waters?
EPA FORM 6100-29
Yes (Skip to 3)
No (Skip to 4)
(mg/L)
Yes
No
Page 2 of 7
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
MSGP INDUSTRIAL DISCHARGE MONITORING REPORT (DMR)
F. Monitoring Information
1. Nature of Discharge:
Form Approved. OMB No. 2040-0004
Note: Make additional copies of this form as necessary.
Rainfall (Complete line items 2.a., 2.b., & 2.c.)
2.a. Duration of the rainfall event (hours):
3.a. Outfall ID
(list the same 3- 3.b. Check if Any Outfalls
digit outfalls
are Substantially Identical
identified on
to Other Outfalls Listed
the NOI form)
Snowmelt
2.b. Rainfall amount (inches):
3.c.
Check if No
Discharge
3.d.
Monitoring
Type QBM,
ELG, S/T, I, O*
3.e. Parameter
.
3.f. Quality or
Concentration
2.c. Time since previous measurable storm event (days):
3.g. Units
3.h. Results
Description
3.i. Collection Date
3.j. Exceedance
due to natural
background
pollutant levels
3.k. No further
pollutant
reductions
achievable?
Substantially identical
to outfall:________
Substantially identical
to outfall:________
Substantially identical
to outfall:________
Substantially identical
to outfall:________
Substantially identical
to outfall:________
Substantially identical
to outfall:________
Substantially identical
to outfall:________
* (QBM) - Quarterly benchmark monitoring; (ELG) - Annual effluent limitations guidelines monitoring; (S/T) - State- or tribal-specific monitoring; (I) - Impaired waters monitoring; (O) -Other monitoring as
required by EPA
4. Comment and/or Explanation of Any Violations (Reference all attachments here)
EPA FORM 6100-29
Page 3 of 7
G. Certification
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly
gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
First Name, Middle Initial, Last
Name:
Title:
Signature:
Date:
/
/
E-mail:
EPA FORM 6100-29
Page 4 of 7
Instructions for Completing EPA Form 6100-29
Discharge Monitoring Report (DMR) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
Who Must Submit A Discharge Monitoring Report to EPA?
Facilities covered under the Multi-Sector General Permit (MSGP or
permit) that are required to monitor pursuant to Parts 6.2 and 8 of
the permit must submit Discharge Monitoring Reports (DMRs)
consistent with the reporting requirements specified in Part 7.1 of
the permit.
Completing the Form
Obtain and read a copy of the 2015 MSGP, viewable at
http://water.epa.gov/polwaste/npdes/stormwater/EPA-MultiSector-General-Permit-MSGP.cfm. To complete this form, type or
print, using uppercase letters, in the appropriate areas only. Please
place each character between the marks. Abbreviate if necessary
to stay within the number of characters allowed for each item. Use
only one space for breaks between words, but not for punctuation
marks unless they are needed to clarify your response. Please
submit original document with signature in ink - do not send a
photocopied signature. Photocopy your DMR form for your records
before you send the completed original form to the appropriate
address.
Section A. Approval to Use Paper DMR Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper DMR form unless the EPA
Regional Office has approved its use. Where you have obtained
approval to use this form, indicate the waiver that you have been
granted, the name of the EPA staff person who granted the waiver,
and
the
date
that
approval
was
provided.
See
http://water.epa.gov/polwaste/npdes/stormwater/EPA-MultiSector-General-Permit-MSGP.cfm for a list of EPA Regional Office
contacts.
Section B. Permit Information
Provide the NPDES ID (i.e., NOI tracking number) assigned to the
facility for which this DMR is being submitted.
Indicate your reason(s) for submitting this DMR by checking all
boxes that apply. The reasons for submission are defined as follows:
• Submitting monitoring data: For each storm sampled, submit
one DMR form with data for all outfalls sampled. Select this
reason even if you only have monitoring data for some of your
outfalls (i.e., some outfalls did not discharge). If you select this
reason you are required to complete all Sections of the form.
• Reporting no discharge for all outfalls for this monitoring period:
Indicates that there were no discharges from all outfalls during
this monitoring period. If you select this reason you are only
required to complete Sections A, B, C, D, E.1, and G.
• Reporting that your site status has changed to inactive and
unstaffed: Indicates that your facility is currently inactive and
unstaffed (See Part 6.2.1.3 of the permit for more information).
If you select this reason you are only required to complete
Sections A, B, C, D, and F and include date of status change in
comment field in Section F.4
• Reporting that your site status has changed from inactive to
active: Indicates that your facility is currently active (See Part
6.2.1.3 of the permit for more information). If you select this
reason you are required to complete all Sections of the form
and include date of status change in the comment field in
Section F.4.
EPA FORM 6100-29
Form Approved OMB No. 2040-0004
• Reporting that no further reductions are achievable for all
outfalls and for all pollutants via Part 6.2.1.2 of the permit:
Indicates that you have determined that no further pollutant
reductions are technologically and economically practicable
in light of best industry practice to meet the technology-based
effluent limits or are necessary to meet the water-quality-based
effluent limitations in Parts 2 of the permit (See Part 6.2.1.2 of the
permit for more information). If you select this reason you are
required to complete Sections A, B, C, D and G. However, if you
can make this finding for some outfalls and pollutants, but not
for others, you cannot select this reason; you will instead be
able to identify which outfalls and which pollutants you can
make this finding for in Section F.
Section C. Facility Operator Information.
Provide the legal name of the person, firm, public organization, or
any other entity that operates the facility for which this DMR is being
submitted. An operator of a facility is the legal entity that controls
the operation of the facility. Refer to Appendix A of the permit for
the definition of “operator”. Provide the operator’s mailing address,
phone number, and e-mail. The operator information in this Section
should match the operator information provided on your NOI form.
Provide the name, organization, phone number, an email address
for the person who prepared this DMR form.
Section D. Facility Information
Enter the official or legal name and complete street address,
including city, state, ZIP code, and county or similar government
subdivision of the facility. If the facility lacks a street address,
indicate the general location of the facility (e.g., Intersection of
State Highways 61 and 34). Complete facility information must be
provided for permit coverage to be granted. The facility
information in this Section should match the facility information
provided on your NOI form.
Section E. Discharge Information.
Indicate the appropriate monitoring period (Quarter 1, 2, 3, or 4)
covered by the DMR. “Alternative” monitoring periods can apply
to facilities located in arid and semi-arid climates, or in areas subject
to snow or prolonged freezing. To use alternative monitoring
periods, you must provide a revised monitoring schedule here. If
using alternative monitoring periods, identify the first day of the
monitoring period through the last day of the monitoring period for
each of the four periods. The dates should be displayed as month
(Mo) / day (Day). See Parts 6.1.6 and 6.1.7 of the permit for more
information.
If you are submitting benchmark monitoring data, identify if your
facility is required to collect benchmark samples for one or more
hardness-dependent metals (i.e., cadmium, copper, lead, nickel,
silver, and zinc). If you select “yes” to this question provide the
hardness level of the receiving water (in mg/L)). If you select “no”
to this question, you must identify if your facility discharges into any
saltwater receiving waters.
Page 5 of 7
Instructions for Completing EPA Form 6100-29
Discharge Monitoring Report (DMR) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
F. Monitoring Information
For the reported monitoring event indicate whether the discharge
was from a rainfall or snowmelt event. If you select “rainfall” then
indicate the duration (in hours) of the rainfall event, rainfall total (in
inches) for that rainfall event, and time (in days) since the previous
measurable storm event in line items 2.a-c. For both rainfall and
snowmelt monitoring, you must identify the date of collection for
the monitoring event in column 3.i. of the table. If the discharge
occurs during a period of both rainfall and snowmelt, check both
the rainfall and snowmelt boxes and report the appropriate rainfall
information in item 2.a-c. To report multiple monitoring events in the
same reporting period, copy this form and enter each monitoring
event separately with data for all outfalls sampled.
Identify all the outfalls from your facility that discharge stormwater.
Each outfall must be assigned a unique 3-digit number (e.g., 001,
002, 003), and should match the outfalls identified on your NOI form.
If any outfalls are substantially identical, check the box in 3.b and
identify the outfall that the outfall in 3.a is substantially identical to.
In 3.d – k, you only need to provide benchmark monitoring data for
one of the outfalls.
For any outfall for which there was no discharge during the
monitoring period, check the box in 3.
In 3.d, identify the type of monitoring using the specified codes, in
parentheses, below:
•
•
•
•
•
(QBM) – Quarterly benchmark monitoring
(ELG) – Annual effluent limitations guidelines monitoring;
(S/T) – State- or Tribal-specific monitoring;
(I) – Impaired waters monitoring; or
(O) – Other monitoring as required by EPA.
In 3.e, enter each “parameter” (or “pollutant”) monitored. For QBM
and ELG monitoring, use the same parameter name as in Part 8 of
the permit.
In 3.f., enter a sample measurement value for each parameter
analyzed and required to be reported. Enter “ND” (i.e., not
detected) for any sample results below the method detection limit
or “BQL” (i.e., below quantitation limit) for sample results above the
detection limit but below the quantitation limit.
In 3.g., enter the units for sample measurement values (i.e., “mg/L”
for milligrams per liter) for each parameter analyzed and required
to be reported. For monitoring results reported as ND or BQL this
space will be left blank and the units will be reported in Column 3.f.
3.h. must be completed for any monitoring results reported as ND or
BQL in the “Quality or Concentration” column. For ND, report the
laboratory detection level and units in this column. For BQL, report
the laboratory quantitation limit and units in this column.
In 3.i. identify the sampling date for each parameter monitoring
result reported on this form.
3.h. Exceedance due to natural background pollutant levels:
Check box if following the first 4 quarters of benchmark monitoring
(or sooner if the exceedance is triggered by less than 4 quarters
of data) you have determined that the exceedance of the
EPA FORM 6100-29
Form Approved OMB No. 2040-0004
benchmark is attributable solely to the presence of that pollutant in
the natural background for that outfall and any substantially
identical outfalls, or for impaired waters monitoring, the presence of
the pollutant is caused solely by natural background. See Part
6.2.1.2 and 6.2.4.1 of the permit for more information.
In 3.j .check the box if after collection of 4 quarterly samples (or
sooner if the exceedance is triggered by less than 4 quarters of
data), the average of the 4 monitoring values for any parameter
exceeds the benchmark and you have made the determination
that no further pollutant reductions are technologically available
and economically practicable and achievable in light of best
industry practice to meet the technology-based effluent limits or
are necessary to meet the water-quality-based effluent
Where violations of the permit requirements are reported, include a
brief explanation to describe the cause and corrective actions
taken, and reference each violation by date. Also, this section
should include any additional comments such as are required when
changing site status from inactive and unstaffed to active or vice
versa. Attach additional pages if you need more space.
Attach additional copies of Section F as necessary to address all
outfalls and parameters.
Section G. Certification Information
DMRs must be signed by a person described below, or by a duly
authorized representative of that person.
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 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 and title of the person
signing the form and the date of signing.
Page 6 of 7
Instructions for Completing EPA Form 6100-29
Discharge Monitoring Report (DMR) for Stormwater Discharges
Associated with Industrial Activity Under the NPDES Multi-Sector General Permit
NPDES Form Date (06/15)
A person is a duly authorized representative only if:
1. The authorization is made in writing by a person described above;
2. The authorization specifies either an individual or a position
having responsibility for the overall operation of the regulated
facility or activity such as the position of plant manager, operator
of a well or a well field, superintendent, position of equivalent
responsibility, or an individual or position having overall responsibility
for environmental matters for the company, (A duly authorized
representative may thus be either a named individual or any
individual occupying a named position.) and
3. The written authorization is submitted to the Director.
An unsigned or undated DMR form be considered incomplete.
Paperwork Reduction Act Notice
Public reporting burden for this form is estimated to average 7.25
hours per response, 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: Director,
Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number of this form on any
correspondence. Do not send the completed DMR form to this
address.
Submitting Your Form
If you have been granted a waiver from your Regional Office to
submit a paper DMR form, you must send your DMR form by mail to
one of the following addresses:
Region 1
MSGP Discharge Monitoring Reports (OES4-SMR)
EPA New England, Region 1
5 Post Office Square - Suite 100
Boston, MA 02109-3912
Form Approved OMB No. 2040-0004
Region 5
U.S. Environmental Protection Agency Region 5
77 West Jackson Boulevard (WN-16J)
Chicago, Illinois 60604
Attn: Brian Bell - Storm Water Coordinator
Region 6
U.S. EPA, Region 6 MSGP DMRs
Water Enforcement Branch (6EN-WC)
1445 Ross Avenue
Dallas, TX 75202
Region 7
Neal Gilbert
U.S. Environmental Protection Agency, Region 7
Enforcement Coordination Office
11201 Renner Blvd
Lenexa, KS 66219
Region 8
U.S. EPA, Region 8 (ENF-PJ)
Attention: DMR Coordinator
1595 Wynkoop Street
Denver, CO 80202-1129
Region 9
Sandra Chew
U.S. EPA Region 9
Information Management Section, ENF-4-1
75 Hawthorne Street
San Francisco, CA 94105
Region 10
U.S. EPA Region 10
Attn: NPDES Data Manager, OCE-101
1200 Sixth Avenue, Suite 900
Seattle, WA 98101
Visit this website for instructions on how to submit electronically:
http://water.epa.gov/polwaste/npdes/stormwater/StormwatereNOI-System-for-EPAs-MultiSector-General-Permit.cfm
Region 2
MSGP Discharge Monitoring Reports
290 Broadway
DECA/CAPBS/DMT
21st Floor
New York, NY, 10007-1866
Region 3
Nancy Ford
U.S. EPA Region 3
1650 Arch Street
Mail Code #3WP60
Philadelphia, PA 19103
EPA FORM 6100-29
Page 7 of 7
Multi-Sector General Permit (MSGP)
I-1
Appendix I - Annual Report Form
Part 7.1 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your
Annual Report. However, if you are given a waiver by the EPA Regional Office to use a paper
annual report form, and you elect to use it, you must complete and submit the following form.
I-1 of 6
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
ANNUAL REPORT FOR STORMWATER DISCHARGES ASSOCIATED WITH
INDUSTRIAL ACTIVITY UNDER THE NPDES THE NPDES MULTI-SECTOR GENERAL PERMIT
NPDES
FORM
6100-28
Form Approved.
OMB No. 2040-0004
A. Approval to Use Paper Annual Report Form
1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of
approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is
identified as under-served for broadband Internet access in the most recent report from the Federal Communications
Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the
waiver:
Date approval
obtained:
/
/
* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper annual report form. If you have not obtained
a waiver, you must file this form electronically using the NPDES eReporting Tool (NeT) at http://water.epa.gov/polwaste/npdes/stormwater/StormwatereNOI-System-for-EPAs-MultiSector-General-Permit.cfm
B. Permit Information
1. NPDES ID:
C. Facility Information
1. Facility Name:
2. Facility Phone:
-
-
Ext.
3. Facility Mailing Address:
Street:
City:
State:
ZIP
Code:
-
County or Similar Government Subdivision:
4. Point of Contact:
First Name, Middle Initial, Last Name:
D. General Findings
1. Provide a summary of your past year’s routine facility inspection documentation (see Part 3.1.2 of the permit). In addition, if you are an operator of an
airport facility (Sector S) that is subject to the airport effluent limitations guidelines, and are complying with the MSGP Part 8.S.8.1 effluent limitation through
the use of non-urea-containing deicers, provide a statement certifying that you do not use pavement deicers containing urea (e.g., “Urea was not used at
[name of airport] for pavement deicing in the past year and will also not be used in 2015.” (Note: Operators of airport facilities that are complying with Part
8.S.8.1 by meeting the numeric effluent limitation for ammonia do not need to include this statement.)
EPA FORM 6100-28 (Revised 6-2015)
Page 1 of 5
2. Provide a summary of your past year’s quarterly visual assessment documentation (see Part 3.2.2 of the permit).
3. For any four-sample (minimum) average benchmark monitoring exceedance, if after reviewing the selection, design, installation, and implementation
of your control measures and considering whether any modifications are necessary to meet the effluent limits in the permit, you determine that no further
pollutant reductions are technologically available and economically practicable and achievable in light of best industry practice, provide your rationale
for why you believe no further reductions are achievable (see Part 6.2.1.2 of the permit). Enter “NA” if not applicable.
4. Provide a summary of your past year’s corrective action documentation (See Part 4.4 of the permit). (Note: If corrective action is not yet completed at
the time of submission of this annual report, you must describe the status of any outstanding corrective action(s).) Also describe any incidents of
noncompliance in the past year or currently ongoing, or if none, provide a statement that you are in compliance with the permit.
EPA FORM 6100-28 (Revised 6-2015)
Page 2 of 5
E. 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.
First Name, Middle Initial, Last Name:
Title:
Signature:
Date:
/
/
E-mail:
EPA FORM 6100-28 (Revised 6-2015)
Page 3 of 5
Instructions for Completing the Annual Report Form
Annual Report for Stormwater Discharges
Associated with Industrial Activity Under an NPDES General Permit
Who Must File an Annual Report
Operators must submit an Annual Report to EPA electronically, per
Part 7.5, by January 30th for each year of permit coverage
containing information generated from the past calendar year.
Completing the Form
To complete this form, type or print, using uppercase letters, in the
appropriate areas only. Please place each character between the
marks. Abbreviate if necessary to stay within the number of
characters allowed for each item. Use only one space for breaks
between words, but not for punctuation marks unless they are
needed to clarify your response. Please submit original document
with signature in ink - do not send a photocopied signature.
Section A. Approval to Use Paper Annual Report Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper form unless the EPA Regional
Office has approved its use. Where you have obtained approval
to use this form, indicate the waiver that you have been granted,
the name of the EPA staff person who granted the waiver, and the
date
that
approval
was
provided.
See
http://water.epa.gov/polwaste/npdes/stormwater/StormwaterContacts.cfm for a list of EPA Regional Office contacts.
Section B. Permit Information
Provide the NPDES ID (i.e., NOI tracking number) assigned to your
facility.
Section C. Facility Information
Enter the official or legal name, phone number, and complete
street address, including city, state, ZIP code, and county or similar
government subdivision, for the facility that is covered by the NPDES
ID identified in Section B. If the facility lacks a street address, indicate
the general location of the facility (e.g., Intersection of State
Highways 61 and 34). Also provide a point of contact name for the
facility.
Section D. General Findings
To complete this section you must provide the following information
in your annual report:
1. A summary of your past year’s routine facility inspection
documentation required by Part 3.1.2 of the permit.
2. A summary of your past year’s quarterly visual assessment
documentation required by Part 3.2.2 of the permit.
3. If, after finding the average of your four monitoring values for
any pollutant exceeds the benchmark, you decide no further
pollutant reductions are technologically available and
economically practicable and achievable in light of best
industry practice, your rationale for why you believe no further
reductions are achievable.
4. Information copied or summarized from the corrective action
documentation required per Part 4.4 (if applicable). If
corrective action is not yet completed at the time of
submission of this Annual Report, you must describe the status
of any outstanding corrective action(s). You must also
describe any incidents of noncompliance in the past year or
currently ongoing, or if none, provide a statement that you are
in compliance with the permit.
EPA FORM 6100-28 (Revised 6-2015)
Section E. Certification Information
The Annual Report must be signed by a person described below, or
by a duly authorized representative of that person.
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 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 and title of the person
signing the form and the date of signing.
A person is a duly authorized representative only if:
1. The authorization is made in writing by a person described above;
2. The authorization specifies either an individual or a position having
responsibility for the overall operation of the regulated facility or
activity such as the position of plant manager, operator of a well or
a well field, superintendent, position of equivalent responsibility, or
an individual or position having overall responsibility for
environmental matters for the company, (A duly authorized
representative may thus be either a named individual or any
individual occupying a named position.) and
3. The written authorization is submitted to the Director.
An unsigned or undated Annual Report form be considered
incomplete.
Paperwork Reduction Act Notice
Public reporting burden for this form is estimated to average 2.5
hours per response, 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: Director,
Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number of this form on any
correspondence. Do not send the completed Annual Report form
to this address.
Page 4 of 5
Instructions for Completing the Annual Report Form
Annual Report for Stormwater Discharges
Associated with Industrial Activity Under an NPDES General Permit
Submitting Your Form
If you have been granted a waiver from your Regional Office to
submit a paper Annual Report form, you must send your Annual
Report form by mail to one of the following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: 2015 MSGP Reports
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
EPA FORM 6100-28 (Revised 6-2015)
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: 2015 MSGP Reports
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
http://water.epa.gov/polwaste/npdes/stormwater/StormwatereNOI-System-for-EPAs-MultiSector-General-Permit.cfm
Page 5 of 5
Multi-Sector General Permit (MSGP)
K-1
Appendix K - No Exposure Certification Form
Part 7.1 requires you to use the NPDES eReporting Tool, or “NeT”, to prepare and submit your No
Exposure Certification (NOE) form. However, if you are given a waiver by the EPA Regional
Office to use a paper NOE form, and you elect to use it, you must complete and submit the
following form.
Page K-1 of 6
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NPDES
FORM
3510-11
NO EXPOSURE CERTIFICATION (NOE) FOR EXCLUSION FROM EPA’S MULTI-SECTOR GENERAL PERMIT FOR
STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY (MSGP)
Form Approved
OMB No. 2040-0004
Submission of this No Exposure Certification constitutes notice that the operator identified in Section C does not require permit authorization under EPA’s
Stormwater Multi Sector General Permit for its stormwater discharges associated with industrial activity from the facility identified in Section D of this form 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 operator in Section C 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).
A. Approval to Use Paper NOE Form
1. Have you been granted a waiver from electronic reporting from the EPA Regional Office*?
YES
NO
If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:
The owner/operator’s headquarters is physically located in a geographic area (i.e., ZIP code or census tract) that is
identified as under-served for broadband Internet access in the most recent report from the Federal Communications
Commission.
The owner/operator has issues regarding available computer access or computer capability.
Name of EPA staff person that granted the waiver:
/
Date approval obtained:
/
* Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper NOE form. If you have not obtained a waiver,
you must file this form electronically using the NPDES eReporting Tool (NeT) at http://water.epa.gov/polwaste/npdes/stormwater/Stormwater-eNOI-Systemfor-EPAs-MultiSector-General-Permit.cfm
B. Reason for Submission
Select the purpose for filling out this form (check only 1).
To obtain a new No Exposure Certification. Fill in Sections C, D, E and F.
To discontinue an existing No Exposure Certification. Select this option if you would like to discontinue an existing No Exposure Certification because
your facility is no longer subject to regulation under 40 CFR 122.26 (e.g., the facility has ceased the industrial activity that necessitated the No Exposure
Certification)*. Provide the following information and fill out Section G.
Provide the existing NPDES ID for the No Exposure Certification that
you would like to discontinue:
* Note that if your facility no longer qualifies for the No Exposure Certification because permit coverage is required for exposed industrial materials or
activities, you should not check this box, and must instead file for coverage under the Multi-Sector General Permit or an individual permit. Your No Exposure
Certification will be automatically discontinued after you obtain coverage under the MSGP or an individual permit.
C. Facility Operator Information
1. Operator Name:
2. Mailing Address
Street:
City:
3. Phone:
State:
-
-
ZIP Code:
-
Ext.
4. E-mail:
EPA Form 3510-11 (Revised 06/2015)
Page 1 of 5
5. Operator Point of Contact Information:
First Name, Middle Initial, Last Name:
Title:
D. Facility Information
1. Facility Name:
2. Facility Address:
Street/Location:
City:
State:
-
ZIP Code:
County or Similar Government Subdivision:
3. Latitude/Longitude for the facility:
Latitude:
Longitude:
___ ___. ___ ___ ___ ___° N (decimal degrees)
Latitude/Longitude Data Source:
Map
GPS
___ ___ ___. ___ ___ ___ ___° W (decimal degrees)
Other:
If you used a USGS topographic map, what was the scale? _________________________________________________________________________________
Horizontal Reference Datum:
NAD 27
NAD 83
WGS 84
4. Is your project/site located on Indian country lands?
YES
NO
If yes, provide the name of the Indian tribe associated with the area of Indian country (including name of Indian reservation, if applicable):
_________________________________________
5. Are you a “federal operator” as defined in Appendix A?
6. What is the ownership type of the facility?
County Government
District
Corporation
YES
NO
Federal Facility (U.S. Government)
State Government
Mixed Ownership (e.g. Public/Private)
Privately Owned Facility
Tribal Government
Municipality
School District
Municipal or Water District
7. Have stormwater discharges from your facility been covered previously under an NPDES permit?
YES
NO
If yes, provide the NPDES ID if you had coverage under EPA’s MSGP or the NPDES
permit number if you had coverage under an EPA individual permit:
8. Has your facility previously been covered by a No Exposure exclusion?
YES
NO
If yes, provide the NPDES ID for your previous No Exposure exclusion:
9. 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
10. Total size of site associated with industrial activity:
(to the nearest quarter acre)
11. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion?
YES
NO
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 (1) acre
One (1) to five (5) acres
EPA Form 3510-11 (Revised 06/2015)
More than five (5) acres
Page 2 of 5
E. 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, you are not eligible for the no exposure
exclusion.
Yes
No
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
Materials or residuals on the ground or in stormwater inlets from spills/leaks
Materials or products from past industrial activity
Material handling equipment (except adequately maintained vehicles)
Materials or products during loading/unloading or transporting activities
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)
Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
Materials or products handled/stored on roads or railways owned or maintained by the discharger
Waste material (except waste in covered, non-leaking containers [e.g., dumpsters])
Application or disposal of process wastewater (unless otherwise permitted)
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
F. Certification Information
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.
First Name, Middle Initial, Last Name:
Title:
Signature:
Date:
/
/
E-mail:
G. Discontinuation of No Exposure 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.
First Name, Middle Initial, Last Name:
Title:
Signature:
Date:
/
/
E-mail:
EPA Form 3510-11 (Revised 06/2015)
Page 3 of 5
Instructions for Completing EPA Form 3510-11
No Exposure Certification (NOE) for Exclusion from Stormwater Discharges
Associated with Industrial Activity Under an NPDES General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-11 (09/08)
Who May File a No Exposure Certification
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 40 CFR 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.
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.
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.
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.
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. Approval to Use Paper NOE Form
You must indicate whether you have been granted a waiver from
electronic reporting from the EPA Regional Office. Note that you
are not authorized to use this paper No Exposure Certification
(NOE) form unless the EPA Regional Office has approved its use.
Where you have obtained approval to use this form, indicate the
waiver that you have been granted, the name of the EPA
Regional Office staff person who granted the waiver, and the
date
that
approval
was
provided.
See
http://water.epa.gov/polwaste/npdes/stormwater/StormwaterContacts.cfm for a list of EPA Regional Office contacts.
Section B. Reason for Submission
You must check your reason for submitting this form. You may
submit this form for obtaining a new No Exposure Certification, for
renewing a previous No Exposure Certification, or for discontinuing
an existing No Exposure Certification (for facilities that no longer
need the exclusion from permit coverage for industrial stormwater
discharges).
Form Approved OMB No. 2040-0004
MSGP for the definition of “operator”. Provide the operator’s
mailing address, phone number, and e-mail. Correspondence
for the NOE will be sent to this address. Also provide the name
and title for the operator point of contact (note that the point of
contact name may be the same as the operator name).
Section D. Facility Information
Enter the official or legal name and complete street address,
including city, state, ZIP code, and county or similar government
subdivision of the facility. If the facility lacks a street address,
indicate the general location of the facility (e.g., Intersection of
State Highways 61 and 34). Complete facility information must
be provided for permit coverage to be granted.
Provide the latitude and longitude of your facility in decimal
degrees 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 and U.S.
Geological Survey (U.S.G.S.) topographic or quadrangle maps.
Refer to http://transition.fcc.gov/mb/audio/bickel/DDDMMSSdecimal.html/ for assistance in providing the proper
latitude/longitude format. For consistency, EPA requests that
measurements be taken form the approximate center of the
facility. Specify which method you used to determine latitude
and longitude. If a U.S.G.S. topographic map is used, specify the
scale of the map used. Enter the horizontal reference datum for
your latitude and longitude. 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.
Indicate whether the facility is on Indian country lands, and if so,
provide the name of the Indian tribe associated with the area of
Indian country (including name of Indian reservation, if
applicable).
Indicate whether you are a “federal operator” as defined in
Appendix A of the MSGP. Also check the facility’s ownership
type.
Indicate whether the facility was previously covered under an
NPDES stormwater permit. If so, include the NPDES ID (i.e., NOI
tracking number).
List the four-digit Standard Industrial Classification (SIC) code or
two character activity code that best describes the primary
industrial activities performed by your facility.
Enter the total size of the site associated with industrial activity in
acres.
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.
Section C. Facility Operator Information
Provide the legal name of the person, firm, public organization, or
any other entity that operates the facility described in this
certification form. An operator of a facility is the legal entity that
controls the operation of the facility. Refer to Appendix A of the
EPA Form 3510-11 (Revised 06/2015)
Page 4 of 5
Instructions for Completing EPA Form 3510-11
No Exposure Certification (NOE) for Exclusion from Stormwater Discharges
Associated with Industrial Activity Under an NPDES General Permit
NPDES Form Date (06/15)
This Form Replaces From 3510-11 (09/08)
Section E. 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 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 F and G. Certification Information
The NOE form 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 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 and title of the
person signing the form and the date of signing.
Form Approved OMB No. 2040-0004
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, Collection Strategies
Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, 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.
Submitting Your Form
If you have been granted a waiver from your Regional Office to
submit a paper No Exposure Certification form, you must send
your No Exposure Certification form by mail to one of the
following addresses:
For Regular U.S. Mail Delivery:
Stormwater Notice Processing Center
Mail Code 4203M, ATTN: MSGP No Exposure
U.S. EPA
1200 Pennsylvania Avenue, NW
Washington, DC 20460
For Overnight/Express Mail Delivery:
Stormwater Notice Processing Center
William Jefferson Clinton East Building - Room 7420
ATTN: MSGP No Exposure
U.S. EPA
1201 Constitution Avenue, NW
Washington, DC 20004
Visit this website for instructions on how to submit electronically:
http://water.epa.gov/polwaste/npdes/stormwater/Stormwater
-eNOI-System-for-EPAs-MultiSector-General-Permit.cfm
Include the name, title, and email address of the person signing
the form and the date of signing.
An unsigned or undated NOE certification will not be considered
valid.
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
EPA Form 3510-11 (Revised 06/2015)
Page 5 of 5
Final 2013 VGP
NOI Form
EPA
NPDES
United States Environmental Protection Agency
Form
Washington, DC 20460 Form Approved
OMB No.
____-_
Notice of Intent (NOI) for Discharges Incidental to the Normal Operation
of a Vessel under the NPDES Vessel General Permit
2040-0004
Submission of this completed Notice of Intent (NOI) constitutes notice that the entity in Section A intends to be authorized to
discharge pollutants to waters of the United States, from the vessel identified in Section B, under EPA’s Vessel General Permit
(VGP). Submission of the NOI also constitutes notice that the party identified in Section B of this form has read, understands,
and meets the eligibility conditions of Part 1 of the VGP; agrees to comply with all applicable terms and conditions of the VGP;
and understands that continued authorization under the VGP is contingent on maintaining eligibility for coverage. In order to be
granted coverage, all information required on this form must be completed. Please read and make sure you comply with all
permit requirements.
A. Vessel Owner/Operator Information
1. Name:
2a. IRS Employer Information Number: _ _ - _ _ _ _ _ _ _ (if applicable)
2b. Company IMO number ________________________(if applicable)
3. Name of Certifying Official
4. Mailing Address: a. Street:
b. City:
c. State/Province: _ _ d. Zip code:
e. Country:
f. Phone (include country code):
g. Fax (Optional):
h. E-mail:
_
B. Vessel Information
1. Vessel Name:
2. Did your vessel previously have permit coverage under the 2008 VGP? □ Yes □ No
2a. If yes, 2008 VGP Permit Tracking Number(s):
3a. Registered Number:
(if applicable)
3b. Vessel IMO number:
(if applicable)
4. Vessel Call Sign
5. Flag State/Port of Registry (complete spellings of state and port city names required)
6. Type of Vessel (select one primary vessel type, and secondary vessel type where appropriate)
□ Commercial Fishing Vessel
□ Emergency and Rescue Vessel
□ Medium Cruise Ship (100 to 499 passengers)
□ Bulk Carrier
□ Large Cruise Ship (500+ passengers)
□ Container Ship
□ Large Ferry (250+ passengers or more than 100 tons of
□ General Cargo Ship
cargo, e.g., cars, trucks, trains, or other land- based
□ Roll-on Roll-Off
transportation.)
□ Utility Vessel, including Tug boats and Offshore supply
□ Barge (□ Hopper Barge, □ Tank Barge, □ Other Barge)
vessels (□ Tug, □ Offshore supply vessel, □ Other Utility))
□ Oil or Gas Tanker
□ Reefer
□ Other:
□ Research/Survey Vessel
7. Vessel Dimensions: a. Tonnage:
□ gross tons or □ gross registered tons
b. Length:
□ feet or □ meters
8. Ballast Water Capacity:
□ gallons or □ meters³
9. Date and Year Vessel Built (i.e., build date or date keel laid): _________________________
10. a. Date of last dry-dock:
.b. Date of next scheduled/anticipated dry-dock:
11. Does vessel currently have, or has vessel ever held, an NPDES permit, other than the VGP, for any part, discharge, or
operation of the vessel?
□ Yes □ No
If yes, please provide the following:
Page 157 of 194
Final 2013 VGP
11a. Permit Number:
11b. Effective Date of Permit:
11c. Expiration Date of Permit
11d. Discharges permitted:
12. Is this a transfer of ownership? □ Yes □ No
12a. If Yes, provide date of transfer:
12b. If yes, provide previous vessel permit tracking number(s):
13. Identify the North American Industry Classification System (NAICS) code that best represents your vessel service for which
you are seeking coverage (if applicable): _________
C. Vessel Voyage Information
1. Home Port/Most Frequented US Port:
2. US Ports Vessel Anticipates Visiting During Permit Term:
3. Number of overnight berths: a. Passengers
b. Crew
a. Maximum passenger capacity
b. Crew
4. Does vessel travel beyond the US EEZ and more than 200 nm from any shore? □ Yes □ No
5. Is the vessel engaged in Nearshore Voyages? □ Yes □ No
D. Discharge Information:
1. Select all applicable discharges vessel may generate:
□ Deck Washdown and Runoff
□ Gas Turbine Washwater
□ Bilgewater/Oily Water Separator Effluent
□ Graywater
□ Ballast Water
□ Motor Gasoline and Compensating Discharge
□ Anti-fouling hull coatings
□ Non-Oily Machinery Wastewater
□ Aqueous Film Forming Foams (AFFF)
□ Refrigeration and Air Condensate Discharge
□ Boiler/Economizer Blowdown
□ Seawater Cooling Overboard Discharge
□ Cathodic Protection
□ Seawater Piping Biofouling Prevention
□ Chain Locker Effluent
□ Small Boat Engine Wet Exhaust
□ Controllable Pitch Propeller Hydraulic Fluid and other
□ Sonar Dome Discharge
Oil-to-Sea Interfaces
□ Underwater Ship Husbandry
□ Distillation or Reverse Osmosis Brine
□ Welldeck Discharges
□ Elevator Pit Effluent
□ Graywater Mixed with Sewage
□ Firemain Systems
□ Exhaust Gas Scrubber Washwater Discharge
□ Freshwater layup
□ Fish Hold/ Fish Hold Cleaning Effluent
2. Does the vessel ever engage in or have capacity to engage in industrial operations? □ Yes □ No
a. If yes, please select appropriate box:
□ Seafood processing
□ Mining
□ Other:
□ Energy exploration
3. Will the vessel be using a ballast water treatment system which discharges residual biocides?
□ Yes □ No
b. If yes, are residual biocide concentrations expected to be below those listed in Part 2.2.3.5.1.1.5 of the Permit?
□ Yes □ No
c. List the biocide residuals or derivatives that may be discharged by the ballast water treatment system:
4. Is your vessel required to collect analytical monitoring? If so, for which of the following discharges must you conduct
monitoring:
□ Ballast Water
□ Bilgewater
□ Exhaust Gas Scrubber Effluent
□ Graywater If yes, please check the appropriate answer: □ I use or □ I do not use a treatment system for Graywater
5. Does the vessel have onboard treatment systems for any waste stream(s) covered by this permit?
□ Yes □ No
Page 158 of 194
Final 2013 VGP
5.a. If yes, check all that apply and complete the following information for each treatment system: □ Ballast Water, □ Bilgewater,
□ Exhaust Gas Scrubber Effluent, □ Graywater, □ Graywater mixed with Sewage, □ Other treatment system: _______________
5.b. Treatment system type/design and manufacturer:
5.c. Treatment System Capacity:
5.d. Residuals (wastes) generated by this treatment system:
5.e. How they are disposed:
For ballast water, bilgewater, and graywater mixed with sewage, is the system type approved by the US Coast Guard: □ Yes □
No
For ballast water, has the system been determined by the US Coast Guard to be an alternate management system (AMS): □ Yes □
No
Average Treatment System Flow Rate:
□ gallons/hour □ m3/hour
Peak Treatment System Flow Rate:
□ gallons/hour □ m3/hour
Residuals (wastes) generated by this treatment system:
How they are disposed:
6. Ballast Water and Invasive Species Management–
a. How often is the ballast tank cleaned and sediment disposed of?
b. How and where do you typically dispose of ballast tank sediment?
c. Does vessel have an existing ballast water management plan? □ Yes □ No
7. a. Type of anti-fouling hull coating on the vessel and list specific product:
□ Copper Based □ Non-Copper Based
b. When and where was anti-fouling hull coating last applied:
c. Describe hull husbandry practices, such as frequency of hull cleaning, method used, how niches and propellers are cleaned, etc:
d. Date of last hull cleaning:
e. Method of last hull cleaning:
f. Location of last hull cleaning:
g. Date of next scheduled/anticipated hull cleaning:
h. Anticipated method of next cleaning:
i. Planned location of next cleaning:
Page 159 of 194
Final 2013 VGP
E. Certifier Name and Title
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 contained
therein. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering
the information, the information contained is, to the best of my knowledge and belief, true, accurate, and complete. I have no
personal knowledge that the information submitted is other than 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:
Email:
Date: _ _ - _ _ - _ _
NOI Preparer (Complete if NOI was prepared by someone other than the certifier)
Prepared By:
Organization:
Phone:
Email:
Date: _ _ - _ _ - _ _
Ext:
Page 160 of 194
Final 2013 VGP
NOT Form
NPDES FORM
____-_
Form Approved. OMB No 2040-0004
Please See Instructions Before Completing This Form
EPA Notice of Termination (NOT) of Coverage under NPDES General Permit for
Discharges Incidental to Normal Vessel Operation
Submission of this Notice of Termination constitutes notice that the party identified in Section B of this form is no longer
authorized to discharge any discharge incidental to the normal operation of a vessel under the NPDES program for the vessel
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.
A. Permit Information
1. NPDES Permit Tracking Number: _ _ _ _ _ _ _ _ _
2. Reason for Termination (check one only):
a. □ You transferred operational control to another
operator.
Date of transfer:
b. □ You terminated vessel operations in waters subject to
the General Permit.
c. □ You obtained coverage under an individual or
alternative NPDES permit.
Permit Number:
Effective Date:
B. Vessel Owner/Operator Information
1. Name:
2. IRS Employer Information Number: _ _ - _ _ _ _ _ _ _
3. Name of Certifying Official:
4. Mailing Address:
a. Street:
b. City:
c. State: _ _
d. Zip code: _ _ _ _ _ - _ _ _ _
e. Phone: _ _ _ - _ _ _ - _ _ _ _
f. Fax (Optional): _ _ _ - _ _ _ - _ _ _ _
g. E-mail:
C. Vessel Information
1. Vessel Name:
2. Vessel ID/Registered Number
3. Vessel Call Sign
4. Port of Registry
D. Certifier Name and Title:
I certify under penalty of law that the information contained in this form is, to the best of my knowledge and belief, true, accurate
and complete. I understand that by submitting this Notice of Termination, I am no longer authorized to discharge any effluent
associated with normal vessel operation under this general permit, and that discharging pollutants related to the normal operation
of a vessel into waters of the United States is unlawful under the CWA where the discharge is not authorized by an 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 CWA.
Furthermore, 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 contained therein. Based on my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information contained is, to the best of my knowledge and belief, true, accurate,
and complete. I have no personal knowledge that the information submitted is other than 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: _ _ - _ _ - _ _
Page 162 of 194
Appendix K – Permit Authorization and Record of Inspection Form (PARI)
(for vessels which need not complete NOIs)
VGP Authorization and Record of Inspection (PARI) Form
I. Vessel Owner/Operator Information
Vessel Owner/Operator
Phone
Address and Email Address
II. Vessel Information
Vessel Name
Vessel Identifier
Vessel Type
Registered number/operating number
IMO number
III. Owner/Operator Acknowledgement
By signing this form, I acknowledge that I have read and am familiar with the VGP and that I am
implementing all permit requirements contained in the VGP.
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 contained therein. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gathering the information, the information contained is, to the
best of my knowledge and belief, true, accurate, and complete. I have no personal knowledge that the
information submitted is other than 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.
Signature and Date
V. Annual Inspections by Year
A. 2014
I certify that I have completed an annual inspection for 2014 in accordance with Part 4.1.3 of the VGP.
Signature and Date
B. 2015
I certify that I have completed an annual inspection for 2015 in accordance with Part 4.1.3 of the VGP.
Signature and Date
C. 2016
I certify that I have completed an annual inspection for 2016 in accordance with Part 4.1.3 of the VGP.
Signature and Date
D. 2017
I certify that I have completed an annual inspection for 2017 in accordance with Part 4.1.3 of the VGP.
Signature and Date
E. 2018
I certify that I have completed an annual inspection for 2018 in accordance with Part 4.1.3 of the VGP.
Signature and Date
Final 2013 VGP
Appendix H – Annual Report
EPA United States Environmental Protection Agency
Washington, DC 20460 Form Approved
OMB No.
One Time Report for Discharges Incidental to the Normal Operation
Of a Vessel under the NPDES Vessel General Permit
2040-0004
Owner/Operator and Vessel Information
Date Submitted ___________________
Vessel NOI Number (if applicable) _________
Vessel Owner/Operator ___________________________ Phone___________________________
Address________________________________________ E-mail___________________________
Vessel Name ____________________________________ Vessel Type ______________________
Length _____________________FEET/METERS (Circle One) Gross Tonnage __________□ gross tons □ gross
registered tons
Date of Vessel Construction ________________________
Calendar Year for which you are submitting the report: _____
Did your vessel operate in waters subject to this permit during the previous calendar year: □ Yes □ No
If you answered No to this question, completion of the remainder the following questions are
voluntary; however you must certify the bottom of the report.
Questions
1. Please list your vessel’s primary geographical regions of operation in U.S. waters last year and
report the approximate percentage of time was your vessel in each region?
□ Gulf Coast ___
□ Pacific Coast ___ □ Atlantic Coast ___ □ Mississippi-Ohio River System
___
□ Great Lakes ___ □ Puerto Rico and the US Virgin Islands □ Other: _________
2a. Did you conduct the following inspections in the last year? (Optional for inland vessels less than
300GT and unmanned, unpowered barges)
Drydock Inspections □ Yes □No Most recent drydock and inspection date: _________
Next scheduled drydocking: _________
Annual Inspections □ Yes □ No Most recent inspection date: _________
All Required Routine Inspections □ Yes □No
If you checked no, how many routine inspections did you miss in the last year?
□ 1-2 □3-4
□5-6 □7 or more
Last below water (or drydock) hull inspection: _________
2b. On average, how often did you conduct routine inspections in the last year?
□ Never □Once per week □Between once per week and once per day □Once per day □More
than once per day □Other: ________________
3a. Did your vessel discharge ballast water in U.S. waters? □ Yes □No
What is the capacity of your vessel’s ballast tanks? _____________□ gallons □ meters3
How many ballast tanks are present on your vessel (include holds or other areas that were used to
carry ballast water)? ___________
Page 181 of 194
Final 2013 VGP
For each tank or hold used to carry ballast, list type, capacity, and identifier: _________
Does your vessel have a ballast water treatment system? □ Yes □No □ N/A
If you answered yes, please attach analytical monitoring data for treated ballast water discharges
required by Parts 2.2.3.5.1.1 of the permit (see VGP Ballast Water DMR below).
Did you operate outside the EEZ and enter the Great Lakes? □ Yes □No □ N/A
If yes, did you discharge ballast water? □ Yes □No □ N/A
If yes, did you conduct ballast water exchange and/or flushing as applicable? □ Yes □No □ N/A
3b. Does your vessel have an exhaust gas scrubber? □ Yes □No
Did your vessel discharge washwater from its exhaust gas scrubber in U.S. waters? □ Yes □No □
N/A
If you answered yes, please attach analytical monitoring data for exhaust gas scrubber washwater
(see VGP Exhaust Gas Scrubber DMR below)
Discharge required by Part 2.2.26 of the permit.
3c. Does your vessel have an oily water separator (OWS)? □ Yes □No
If your vessel is greater than 400 GT did it discharge treated bilgewater within 1 nm of shore? □ Yes
□No □ N/A Did you ever discharge into waters subject to this permit (within 3 nm)? □ Yes □No □
N/A
If you discharged within 1 nm, why did you discharge?
□ Never left waters subject to this permit, but the discharge met a 15 ppm standard. □ Technically
infeasible or unsafe to hold (if checked, please attach explanation as to why it was technically
infeasible or unsafe to hold).
If you discharged within three nautical miles, did you collect analytical oil and grease monitoring
data? □ Yes □ No □ No, I qualified for the analytical monitoring waivers found in Part 2.2.2.1 of the
permit (not available in the first two years of permit coverage).
If you answered yes, please attach analytical monitoring data for bilgewater sampling (see VGP
Bilgewater DMR below)
3d. Did you discharge treated or untreated graywater in U.S. waters? □ Treated □Untreated □None
Does your vessel have and use a treatment system for graywater or graywater mixed with sewage? □
Yes □No □ N/A
If yes, please list the system make and model: __________
Is your vessel subject to analytical monitoring requirements in Parts 2.2.15, 5.1, or 5.2 □ Yes □
No. If yes, please attach analytical monitoring data for treated graywater discharges (see VGP
Graywater DMR below).
3e. Do you use anti-foulant coating? Yes □No □ N/A
If so, what is the type of anti-fouling hull coating on vessel and select specific product?
Date last applied: _________
4. Did your vessel store any discharges incidental to the normal operation of vessels on board for
onshore disposal?
□ Yes (please list) __________________________________________________ □No
If yes, please list disposal method (e.g., onshore treatment, pump out truck)________
Page 182 of 194
Final 2013 VGP
5. Did your vessel use environmentally acceptable lubricants for oil to sea interfaces?
□ Yes (please name the brand(s)) __________________________ □No
If not, why? ________________
6. Did you have to claim a safety exemption for any discharge category, and were therefore unable to
meet effluent limits of the VGP?
□ Yes (please list discharge types) ____________________________________ □No
If yes, reason(s) safety exemptions claimed? ____________________________
7. Did you receive any citations or warnings from EPA or the U.S. Coast Guard for any violations of
environmental laws? If yes, please scan and attach.
□ Yes (explain) _____________________________________________________________________
__________________________________________________________________________________
□No
8. Did you have any instances of noncompliance this year (e.g., discharging untreated bilgewater,
exceeding numeric effluent limits)?
□ Yes □No
If you answered yes, please fill out the table below. Please attach additional pages as necessary.
Date
VGP Requirement Description of
Cause of
Description of
Affected
Noncompliance
Noncompliance
Corrective Action
Performed or
Scheduled
Certification Information
I certify under penalty of law that the information contained in this form is, to the best of my
knowledge and belief, true, accurate and complete. Furthermore, 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 contained therein. Based on my inquiry of the person or persons who manage the system,
or those persons directly responsible for gathering the information, the information contained is, to the
best of my knowledge and belief, true, accurate, and complete. I have no personal knowledge that the
information submitted is other than 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.
__________________________________
Signature and Date
Page 183 of 194
Final 2013 VGP
Annual Report: Ballast Water Treatment System Reporting
Supplemental Addendum (VGP Ballast Water DMR)
A. Ballast Water Treatment System Information
Facility Identifier (i.e., NOI number): ______________
Treatment system description: ___________________________________________________________________
System supplier and model:_____________________________________________________________________
Installation Date: _______________________
First date of operation: _______________________
Technology type (check all that apply):
Akylamines
Deoxygenation
Ozone
Bioremediation
Electric pulse
Peracetic acid
Cavitation
Filtration
Plasma pulse
Chlorine addition/electrochlorination
Heat
Shear
Chlorine dioxide
Hydrocyclone
Ultrasound
Coagulation
Menadione/Vitamin K
Ultraviolet
Other (specify): _______________________
Is the ballast water treatment system type approved?
Yes
No
___________________________
If you answered “Yes” please provide the flag administration(s) that approved that
system?
Are all type approval data available to US EPA or the US Coast Guard (see Part 2.2.3.5.1.1.1 of
Yes No Unknown
this permit)?
Has the system been determined by the US Coast Guard to be an “Alternate Management System?” Yes No Unknown
Note: if you responded “unknown” to the two questions above, you must follow the monitoring
schedule for devices for which high quality data are not available.
B. Monitoring Information
Have all the permit monitoring conditions for the ballast water treatment system(s) that apply to
Yes No
your vessel (Part 2.2.3.5.1.1.1 of this permit) been completed during the previous calendar year?
Please check which monitoring requirements were completed:
Ballast water system functionality monitoring at least monthly.
Calibration of probes/sensors that measure ballast water treatment performance at least annually.
Biological monitoring. Number of sampling events: ___
Residual biocide and derivative monitoring (if applicable). Number of initial: ___ Number of maintenance: ___
Provide ballast water treatment system functional monitoring information and ballast discharge analytical data for the
previous calendar year in the attached tables. Provide any correlations and/or calculations between measured operating
parameters and treatment concentrations in the space below (e.g., correlation between measured ORP and chlorine
concentration in ballast water):
C. Certifier Name and Title
I certify under penalty of law that this document were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information contained therein. Based
on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information contained is, to the best of my knowledge and belief true, accurate, and complete. I have no
personnel knowledge that the information submitted is other than 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:______________________________________________________
Email:_________________________________________________________
Page 184 of 194
Final 2013 VGP
Ballast Water Treatment System Functionality Monitoring (provide information for each month for all that apply; attach pages as needed)
Parameter Used to Measure
Unitsb
Measurement
Monthd
Number of
Minimum
Average
Maximum
a
c
System Functionality
Method
Measurements
Monthly
Monthly
Monthly
per Monthe
Measured
Measured
Measured
Value
Value
Value
a.
b.
c.
d.
e.
System Design
Operating
Range
Part 2.2.3.5.1.1.2 and Appendix J of the permit describes the types of measurements required to verify system functionality (e.g., chlorine concentration, ORP, ozone concentration, etc.).
Units include items such as mg/L or ppm for chemical concentrations, lbs or gallons/month for chemical dosage amounts, watts/month for power consumption, etc.
Measurement methods can include probe, sensor, sample analysis, counts, etc.
Vessels need to provide information for only those months that ballast water was discharged into U.S. waters.
If continuous measurements are recorded for the parameter, note “continuous” in the provided column.
Biological Monitoring of Ballast Water Discharges (provide information for each sampling event for all that apply; attach pages as needed)
Parameter
a.
Analytical Method
Sample Date(s)a
Sample Result(s)a
Units
Total live bacteria
E. coli
Enterococci
Other (specify):
Discharge
Location
Part 2.2.3.5.1.1.4 of the permit provides the required sampling schedule. If you collected multiple samples during the calendar year,
list the samples and corresponding results in order of date collected.
Residual Biocide/Derivative Monitoring of Ballast Water Discharges (provide information for each sampling event for all that apply; attach pages as needed)
Biocide/Derivativea
a.
b.
Analytical Method
Sample Date(s)b
Sample Result(s)b
Section 2.2.3.5.1.1.5 of the permit lists biocides and derivatives the vessel must monitor for based on the type of
treatment system (e.g., chlorine, haloacetic acid, trihalomethanes). You must report those results here.
Section 2.2.3.5.1.1.5 provides the required sampling schedule. If you collected multiple samples during the calendar year,
list the samples and corresponding results in order of date collected.
Page 185 of 194
Units
Discharge
Location
Final 2013 VGP
Annual Report: Exhaust Gas Scrubber Discharge Monitoring Supplemental Addendum
(VGP Exhaust Gas Scrubber Discharge Monitoring Report)
Exhaust Gas Scrubber Analytical Monitoring (provide information for all that apply)
Sample Date: ____________ Sample Type (inlet water, water after the scrubber, discharge water): _______________ Facility Identifier (i.e., NOI number): ______________
Sample #:
(Please provide a separate page for each sampling event)
Parameter
Nitrate-Nitrite
pH
Arsenic
Cadmium
Chromium
Copper
Lead
Nickel
Selenium
Vanadium
Zinc
Acenaphthylene
Acenaphthene
Anthracene
Benz[a]anthracene
Benzo[ghi]perylene
Benzo[a]pyrene
Benzo[b]fluoranthene +
benzo[k]fluoranthene
Chrysene
Dibenz[a,h]anthracene
Fluoranthene
Fluorene
Indeno[1,2,3,c,d]pyrene
Naphthalene
Phenanthrene
Pyrene
Analytical
Methoda
b
Sample Date(s)
(MM/DD/YYYY)
Sample Result(s)
Units
Flow Rate
Discharge
Location
(Lat/Long)c
Additional Detail:
pH Probe Value (at same time sample collected):
PAH Probe Value (at same time sample collected):
Turbidity Probe Value (at same time sample collected):
Maximum continuous rating or 80 percent of the power rating of the fuel oil combustion unit in MWh:
Sampling performed downstream of the water treatment equipment but upstream of washwater dilution (or other reactant dosing) prior to discharge? □ Yes
□No
a)
b)
c)
Part 2.2.26.2.3 of the permit discusses appropriate methods for monitoring. Please select methods that correct for matrix interference.
Part 2.2.26.2.2 of the permit provides the required sampling schedule. If you collected multiple samples during the calendar year, list the samples and corresponding results
in order of date collected.
Provide latitude and longitude of discharge location during sampling.
Page 186 of 194
Was the Sample
Taken in U.S.
Waters?
Final 2013 VGP
Exhaust Gas Scrubber Continuous Monitoring (provide information for all that apply)
Month: _____
Parameter
_ (Please provide a separate page for each month of the discharge)
Unitsa
pH
Standard Units
PAH (if available)
µ/L PAHphe
Minimum Monthly
Measured Value
Average Monthly
Measured Value
Maximum Monthly
Measured Value
Did You Operate in US
Waters this Month?
Turbidity
Temperature
Additional Details:
pH probe calibration date:
PAH probe calibration date (if available):
Turbidity probe calibration date:
Temperature probe calibration date:
Maximum continuous rating or 80 percent of the power rating of the fuel oil combustion unit in MWh:
Sampling performed downstream of the water treatment equipment but upstream of washwater dilution (or other reactant dosing) prior to discharge?
Exhaust gas scrubber treatment system additives (names of any additives and dosage (if available) used, i.e., coagulant, flocculant, reaction water):
a.
Units for turbidity are either FNU or NTU, and units for temperature are either °C or °F.
Page 187 of 194
Yes
No
Final 2013 VGP
Annual Report: Graywater Discharge Monitoring Supplemental Addendum
(VGP Graywater Discharge Monitoring Report)
Graywater Monitoring (provide information for all that apply)
My vessel had to conduct sampling
Sample #:
Parameter
pH
BOD
Fecal coliform
Suspended Solids
Total Residual chlorinee
E. colif
Total phosphorus(TP)f
Ammoniaf
Nitrate + Nitritef
times in year
Facility Identifier (i.e., NOI number): ______________
(Please provide a separate form for each sampling event)
Analytical
Methoda
Sample Date(s)b
(MM/DD/YYYY)
Sample
Time
Sample
Result(s)
Units
Discharge
Locationc
(Lat/Long)
Total Kjeldahl
Nitrogen (TKN)f
a.
b.
c.
d.
e.
f.
Part 2.2.15.2, 5.1.2 and 5.2.2 of the permit discusses appropriate methods for monitoring.
Part 2.2.15.2, 5.1.2 and 5.2.2 of the permit provides the required sampling schedule.
Provide latitude and longitude of discharge location during sampling and the sampled overboard discharge port location
Provide both the name of analyst and analysis date in MM/DD/YYYY format.
Parameter not required for medium and large cruise ships meeting certain criteria per Parts 5.1.2.2.1 and 5.2.2.2.1.
Parameter must be analyzed only by medium and large cruise ships.
Page 188 of 194
Overboard
Discharge Port
Locationc
Analysis Date/
Analystd
(MM/DD/YYYY)
Was the
Sample Taken
in U.S. Waters?
Final 2013 VGP
Annual Report: Bilgewater Discharge Monitoring Supplemental Addendum
(VGP Bilgewater Discharge Monitoring Report)
Bilgewater Monitoring (provide information for all that apply)
Sample #:
Parameter
Oil and Grease
(Please provide a separate form for each sampling event)
Analytical
Methoda
Sample Date(s)
(MM/DD/YYYY)
Sample Time
Sample
Result(s)
Facility Identifier (i.e., NOI number): ______________
Units
Discharge
Locationb
Overboard
Discharge Port
Locationb
Analysis Date/
Analyst Namec
(MM/DD/YYYY)
Was the
Sample
Taken in
U.S.
Waters?
ppm
Additional Details:
OCM Value (at same time sample collected)
OCM Make and Model Number
OMC calibration date and name of calibrator
Oil/water separator additive type (name of any additives used, i.e, solidifier, flocculant):
a.
b.
c.
Part 2.2.2.1 of the permit discusses monitoring methods. Samples must be analyzed for oil by either Method ISO 9377-2 (2000) Water Quality–Determination of hydrocarbon
oil index–Part 2: Method Using Solvent Extraction and Gas Chromatography (incorporation by reference, see 46 CFR §162.050–4) or EPA Method 1664.
Provide latitude and longitude of discharge location during sampling and the sampled overboard discharge port location
Provide both the name of analyst and analysis date in MM/DD/YYYY format.
Page 189 of 194
Final 2014 sVGP
APPENDIX A – PERMIT AUTHORIZATION AND RECORD OF INSPECTION (PARI)
FORM
Small Vessel General Permit (sVGP) Authorization and Record of Inspection (PARI) Form
I. Vessel Owner/Operator Information
Vessel Owner/Operator ____________________________ Phone ________________________
Address and Email Address: ________________________________________________________
II. Vessel Information
Vessel Name _____________________________
Vessel Type ___________________
Vessel Identifier __________________________ □ Registered number/operating number □ IMO number
III. Owner/Operator Acknowledgement
By signing this form, I acknowledge that I have read and am familiar with the sVGP and that I am implementing all permit
requirements contained in the sVGP.
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 contained therein. Based on
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information contained is, to the best of my knowledge and belief, true, accurate, and complete. I have no personal knowledge that the
information submitted is other than 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.
___________________________________________ (Signature and Date)
V. Quarterly Inspections by Year
A. 2015
1st Qtr Inspection
2nd Qtr Inspection
3rd Qtr Inspection
4th Qtr Inspection
Completed:
□
Completed:
□
Completed:
□
Completed:
□
Date
__/__/____
__/__/____
__/__/____
__/__/____
Sign Here
I certify that I have completed all of my quarterly inspections for 2015 in accordance with Part 3.2 of the sVGP
___________________________________________ (Signature and Date)
B. 2016
1st Qtr Inspection
Completed:
□
__/__/____
2nd Qtr Inspection
Completed:
□
__/__/____
3rd Qtr Inspection
Completed:
□
__/__/____
4th Qtr Inspection
Completed:
□
__/__/____
1st Qtr Inspection
Completed:
□
__/__/____
2nd Qtr Inspection
Completed:
□
__/__/____
3rd Qtr Inspection
Completed:
□
__/__/____
4th Qtr Inspection
Completed:
□
__/__/____
1st Qtr Inspection
Completed:
□
__/__/____
2nd Qtr Inspection
Completed:
□
__/__/____
3rd Qtr Inspection
Completed:
□
__/__/____
4th Qtr Inspection
Completed:
□
__/__/____
1st Qtr Inspection
Completed:
□
__/__/____
2nd Qtr Inspection
Completed:
□
__/__/____
3rd Qtr Inspection
Completed:
□
__/__/____
4th Qtr Inspection
Completed:
□
__/__/____
Date
Sign Here
I certify that I have completed all of my quarterly inspections for 2016 in accordance with Part 3.2 of the sVGP
___________________________________________ (Signature and Date)
C. 2017
Date:
Sign Here
I certify that I have completed all of my quarterly inspections for 2017 in accordance with Part 3.2 of the sVGP
___________________________________________ (Signature and Date)
D. 2018
Date
Sign Here
I certify that I have completed all of my quarterly inspections for 2018 in accordance with Part 3.2 of the sVGP
___________________________________________ (Signature and Date)
E. 2019
Date
Sign Here
I certify that I have completed all of my quarterly inspections for 2019 in accordance with Part 3.2 of the sVGP
___________________________________________ (Signature and Date)
Final 2014 sVGP
Corrective Action Records for the sVGP
If you need to take any corrective actions resulting from your quarterly visual inspections please record your findings on the next page
Date
sVGP Requirement
Description
Cause
Description of Corrective Action
Affected
Performed or Scheduled
Please include additional pages as necessary.
Final 2014 sVGP
APPENDIX B – ANNUAL NONCOMPLIANCE FORM
United States Environmental Protection Agency, Washington, DC 20460
Annual Noncompliance Form for Discharges Incidental to the Normal Operation
of a Vessel under the NPDES small Vessel General Permit (sVGP)
A. Vessel Owner/Operator Information:
Name:
Street:
City:
Country:
Phone:
E-mail:
State:
Zip:
Fax (optional):
B. Vessel Information:
Vessel Name:
Vessel ID/ Registered Number/ IMO number:
Vessel Call Sign:
Flag State/Port of Registry:
Type of Vessel (select one):
□ Commercial Fishing Vessel
□ Ferry
□ Rescue Vessel
□ Passenger Vessel
Vessel Weight:
Vessel Length:
□ Barge
□ Research Vessel
□ Other: __________________________
□ Gross Tons
□ Feet
□ Gross Registered Tons
□ Meters
C. Instances of Noncompliance
Please fill out the information below describing your instances of noncompliance (e.g., not using phosphate free soaps). Use additional pages if
necessary
Date
sVGP Requirement Description of
Affected
Noncompliance
Cause of
Noncompliance
Description of Corrective Action
Performed or Scheduled
D. Certification Information
I certify under penalty of law that the information contained in this form is, to the best of my knowledge and belief, true, accurate and
complete. Furthermore, 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 contained therein.
Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information contained is, to the best of my knowledge and belief, true, accurate, and complete. I have no personal knowledge that the
information submitted is other than 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.
__________________________________
Signature and Date
Print Name:
Title:
E-mail:
Page 53 of 53
STANDARD FORM 299 (05/2009)
Prescribed by DOI/USDA/DOT
P.L. 96-487 and Federal
Register Notice 5-22-95
APPLICATION FOR TRANSPORTATION AND
UTILITY SYSTEMS AND FACILITIES
ON FEDERAL LANDS
FORM APPROVED
OMB Control Number: 0596-0082
Expiration Date: 1/31/2017
FOR AGENCY USE ONLY
NOTE: Before completing and filing the application, the applicant should completely review this package and schedule a
Application Number
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)
Date Filed
3. Telephone (area code)
Applicant
Authorized Agent
4. As applicant are you? (check one)
5. Specify what application is for: (check one)
a.
a.
b.
c.
d.
e.
f.
b.
c.
d.
e.
f.
Individual
Corporation*
Partnership/Association*
State Government/State Agency
Local Government
Federal Agency
* If checked, complete supplemental page
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) 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.
STANDARD FORM 299 (REV. 5/2009)
13a. Describe other reasonable alternative routes and modes considered.
b. Why were these alternatives not selected?
c. Give explanation as t o 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. 6901 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.
Signature of Applicant
Date
Title 18, U.S.C. Section 1001, makes 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.
STANDARD FORM 299 (REV. 5/2009) PAGE 2
Department of Transportation
Federal Aviation Administration
Alaska Region AAL-4, 222 West 7th Ave., Box 14
Anchorage, Alaska 99513-7587
Telephone: (907) 271-5285
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.
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 department/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.
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 right-of-way for snow machines, air cushion vehicles, and allterrain 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
Federal Building Annex
9109 Mendenhall Mall Road, Suite 5
Juneau, Alaska 99802
Telephone: (907) 586-7177
Department of the Interior
Bureau of Land Management
222 West 7th Avenue
P.O. Box 13
Anchorage, Alaska 99513-7599
Telephone: (907) 271-5477 (or a local BLM Office)
U.S. Fish & Wildlife Service (FWS)
Office of the Regional Director
1011 East Tudor Road
Anchorage, Alaska 99503
Telephone: (907) 786-3440
National Park Service (NPA)
Alaska Regional Office, 2225
Gambell St., Rm. 107
Anchorage, Alaska 99502-2892
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 Office, P.O. Box 120, 1675 C Street, Anchorage, Alaska
9513.
SPECIFIC INSTRUCTIONS
(Items not listed are self-explanatory)
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
range(s) 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 is 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.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the
information is voluntary. If all the information is not provided, the
application may be rejected.
DATA COLLECTION STATEMENT
The Federal agencies collect this information from applicants requesting
right-of-way, permit, license, lease, or certification for the use of Federal
lands. The Federal agencies use this information to evaluate the
applicant's proposal. The public is obligated to submit this form if they wish
to obtain permission to use Federal lands.
STANDARD FORM 299 (REV. 5/2009) PAGE 3
SUPPLEMENTAL
CHECK APPROPRIATE
BLOCK
NOTE: The responsible agency(ies) will provide instructions
I - PRIVATE CORPORATIONS
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.
II - PUBLIC CORPORATIONS
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.
STANDARD FORM 299 (REV. 5/2009) PAGE 4
NOTICES
Note: This applies to the Department of Agriculture/Forest Service (FS)
This information is needed by the Forest Service to evaluate the requests to use National Forest
System lands and manage those lands to protect natural resources, administer the use, and ensure
public health and safety. This information is required to obtain or retain a benefit. The authority for
that requirement is provided by the Organic Act of 1897 and the Federal Land Policy and
Management Act of 1976, which authorize the secretary of Agriculture to promulgate rules and
regulations for authorizing and managing National Forest System lands. These statutes, along with
the Term Permit Act, National Forest Ski Area Permit Act, Granger-Thye Act, Mineral Leasing Act,
Alaska Term Permit Act, Act of September 3, 1954, Wilderness Act, National Forest Roads and Trails
Act, Act of November 16, 1973, Archeological Resources Protection Act, and Alaska National Interest
Lands Conservation Act, authorize the Secretary of Agriculture to issue authorizations or the use and
occupancy of National Forest System lands. The Secretary of Agriculture's regulations at 36 CFR
Part 251, Subpart B, establish procedures for issuing those authorizations.
BURDEN AND NONDISCRIMINATION STATEMENTS
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0596-0082. The time required
to complete this information collection is estimated to average 8 hours hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities
on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status,
familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all
prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s
TARGET Center at 202-720- 2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can
contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642
(relay voice). USDA is an equal opportunity provider and employer.
The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern
the confidentiality to be provided for information received by the Forest Service.
STANDARD FORM 299 (REV. 5/2009) PAGE 5
| File Type | application/pdf |
| File Title | Microsoft Word - Cover Pg Appendix G Forms |
| Subject | This form must be completed by all persons applying for a permit under EPAs Consolidated Permits Program. |
| Author | john.sunda |
| File Modified | 2017-09-14 |
| File Created | 2017-09-14 |