Form 3510-1, 3501-2A th 3510-1, 3501-2A th NPDES Application Forms

Information Collection Request for National Pollutant Discharge Elimination System (NPDES): Specific Provisions Affecting Applications and Program Updates (Final Rule)

Revised NPDES Application Forms_(11-30-18)

Applicants seeking coverage under an NPDES Permit- Private Sector

OMB: 2040-0004

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2040-0004 can be found here:

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Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-1
Revised

Water Permits Division

Application Form 1
General Information

NPDES Permitting Program

Note: All applicants to the National Pollutant Discharge Elimination System (NPDES) permits
program, with the exception of publicly owned treatment works and other treatment works treating
domestic sewage, must complete Form 1. Additionally, all applicants must complete one or more of the
following forms: 2B, 2C, 2D, 2E, or 2F. To determine the specific forms you must complete, consult the
“General Instructions” for this form.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect information
and complete Form 1 to be 3 hours for new applicants and 1 hour for applicants renewing
existing permits. This estimate includes time to review instructions, search existing data sources,
gather and maintain the needed data, and complete and review the collection of information.
New respondents must also prepare a topographic map. Send comments about the burden
estimate or any other aspect of this collection of information to the Chief, Information Policy
Branch (PM-223), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW,
Washington, DC 20460, and to the Office of Information and Regulatory Affairs, Office of
Management and Budget, 725 17th Street, NW, Washington, DC 20503, marked “Attention:
Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

DESCRIPTION OF NPDES PERMIT APPLICATION FORMS

CONTENTS OF FORM 1 PACKAGE

The application forms for individual National Pollutant Discharge
Elimination System (NPDES) permits include the following:
Form 1—General Information (included in this package).

Form 1—General Instructions
Form 1—Line-by-Line Instructions
Form 1—Activities That Do Not Require Permits
Form 1—Glossary
Form 1—Application

Form 2—Forms Based on Facility or Activity Type (not included
in this package):

2C.
2D.

2E.

2F.
2S.

New and Existing Publicly Owned Treatment Works
Concentrated Animal Feeding Operations and
Concentrated Aquatic Animal Production Facilities
Existing Manufacturing, Commercial, Mining, and
Silvicultural Operations
New Manufacturing, Commercial, Mining, and Silvicultural
Operations That Have Not Yet Commenced Discharge of
Process Wastewater
Manufacturing, Commercial, Mining, and Silvicultural
Facilities Which Discharge Only Nonprocess Wastewater
Stormwater Discharges Associated with Industrial Activity
New and Existing Treatment Works Treating Domestic
Sewage
FORM 1—GENERAL INSTRUCTIONS

2A.
2B.

Who Must Apply for an NPDES Permit?

Upon your request, and based on information supplied by you,
EPA or the authorized NPDES state will determine whether you
are required to obtain a permit for a particular facility or activity.
Be sure to contact EPA or your state if you have a question.

With the exceptions described in “Form 1—Activities That Do Not
Require Permits,” the federal Clean Water Act (33 U.S.C. 1251 et
seq.) prohibits any person from discharging pollutants into waters
of the United States without first having been issued a permit
under the NPDES program.

Form 1 collects general information only. You must also complete
a more detailed application based on your proposed discharge
activity, as follows:

Who Must Complete Form 1?

All applicants, other than publicly owned treatment works
(POTWs) and treatment works treating domestic sewage
(TWTDS), must submit Form 1. If you operate one of the
following facilities, you must submit Form 1: concentrated animal
feeding operations and aquatic animal production facilities;
manufacturing, commercial, mining, and silvicultural operations;
or other industrial facilities.

At the state level, either the U.S. Environmental Protection
Agency (EPA) or an approved state agency administers the
NPDES permit program. If you are located in a jurisdiction in
which an EPA regional office administers the NPDES permit
program, you should use Form 1 and all other applicable forms
described in these instructions. If you are located in a jurisdiction
where a state administers the NPDES permit program, contact
the state to determine the forms you should complete. States
often develop their own application forms rather than use the
federal forms. See http://www.epa.gov/npdes/npdes-stateprogram-information for a list of states that have approved
NPDES permit programs and those that do not.
Exhibit 1–1 (see end of this section) provides contact information
for each of EPA’s 10 regional offices. Since the exhibit’s content is
subject to change, consult EPA’s website for the latest information:
http://www.epa.gov/aboutepa#regional.

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

If your facility is a concentrated animal feeding operation
or a concentrated aquatic animal production facility, you
must also complete Form 2B.



If your facility is an existing manufacturing, commercial,
mining, or silvicultural facility that currently discharges
process wastewater, you must also complete Form 2C.



If your facility is a new manufacturing, commercial, mining,
or silvicultural facility that has yet to commence discharge of
process wastewater, you must also complete Form 2D.



If your facility is a new or existing facility (including
manufacturing, commercial, mining, and silvicultural
facilities) that discharges only nonprocess wastewater,
you must also complete Form 2E.



If your facility is a new or existing facility whose discharge
is composed entirely of stormwater associated with industrial
activity—excluding discharges from construction activity
under 122.26(b)(14)(x) or (b)(15)—you must also complete
Form 2F. If the discharge is composed of stormwater and
non-stormwater, you must complete Form 2F and you must
also complete Forms 2C, 2D, and/or 2E, as appropriate. See
Form 2F’s instructions for further details.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 1—GENERAL INSTRUCTIONS CONTINUED
Where to File Your Completed Form

Completion of Forms



If you are in a jurisdiction with an approved state NPDES
permit program, file according to the instructions on the state
forms.



If you are in a jurisdiction where EPA is the NPDES
permitting authority (i.e., the state is not an NPDESauthorized state), mail the completed application forms to the
EPA regional office that covers the state in which your facility
is located (see Exhibit 1–1).

Because of statutory and regulatory requirements, the deadlines
for filing applications vary according to your facility or activity type
and the type of permit you need. The various permit application
deadlines are listed in Exhibit 1–2 at the end of this section.
Fees

Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 1 and any attachments. If your facility is new
(i.e., not yet constructed), write or type “New Facility” in the space
provided for the EPA Identification Number and NPDES number.
If you do not know your EPA Identification Number, contact your
NPDES permitting authority. See Exhibit 1–1 for contact
information.

When to File Your Completed Form

The NPDES permitting authority could consider your application
incomplete if you do not provide an answer (or indicate "NA" for
"not applicable") for all questions on Form 1 and the applicable
Form 2.

Public Availability of Submitted Information

EPA will make information from NPDES permit application forms
available to the public for inspection and copying upon request.
You may not claim any information on Form 1 (or related
attachments) as confidential.

You may make a claim of confidentiality for any information that
you submit to EPA that goes beyond the information required by
Form 1. If you do not assert a claim of confidentiality at the time
you submit your information to the NPDES permitting authority,
EPA may make the information available to the public without
further notice to you. EPA will handle claims of confidentiality in
accordance with the Agency’s business confidentiality regulations
at Part 2 of Title 4 of the Code of Federal Regulations (CFR).

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FORM 1—GENERAL INSTRUCTIONS CONTINUED
Exhibit 1–1. Addresses of EPA Regional Contacts and Covered States
REGION 6
U.S. Environmental Protection Agency, Region 6
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733
Phone: (214) 665-2200; toll free: (800) 887-6063
Fax: (214) 665-7113
Website: http://www.epa.gov/aboutepa/epa-region-6-south-central
Covered states: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas

REGION 2
U.S. Environmental Protection Agency, Region 2
290 Broadway, New York, NY 10007-1866
Phone: (212) 637-3000; toll free: (877) 251-4575
Fax: (212) 637-3526
Website: http://www.epa.gov/aboutepa/epa-region-2
Covered states: New Jersey, New York, Virgin Islands, and Puerto Rico

REGION 7
U.S. Environmental Protection Agency, Region 7
11201 Renner Boulevard, Lenexa, KS 66219
Phone: (913) 551-7003; toll free: (800) 223-0425
Website: http://www.epa.gov/aboutepa/epa-region-7-midwest
Covered states: Iowa, Kansas, Missouri, and Nebraska

REGION 3
U.S. Environmental Protection Agency, Region 3
1650 Arch Street, Philadelphia, PA 19103-2029
Phone: (215) 814-5000; toll free: (800) 438-2474
Fax: (215) 814-5103
Website: http://www.epa.gov/aboutepa/epa-region-3-mid-atlantic
Covered states: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia,
and West Virginia

REGION 8
U.S. Environmental Protection Agency, Region 8
1595 Wynkoop Street, Denver, CO 80202-1129
Phone: (303) 312-6312; toll free: (800) 227-8917
Fax: (303) 312-6339
Website: http://www.epa.gov/aboutepa/epa-region-8-mountains-and-plains
Covered states: Colorado, Montana, North Dakota, South Dakota, Utah, and
Wyoming

REGION 1
U.S. Environmental Protection Agency, Region 1
5 Post Office Square, Suite 100, Boston, MA 02109-3912
Phone: (617) 918-1111; toll free: (888) 372-7341
Fax: (617) 918-0101
Website: http://www.epa.gov/aboutepa/epa-region-1-new-england
Covered states: Connecticut, Maine, Massachusetts, New Hampshire, Rhode
Island, and Vermont

REGION 9
U.S. Environmental Protection Agency, Region 9
75 Hawthorne Street, San Francisco, CA 94105
Phone: (415) 947-8000; toll free: (866) EPA-WEST
Fax: (415) 947-3553
Website: http://www.epa.gov/aboutepa/epa-region-9-pacific-southwest
Covered states: Arizona, California, Hawaii, Nevada, Guam, American Samoa,
and Trust Territories

REGION 5
U.S. Environmental Protection Agency, Region 5
77 West Jackson Boulevard, Chicago, IL 60604-3507
Phone: (312) 353-2000; toll free: (800) 621-8431
Fax: (312) 353-4135
Website: http://www.epa.gov/aboutepa/epa-region-5
Covered states: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin

REGION 10
U.S. Environmental Protection Agency, Region 10
1200 Sixth Avenue, Suite 900, Seattle, WA 98101
Phone: (206) 553-1200; toll free: (800) 424-4372
Fax: (206) 553-2955
Website: http://www.epa.gov/aboutepa/epa-region-10-pacific-northwest
Covered states: Alaska, Idaho, Oregon, and Washington

REGION 4
U.S. Environmental Protection Agency, Region 4
Sam Nunn Atlanta Federal Center
61 Forsyth Street, SW, Atlanta, GA 30303-8960
Phone: (404) 562-9900; toll free: (800) 241-1754
Fax: (404) 562-8174
Website: http://www.epa.gov/aboutepa/about-epa-region-4-southeast
Covered states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina,
South Carolina, and Tennessee

Exhibit 1–2. Filing Dates for NPDES Permit Applications

Permit Application
2A

2C
2D
2E
2F
2S

When to File
180 days before your present NPDES permit expires or, if you are a
new discharger, 180 days before the date on which the discharge is
to commence unless the NPDES permitting authority has granted
permission for a later date.
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.
180 days before your present NPDES permit expires.
180 days prior to startup.
180 days before your present NPDES permit expires, or 180 days
prior to startup if you are a new facility.
Construction: 90 days prior to date construction is to commence.
Nonconstruction: 180 days before your present NPDES permit
expires or 180 days prior to startup if you are a new facility.
180 days before your present NPDES permit expires or 180 days
prior to startup if you are a new facility.

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FORM 1—LINE-BY-LINE INSTRUCTIONS

If you answer “Yes” to a question in Item 1.1, then you do not
need to complete Form 1, but you must comply with the
application requirements specified.
Item 1.2. Respond to the questions in Items 1.2.1 to 1.2.5. If you
answer “Yes” to any question, you must complete Form 1 and the
Form 2 application specified. See Exhibit 1–2 for filing deadlines.
If you answer “No” to every question in Items 1.1 and 1.2, then
you do not need an NPDES permit, and you do not need to
complete and return any of the NPDES application forms.
Section 2. Name, Mailing Address, and Location
Item 2.1. Enter the facility’s official or legal name. Do not use a
colloquial name.

You can find NAICS code numbers and descriptions in the North
American Industrial Classification System Manual prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the National Technical
Information Service (NTIS) in Alexandria, Virginia. It is also
available online at http://www.census.gov/eos/www/naics/.
Use the latest edition of the manuals. If you have any questions
about the appropriate SIC or NAICS codes for your facility,
contact your NPDES permitting authority.
Section 4. Operator Information
Item 4.1. Give the legal name of the person, firm, public
organization, or other entity that operates the facility described in
this application. This may or may not be the same as the facility’s
name. The operator of the facility is the legal entity that controls
the facility’s operation rather than the plant or site manager. Do
not use a colloquial name.

Item 2.2. Provide your EPA Identification Number from the
Federal Registry System if you have an existing facility. If you do
not know your EPA Identification Number, contact your NPDES
permitting authority. If your facility is new (i.e., not yet
constructed), write or type “New Facility.”

You can find SIC code numbers and descriptions in the
1987 Standard Industrial Classification Manual, prepared by the
Executive Office of the President, Office of Management and
Budget. This document is available from the Government Printing
Office, Washington, D.C. An online version of the manual is also
available courtesy of the Occupational Safety and Health
Administration at http://www.osha.gov/pls/imis/sic_manual.html.

Section 1. Activities Requiring an NPDES Permit
Item 1.1. Review the questions in Item 1.1 to determine if you are
required to submit Form 1. Be sure to check the Form 1—
Glossary for the legal definitions of any key terms.

Item 2.3. Give the name (first and last), title, work telephone
number, and email address of the person who is thoroughly
familiar with the operation of the facility and with the facts
reported in this application. The NPDES permitting authority will
contact the person listed if they have questions on the material
submitted.

Item 2.4. Give the complete mailing address of the office to which
the NPDES permitting authority should send correspondence.
This often is not the address used to designate the location of the
facility or activity.

Item 2.5. Give the address or location of the facility identified
under Item 2.1. 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 Routes 425 and 22"). Also provide the county
name, county code (if known), city or town, state, and zip code.
For concentrated aquatic animal production facilities, provide the
address or location of the production area (i.e., the location where
the animals are contained, grown, or held).
Section 3. SIC and NAICS Codes
Items 3.1 and 3.2. List, in descending order of significance, up to
four 4-digit standard industrial classification (SIC) codes and
North American Industrial Classification System (NAICS) codes
that best describe your facility in terms of the principal products or
services it produces or provides. If the SIC or NAICS codes do
not adequately describe your facility’s products or services, you
have the option to provide additional descriptive information.

Item 4.2. Indicate whether the entity listed in response to Item 4.1
also owns the facility by marking the appropriate box.
Item 4.3. Indicate the ownership status of the operator of the
facility by marking the appropriate box. If the facility is a federal
facility (i.e., owned by the U.S. government), check the box for
“Public—federal.” If the facility is owned by a state government,
check the box for “Public—state.” If the facility is owned by a
county government, municipal (e.g., city or town) government,
tribal government, school district, water district, or other local
government entity, check the box for “Other public” and specify
the type of government entity. If the facility is owned by a
corporation or other private entity, check the box for “Private.” If
the facility has mixed ownership (e.g., public/private) or is not
owned by an entity of the types previously listed, check the box
for “Other” and specify the type of entity.
Items 4.4 to 4.6. Enter the telephone number, address, and email
address of the operator identified in Item 4.1.
Section 5. Indian Land
Item 5.1. Indicate whether the facility is located on Indian Land.
Section 6. Existing Environmental Permits
Item 6.1. Check the appropriate boxes and provide the permit
numbers for all relevant federal, state, and local environmental
permits or construction approvals received or applied for under
any of the programs listed below. If you have more than one
currently effective permit under a particular permit program for
your facility, list the additional permit numbers on the application
form or on a separate sheet of paper.

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FORM 1—LINE-BY-LINE INSTRUCTIONS CONTINUED
Hazardous waste management program under the Resource
Conservation and Recovery Act (RCRA).



Underground Injection Control (UIC) program under the Safe
Drinking Water Act (SDWA).



NPDES program under the Clean Water Act (CWA).



Prevention of Significant Deterioration (PSD) program under
the Clean Air Act (CAA).



Nonattainment program under the CAA.



National Emission Standards for Hazardous Pollutants
(NESHAPs) preconstruction approval under the CAA.



Ocean dumping permits under the Marine Protection
Research and Sanctuaries Act (MPRSA).



Dredge or fill permits under Section 404 of the CWA.



Other federal, state, or local environmental permits.

If the facility is a concentrated animal feeding operation, you are
not required to provide the topographic map required by this
section of Form 1. Instead, you are required to provide a
topographic map as specified in Section 4 of Form 2B.
Item 7.1. Note that you have completed your topographic map
and attached it to the application.
Section 8. Nature of Business
Briefly describe the nature of your business (e.g., products
produced or services provided). See Examples 1 and 2.
Example 1
Facilities Subject to 40 CFR 426, Subparts F and G

Industry A is an auto tempered and auto laminated glass
manufacturing facility subject to effluent limitation guidelines
(ELGs) for the “Automotive Glass Tempering” and “Automotive
Glass Laminating” subcategories of the “Glass Manufacturing”
point source category at 40 CFR 426, subparts F and G. At the
facility, glass is cut and then passed through a series of
processes that grind and polish the edges, bend the glass, and
then temper the glass to produce side and back windows for
automobiles. Tempering involves heating the glass near the
melting point, then rapidly cooling it to increase its mechanical
and thermal endurance. The facility also produces automobile
windshields and undertakes processes that laminate a plastic
sheet between two layers of glass and that prepare the glass for
lamination (e.g., cutting, bending, and washing).

Section 7. Map
Unless the facility is a concentrated animal feeding operation,
provide a topographic map(s) of the area extending at least one
mile beyond the property boundaries of the facility that clearly
shows the following:

(e.g., residential, commercial). An example of an acceptable
location map is shown as Exhibit 1–3 at the end of these
instructions. Note: Exhibit 1–3 is provided for illustration only; it
does not show an actual facility.



The legal boundaries of the facility.



The location and serial number of each of your existing and
proposed intake and discharge structures.



All hazardous waste management, storage, and disposal
facilities.



Each well where you inject fluids underground.



All wells, springs, surface water bodies, and drinking water
wells that are in the public record or otherwise known to you
and that are located in the map area.

Example 2
Facility Not Subject to ELGs



If the facility has associated water intakes, discharge structures,
hazardous waste disposal sites, or injection wells and these items
are located more than one mile from the facility, include them on
the map if possible. If you cannot, attach additional sheets
describing the location of the structures, disposal site(s), or well(s)
and identify the U.S. Geological Survey (USGS) or other map
corresponding to the location(s).

Industry B undertakes batch-type resin manufacturing operations.
It has aboveground storage tanks for raw materials and finished
goods, resin loading operations, and warehouses for 55-gallon
drums of finished product. Industry B manufactures alkyd,
saturated and unsaturated polyester resins in batches using
reactor vessels and mix tanks. Most of the feedstock liquids are
pumped from storage tanks to the kettles and mixers via a closed
piping system. Additional feedstocks are added manually as
solids from bags and sacks via manways, which are located on
top of the kettles. The resin is then chemically reacted in the
kettles. After the reaction step finishes, the resin is transferred
from the kettles to the mix tanks, where solvents are added to
thin it. The primary byproduct of the reaction is water vapor
containing condensed soluble organics. The byproduct flows to
an isolation tank where the vapors are directed to an onsite
thermal oxidizer. The finished resin is then pumped through one
of three types of filtration systems into finished goods storage
tanks, 55-gallon drums, 350-gallon intermediate bulk container
totes, or directly into tanker trucks. A typical batch takes about 30
hours to complete.

On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude to the nearest second. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., USGS).
On all maps of rivers, show the direction of the current. In tidal
waters, show the directions of ebb and flow tides.
You may develop your map by going to USGS’s National Map
website at http://nationalmap.gov/. (For a map from this site, use
the traditional 7.5-minute quadrangle format. If none is available,
use a USGS 15-minute series map.) You may also use a plat or
other appropriate map. Briefly describe land uses in the map area
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FORM 1—LINE-BY-LINE INSTRUCTIONS CONTINUED

Item 9.2. Identify the source of the cooling water. For example,
indicate whether the cooling water is from a surface water,
groundwater well, public water system, or treated effluent that
would otherwise be discharged to a water of the U.S.
If the facility uses a cooling water intake structure as described in
40 CFR 125, Subparts I and J, the facility may have additional
application requirements under 40 CFR 122.21(r). Note that the
information required by 40 CFR 122.21(r) is not requested as part
of Form 1. Contact your NPDES permitting authority to determine
the specifics of what you should provide and when.
Section 10. Variance Requests
An applicant (other than a POTW) may request a variance from
otherwise applicable effluent limitations under certain conditions
described at 40 CFR 122.21(m).

For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer
means: (1) 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 decisionmaking functions for the corporation, or (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).

Item 10.1. If known at the time of application, check all of the
authorized variances that you plan to request or renew. Note that
you are not being asked to submit any other information at this
time. Contact your NPDES permitting authority to determine the
specifics of what you should provide and when. The ability to
request a variance is not limited to the time of application, and an
applicant may request a variance consistent with statutory and
regulatory requirements.

FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:

Section 9. Cooling Water Intake Structures
Item 9.1. Indicate whether the facility uses cooling water. If yes,
continue to Item 9.2. If no, skip to Item 10.1.

Section 11. Checklist and Certification
Item 11.1. Review the checklist provided. In Column 1, mark the
sections of Form 1 that you have completed and are submitting
with your application. In Column 2, indicate for each section
whether you are submitting attachments.

Item 11.2. The Clean Water Act provides for severe penalties for
submitting false information on this application form. CWA Section
309(c)(2) 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.”

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Exhibit 1–3. Example Topographic Map

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FORM 1—ACTIVITIES THAT DO NOT REQUIRE PERMITS
You are not required to obtain an NPDES permit if your discharge
is in one of the following categories, as provided by the CWA and
NPDES regulations at 40 CFR 122 to 125. (However, under CWA
Section 510, a discharge exempted from the federal NPDES
requirements may still be regulated by a state NPDES permitting
authority.)
Any discharge of sewage from vessels and any effluent from
properly functioning marine engines, laundry, shower, and
galley sink wastes, or any other discharge incidental to the
normal operation of: (1) A vessel of the Armed Forces within
the meaning of section 312 of the CWA; and (2) A
recreational vessel within the meaning of section 502(25) of
the CWA. None of these exclusions apply to rubbish, trash,
garbage, or other such materials discharged overboard; nor
to other discharges when the vessel is operating in a
capacity other than as a means of transportation such as
when used as an energy or mining facility, a storage facility
or a seafood processing facility, or when secured to a
storage facility or a seafood processing facility, or when
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.



Discharges of dredged or fill material into waters of the
United States that are regulated under CWA Section 404.



The introduction of sewage, industrial wastes, or other
pollutants into publicly owned treatment works by indirect
dischargers. Plans or agreements to switch to this method of
disposal in the future do not relieve dischargers of the
obligation to have and comply with permits until all
discharges of pollutants to waters of the United States are
eliminated. (See also 40 CFR 122.47(b).) This exclusion
does not apply to the introduction of pollutants to privately
owned treatment works or to other discharges through pipes,
sewers, or other conveyances owned by a state, municipality,
or other party not leading to treatment works.

Any discharge in compliance with the instructions of an OnScene Coordinator pursuant to 40 CFR 300 (The National Oil
and Hazardous Substances Pollution Contingency Plan) or
33 CFR 153.10(e) (Pollution by Oil and Hazardous
Substances).



Any introduction of pollutants from non point-source
agricultural and silvicultural activities, including stormwater
runoff from orchards, cultivated crops, pastures, range lands,
and forest lands, but not discharges from concentrated
animal feeding operations as defined in 40 CFR 122.23,
discharges from concentrated aquatic animal production
facilities as defined in 40 CFR 122.23, discharges from
concentrated aquatic animal production facilities as defined
in 40 CFR 122.24, discharges to aquaculture projects as
defined in 40 CFR 122.25, and discharges from silvicultural
point sources as defined in 40 CFR 122.27. Note: Per 40
CFR 122.26(b)(14)(ii), facilities classified within SIC 24,
Industry Group 241, that are rock crushing, gravel washing,
log sorting, or log storage facilities operated in connection
with silvicultural activities defined in 40 CFR 122.27(b)(2)–(3)
and Industry Groups 242 through 249; 26 (except 265 and
267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441,
and 373 (not included are all other types of silviculture
facilities) are considered stormwater discharges associated
with industrial activity, and are required to obtain an NPDES
permit.



Return flows from irrigated agriculture.



Discharges into a privately owned treatment works, except as
the NPDES permitting authority may otherwise require under
40 CFR 122.44(m).



Discharges from a water transfer. “Water transfer” means an
activity that conveys or connects waters of the United States
without subjecting the transferred water to intervening
industrial, municipal, or commercial use. This exclusion does
not apply to pollutants introduced by the water transfer
activity itself to the water being transferred.



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FORM 1—GLOSSARY
Note: This glossary includes terms used in the various NPDES application forms, including Form 1. The definitions are from the NPDES
regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms, contact
your NPDES permitting authority.
ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (other than an aquatic animal production facility) where the
following conditions are met;


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



Crops, vegetation, forage growth, or post-harvest residues are not sustained in the normal growing season over any portion of the lot
or facility.

APPROVED PROGRAM or APPROVED STATE means a State or interstate program which has been approved or authorized by EPA
under part 123.

AQUACULTURE PROJECT (defined at § 122.25) 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
PROJECT AREA means the portions of the waters of the United States within which the permittee or permit applicant plans to confine the
cultivated species, using a method or plan or operation (including, but not limited to, physical confinement) which, on the basis of reliable
scientific evidence, is expected to ensure that 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.
AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month,
calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured during that
month.
AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week,
calculated as the sum of all daily discharges measured during a calendar week divided by the number of daily discharges measured during
that week.

BEST MANAGEMENT PRACTICES (BMPs) 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. BMPs 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.
BIOSOLIDS (see sewage sludge).

BYPASS (defined at § 122.41(m)) means the intentional diversion of waste streams from any portion of a treatment facility.
COMBINED SEWER OVERFLOW (CSO) means a discharge from a combined sewer system (CSS) at a point prior to the Publicly Owned
Treatment Works (POTW) Treatment Plant (defined at § 403.3(r)).

COMBINED SEWER SYSTEM (CSS) means a wastewater collection system owned by a State or municipality (as defined by section
502(4) of the CWA) which conveys sanitary wastewaters (domestic, commercial and industrial wastewaters) and storm water through a
single-pipe system to a Publicly Owned Treatment Works (POTW) Treatment Plant (as defined at § 403.3(r)).

CONCENTRATED ANIMAL FEEDING OPERATION (defined at § 122.23) means an animal feeding operation that is defined as a Large
CAFO or as a Medium CAFO by the terms of (A) or (B) below, or that is designated as a CAFO in accordance with 40 CFR 122.23(c). Two
or more AFOs under common ownership are considered to be a single AFO for the purposes of determining the number of animals at an
operation, if they adjoin each other or if they use a common area or system for the disposal of wastes.
A.

700 mature dairy cows, whether milked or dry;
1,000 veal calves;
1,000 cattle other than mature dairy cows or veal calves. Cattle includes but is not limited to heifers, steers, bulls and cow/calf
pairs;
2,500 swine each weighing 55 pounds or more;
10,000 swine each weighing less than 55 pounds;
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FORM 1—GLOSSARY CONTINUED
6.
7.
8.
9.
10.
11.
12.
13.
B.

500 horses;
10,000 sheep or lambs;
55,000 turkeys;
30,000 laying hens or broilers, if the AFO uses a liquid manure handling system;
125,000 chickens (other than laying hens), if the AFO uses other than a liquid manure handling system;
82,000 laying hens, if the AFO uses other than a liquid manure handling system;
30,000 ducks (if the AFO uses other than a liquid manure handling system); or
5,000 ducks (if the AFO uses a liquid manure handling system).

MEDIUM CONCENTRATED ANIMAL FEEDING OPERATION (MEDIUM CAFO) means any AFO with the type and number of
animals that fall within any of the ranges listed below and which has been defined or designated as a CAFO. An AFO is defined as a
Medium CAFO if:

The type and number of animals that it stables and confines falls within any of the following ranges:
a. 200 to 699 mature dairy cows, whether milked or dry;
b. 300 to 999 veal calves;
c. 300 to 999 cattle other than mature dairy cows or veal calves. Cattle includes but is not limited to heifers, steers, bulls and
cow/calf pairs;
d. 750 to 2,499 swine each weighing 55 pounds or more;
e. 3,000 to 9,999 swine each weighing less than 55 pounds;
f. 150 to 499 horses;
g. 3,000 to 9,999 sheep or lambs;
h. 16,500 to 54,999 turkeys;
i. 9,000 to 29,999 laying hens or broilers, if the AFO uses a liquid manure handling system;
j. 37,500 to 124,999 chickens (other than laying hens), if the AFO uses other than a liquid manure handling system;
k. 25,000 to 81,999 laying hens, if the AFO uses other than a liquid manure handling system;
l. 10,000 to 29,999 ducks (if the AFO uses other than a liquid manure handling system); ore
m. 1,500 to 4,999 ducks (if the AFO uses a liquid manure handling system); and
2. Either one of the following conditions are met:
a. Pollutants are discharged into waters of the United States through a man-made ditch, flushing system, or other similar manmade device; or
b. Pollutants are discharged directly into waters of the United States which originate outside of and pass over, across, or
through the facility or otherwise come into direct contact with animals confined in the operation.
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY (defined at § 122.24) 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:

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:

1. Facilities which produce less than 9,090 harvest weight kilograms (approximately 20,000 pounds) of aquatic animals per year;
and
2. Facilities which feed less than 2,272 kilograms (approximately 5,000 pounds) of food during the calendar month of maximum
feeding.

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;
1.

Closed ponds which discharge only during periods of excess runoff; or

Facilities which produce less than 45,454 harvest weight kilograms (approximately 100,000 pounds) of aquatic animals per year.

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FORM 1—GLOSSARY CONTINUED
CWA means the Clean Water Act (formerly referred to as the Federal Water Pollution Control Act or Federal Water Pollution Control Act
Amendments of 1972) Public Law 92–500, as amended by Public Law 95–217, Public Law 95–576, Public Law 96–483 and Public Law
97–117, 33 U.S.C. 1251 et seq.
CWA AND REGULATIONS means the Clean Water Act (CWA) and applicable regulations promulgated thereunder. In the case of an
approved State program, it includes State program requirements.
DAILY DISCHARGE means the “discharge of a pollutant” measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling. For pollutants with limitations expressed in units of mass, the “daily discharge” is
calculated as the total mass of the pollutant discharged over the day. For pollutants with limitations expressed in other units of
measurement, the “daily discharge” is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the “discharge of a pollutant.”

DISCHARGE (OF A POLLUTANT) means:

DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an authorized representative. When there
is no “approved State program,” and there is an EPA administered program, “Director” means the Regional Administrator. When there is
an approved State program, “Director” normally means the State Director. In some circumstances, however, EPA retains the authority to
take certain actions even when there is an approved State program. (For example, when EPA has issued an NPDES permit prior to the
approval of a State program, EPA may retain jurisdiction over that permit after program approval, see § 123.1.) In such cases, the term
“Director” means the Regional Administrator and not the State Director.
Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or



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.



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 a treatment
works; 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”.
DISCHARGE MONITORING REPORT means the EPA uniform national form, including any subsequent additions, revisions, or
modifications for the reporting of self-monitoring results by permittees. DMRs must be used by “approved States” as well as by EPA. EPA
will supply DMRs to any approved State upon request. The EPA national forms may be modified to substitute the state agency name,
address, logo, and other similar information, as appropriate, in place of EPA's.

DRAFT PERMIT means a document prepared under § 124.6 indicating the Director's tentative decision to issue or deny, modify, revoke
and reissue, terminate, or reissue a “permit.” A notice of intent to terminate a permit, and a notice of intent to deny a permit, as discussed
in § 124.5, are types of “draft permits.” A denial of a request for modification, revocation and reissuance, or termination, as discussed in
§ 124.5, is not a “draft permit.” A “proposed permit” is not a “draft permit.”

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 “contiguous zone,” or the ocean.
EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administrator under section 304(b) of the CWA to adopt or
revise “effluent limitations.”
ENVIRONMENTAL PROTECTION AGENCY (EPA) means the United States Environmental Protection Agency.
FACILITY or ACTIVITY means any NPDES “point source” or any other facility or activity (including land or appurtenances thereto) that is
subject to regulation under the NPDES program.

GENERAL PERMIT means an NPDES “permit” issued under § 122.28 authorizing a category of discharges under the CWA within a
geographical area.
HAZARDOUS SUBSTANCE means any substance designated under 40 CFR part 116 pursuant to section 311 of the CWA.
INDIAN COUNTRY (or INDAN LANDS) means:


All land within the limits of any Indian reservation under the jurisdiction of the United States Government, notwithstanding the
issuance of any patent, and, including rights-of-way running through the reservation;



All dependent Indian communities with the borders of the United States whether within the originally or subsequently acquired territory
thereof, and whether within or without the limits of a state; and



All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same.
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FORM 1—GLOSSARY CONTINUED
INDIAN TRIBE means any Indian Tribe, band, group, or community recognized by the Secretary of the Interior and exercising
governmental authority over a Federal Indian reservation.
INDIRECT DISCHARGE means a nondomestic discharger introducing “pollutants” to a “publicly owned treatment works.”
LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(4)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census (Appendix F of 40 CFR 122); or
(ii) Located in the counties listed in appendix H of 40 CFR 122, except municipal separate storm sewers that are located in the
incorporated places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraphs (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs (i) or (ii). In making this determination
the Director may consider the following factors:

(A) Physical interconnections between the municipal separate storm sewers;

(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(E) Other relevant factors; or

(D) The nature of the receiving waters; and

(iv) The Director may, upon petition, designate as a large municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii).
LOG SORTING AND LOG STORAGE FACILITIES (defined at § 122.27) means facilities whose discharges result from the holding of
unprocessed wood, for example, logs or roundwood with bark or after removal of bark held 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 429, subpart I, including the
effluent limitations guidelines.)

MAJOR FACILITY means any NPDES “facility or activity” classified as such by the Regional Administrator, or, in the case of “approved
State programs,” the Regional Administrator in conjunction with the State Director.
MAXIMUM DAILY DISCHARGE LIMITATION means the highest allowable “daily discharge.”
MEDIUM MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(7)) means all municipal separate storm sewers that
are either:

(i) Located in an incorporated place with a population of 100,000 or more but less than 250,000, as determined by the 1990 Decennial
Census by the Bureau of the Census (appendix G of 40 CFR 122); or

(ii) Located in the counties listed in appendix I of 40 CFR 122, except municipal separate storm sewers that are located in the incorporated
places, townships or towns within such counties; or

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FORM 1—GLOSSARY CONTINUED
(iv) The Director may, upon petition, designate as a medium municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii) of this section.
MUNICIPALITY means a city, 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 the CWA.
MUNICIPAL SEPARATE STORM SEWER (defined at § 122.26(b)(8)) means a conveyance or system of conveyances (including roads
with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels, or storm drains):
Owned or operated by a State, city, town, borough, county, parish, district, association, or other public body (created by or pursuant to
State law) having jurisdiction over disposal of sewage, industrial wastes, stormwater, or other wastes, including special districts under
State law such as a sewer district, flood control district or drainage district, or similar entity, or an Indian tribe or an authorized Indian
tribal organization, or a designated and approved management agency under section 208 of the CWA that discharges to waters of the
United States.



Designed or used for collecting or conveying stormwater.



Which is not a combined sewer; and



Which is not part of a POTW as defined at 40 CFR 122.2.

MUNICIPAL SLUDGE (see sewage sludge)



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,
402, 318, and 405 of the CWA. The term includes an “approved program.”
NEW DISCHARGER means any building, structure, facility, or installation:


From which there is or may be a “discharge of pollutants;”



That did not commence the “discharge of pollutants” at a particular “site” prior to August 13, 1979;



Which is not a “new source;” and



Which has never received a finally effective NPDES permit for discharges at that “site.”

An offshore or coastal mobile exploratory drilling rig or coastal mobile developmental drilling rig will be considered a “new discharger” only
for the duration of its discharge in an area of biological concern.
NEW SOURCE means any building, structure, facility, or installation from which there is or may be a “discharge of pollutants,” the
construction of which commenced:


After promulgation of standards of performance under section 306 of the CWA which are applicable to such source, or



After proposal of standards of performance in accordance with section 306 of the 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.

OWNER OR OPERATOR means the owner or operator of any “facility or activity” subject to regulation under the NPDES program.
PERMIT means an authorization, license, or equivalent control document issued by EPA or an “approved State” to implement the
requirements of this part and parts 123 and 124. “Permit” includes an NPDES “general permit” (§ 122.28). Permit does not include any
permit which has not yet been the subject of final agency action, such as a “draft permit” or a “proposed permit.”
PESTICIDE DISCHARGES TO WATERS OF THE UNITED STATES FROM PESTICIDE APPLICATION means the application of
biological pesticides, and the application of chemical pesticides that leave a residue, from point sources to waters of the United States. In
the context of this definition of pesticide discharges to waters of the United States from pesticide application, this does not include
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FORM 1—GLOSSARY CONTINUED
agricultural storm water discharges and return flows from irrigated agriculture, which are excluded by law (33 U.S.C. 1342(l); 33 U.S.C.
1362(14)).
PESTICIDE RESIDUE for the purpose of determining whether a NPDES permit is needed for discharges to waters of the United States
from pesticide application, means that portion of a pesticide application that is discharged from a point source to waters of the United
States and no longer provides pesticidal benefits. It also includes any degradates of the pesticide.
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, landfill leachate collection system, vessel or
other floating craft from which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff. (See § 122.3).
POLLUTANT means dredged spoil, solid waste, incinerator residue, filter backwash, sewage, garbage, sewage sludge, munitions,
chemical wastes, biological materials, radioactive materials (except those regulated under the Atomic Energy Act of 1954, as amended (42
U.S.C. 2011 et seq.)), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste
discharged into water. It does not mean:
Sewage from vessels; or



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. 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).



PRIMARY INDUSTRY CATEGORY means any industry category listed in the NRDC settlement agreement (Natural Resources Defense
Council et al. v. Train, 8 E.R.C. 2120 (D.D.C. 1976), modified 12 E.R.C. 1833 (D.D.C. 1979)); also listed in appendix A of part 122.
PRIVATELY OWNED TREATMENT WORKS means any device or system which is (1) used to treat wastes from any facility whose
operator is not the operator of the treatment works and (2) not a “POTW.”
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.

PROPOSED PERMIT means a state NPDES “permit” prepared after the close of the public comment period (and, when applicable, any
public hearing and administrative appeals) which is sent to EPA for review before final issuance by the State. A “proposed permit” is not a
“draft permit.”
PUBLICLY OWNED TREATMENT WORKS or POTW (defined at § 403.3) means a treatment works as defined by CWA Section 212,
which is owned by a state or municipality (as defined by CWA Section 502(4)). This definition includes any devices or systems used in the
storage, treatment, recycling, and reclamation) of municipal sewage or industrial wastes of a liquid nature. This definition also includes
sewers, pipes, and other conveyances only if they convey wastewater to a POTW. The term also means the municipality as defined in
CWA Section 502(4), which has jurisdiction over the indirect discharges to and the discharges from such a treatment works.

REGIONAL ADMINISTRATOR means the Regional Administrator of the appropriate Regional Office of the Environmental Protection
Agency or the authorized representative of the Regional Administrator.
ROCK CRUSHING AND GRAVEL WASHING FACILITIES (defined at § 122.27) means facilities which process crushed and broken
stone, gravel, and riprap (See 40 CFR 436, subpart B, including the effluent limitations guidelines).
SCHEDULE OF COMPLIANCE means a schedule of remedial measures included in a “permit”, including an enforceable sequence of
interim requirements (for example, actions, operations, or milestone events) leading to compliance with the CWA and regulations.
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 the 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.
SEWAGE SLUDGE means any solid, semi-solid, or liquid residue removed during the treatment of municipal waste water or domestic
sewage. Sewage sludge includes, but is not limited to, solids removed during primary, secondary, or advanced waste water treatment,
scum, septage, portable toilet pumpings, type III marine sanitation device pumpings (33 CFR 159), and sewage sludge products. Sewage
sludge does not include grit or screenings, or ash generated during the incineration of sewage sludge.
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SlLVICULTURAL POINT SOURCE (defined at § 122.27) means any discernible, 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 non-point 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 (see 33 CFR 209.120 and part 233).
SITE means the land or water area where any “facility or activity” is physically located or conducted, including adjacent land used in
connection with the facility or activity.
SLUDGE-ONLY FACILITY means any “treatment works treating domestic sewage” whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d) of the CWA
which govern minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.

STATE means any of the 50 States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Commonwealth of the Northern Mariana Islands, the Trust Territory of the Pacific Islands, or an Indian Tribe as defined in
these regulations which meets the requirements of § 123.31 of this chapter.

STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an “approved program,” or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, “State Director”
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.
STORMWATER (or STORM WATER) (defined at § 122.26(b)(13)) means stormwater runoff, snow melt runoff, and surface runoff and
drainage.

STORMWATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY (defined at § 122.26(b)(14)) means the discharge from any
conveyance that is used for collecting and conveying stormwater and that is directly related to manufacturing, processing or raw materials
storage areas at an industrial plant. The term does not include discharges from facilities or activities excluded from the NPDES program
under this part 122. For the categories of industries identified in this section, the term includes, but is not limited to, stormwater discharges
from industrial plant yards; immediate access roads and rail lines used or traveled by carriers of raw materials, manufactured products,
waste material, or by-products used or created by the facility; material handling sites; refuse sites; sites used for the application or disposal
of process waste waters (as defined at 40 CFR 401); sites used for the storage and maintenance of material handling equipment; sites
used for residual treatment, storage, or disposal; shipping and receiving areas; manufacturing buildings; storage areas (including tank
farms) for raw materials, and intermediate and final products; and areas where industrial activity has taken place in the past and significant
materials remain and are exposed to stormwater. For the purposes of this paragraph, material handling activities include storage, loading
and unloading, transportation, or conveyance of any raw material, intermediate product, final product, by-product or waste product. The
term excludes areas located on plant lands separate from the plant's industrial activities, such as office buildings and accompanying
parking lots as long as the drainage from the excluded areas is not mixed with stormwater drained from the above described areas.
Industrial facilities (including industrial facilities that are federally, State, or municipally owned or operated that meet the description of the
facilities listed in paragraphs 1 through 14 below) include those facilities designated under the provisions of 40 CFR 122.26(a)(1)(v). The
following categories of facilities are considered to be engaging in “industrial activity” for purposes of 40 CFR 122.26(b)(14):
1.

Facilities subject to stormwater effluent limitations guidelines, new source performance standards, or toxic pollutant effluent standards
under 40 CFR Subchapter N (except facilities with toxic pollutant effluent standards which are exempted under paragraph 11 below);
Facilities classified as Standard Industrial Classification 24, Industry Group 241 that are rock crushing, gravel washing, log sorting, or
log storage facilities operated in connection with silvicultural activities defined in 40 CFR 122.27(b)(2)–(3) and Industry Groups 242
through 249; 26 (except 265 and 267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441, 373; (not included are all other types of
silvicultural facilities);
Facilities classified as Standard Industrial Classifications 10 through 14 (mineral industry) including active or inactive mining
operations (except for areas of coal mining operations no longer meeting the definition of a reclamation area under 40 CFR 434.11(1)
because the performance bond issued to the facility by the appropriate SMCRA authority has been released, or except for areas of
non–coal mining operations which have been released from applicable State or Federal reclamation requirements after
December 17, 1990) and oil and gas exploration, production, processing, or treatment operations, or transmission facilities that
discharge stormwater contaminated by contact with or that has come into contact with, any overburden, raw material, intermediate
products, finished products, byproducts or waste products located on the site of such operations; (inactive mining operations are
mining sites that are not being actively mined, but which have an identifiable owner/operator; inactive mining sites do not include sites
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FORM 1—GLOSSARY CONTINUED

where mining claims are being maintained prior to disturbances associated with the extraction, beneficiation, or processing of mined
materials, nor sites where minimal activities are undertaken for the sole purpose of maintaining a mining claim);
Hazardous waste treatment, storage, or disposal facilities, including those that are operating under interim status or a permit under
subtitle C of RCRA;

Landfills, land application sites, and open dumps that receive or have received any industrial wastes (waste that is received from any
of the facilities described under this subsection) including those that are subject to regulation under subtitle D of RCRA;
6. Facilities involved in the recycling of materials, including metal scrapyards, battery reclaimers, salvage yards, and automobile
junkyards, including but limited to those classified as Standard Industrial Classification 5015 and 5093;
7. Steam electric power generating facilities, including coal handling sites;
8. Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221–25), 43, 44, 45, and 5171 which have
vehicle maintenance shops, equipment cleaning operations, or airport deicing operations. Only those portions of the facility that are
either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication),
equipment cleaning operations, airport deicing operations, or which are otherwise identified under paragraphs 1–7 or 9–11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system, used in the
storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved
pretreatment program under 40 CFR 403. Not included are farm lands, domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility, or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing, grading and excavation, except operations that result in the disturbance of less than five acres
of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34
(except 3441), 35, 36, 37 (except 373), 38, 39, and 4221–25.

TOXIC POLLUTANT means any pollutant listed as toxic under section 307(a)(1) or, in the case of “sludge use or disposal practices,” any
pollutant identified in regulations implementing section 405(d) of the CWA.

TREATMENT WORKS TREATING DOMESTIC SEWAGE (TWTDS) means a POTW or any other sewage sludge or waste water
treatment devices or systems, regardless of ownership (including federal facilities), used in the storage, treatment, recycling, and
reclamation of municipal or domestic sewage, including land dedicated for the disposal of sewage sludge. This definition does not include
septic tanks or similar devices. For purposes of this definition, “domestic sewage” includes waste and waste water from humans or
household operations that are discharged to or otherwise enter a treatment works. In States where there is no approved State sludge
management program under section 405(f) of the CWA, the Regional Administrator may designate any person subject to the standards for
sewage sludge use and disposal in 40 CFR 503 as a “treatment works treating domestic sewage,” where he or she finds that there is a
potential for adverse effects on public health and the environment from poor sludge quality or poor sludge handling, use or disposal
practices, or where he or she finds that such designation is necessary to ensure that such person is in compliance with 40 CFR 503.
UPSET (defined at § 122.41(n)) 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.

VARIANCE means any mechanism or provision under section 301 or 316 of the CWA or under 40 CFR 125, or in the applicable “effluent
limitations guidelines” which allows modification to or waiver of the generally applicable effluent limitation requirements or time deadlines of
the CWA. This includes provisions which allow the establishment of alternative limitations based on fundamentally different factors or on
sections 301(c), 301(g), 301(h), 301(i), or 316(a) of the CWA.
WATERS OF THE UNITED STATES as defined at § 122.2.
WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test.

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EPA Identification Number

NPDES Permit Number

Facility Name

Form Approved
OMB No.
Form Expires

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
1
NPDES

GENERAL INFORMATION

Name, Mailing Address, and Location

Activities Requiring an NPDES Permit

SECTION 1. ACTIVITIES REQUIRING AN NPDES PERMIT (40 CFR 122.21(f) and (f)(1))
1.1
Applicants Not Required to Submit Form 1
Is the facility a new or existing publicly owned
Is the facility a new or existing treatment works
1.1.1
1.1.2
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete
No
If yes, STOP. Do NOT

 No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
1.2.1 Is the facility a concentrated animal feeding
1.2.2 Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
production facility?
currently discharging process wastewater?
Yes

Complete
Form
1
No


 Yes  Complete Form  No
and Form 2B.
1 and Form 2C.
1.2.3 Is the facility a new manufacturing, commercial,
1.2.4 Is the facility a new or existing manufacturing,
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
commenced to discharge?
discharges only nonprocess wastewater?
 Yes  Complete Form 1  No
 Yes  Complete Form  No
and Form 2D.
1 and Form 2E.
1.2.5 Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
 Yes  Complete Form 1
 No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
(b)(15).
SECTION 2. NAME, MAILING ADDRESS, AND LOCATION (40 CFR 122.21(f)(2))
2.1
Facility Name

2.2

EPA Identification Number

2.3

Facility Contact
Name (first and last)

Title

Phone number

State

ZIP code

Email address
2.4

Facility Mailing Address
Street or P.O. box
City or town

EPA Form 3510-1 (revised )

Page 1

Contains Nonbinding Recommendations
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Name, Mailing Address,
and Location Continued

EPA Identification Number

2.5

NPDES Permit Number

Facility Name

Form Approved
OMB No.
Form Expires

Facility Location
Street, route number, or other specific identifier
County name

County code (if known)

City or town

State

ZIP code

3.2

NAICS Code(s)

Description (optional)

SIC and NAICS Codes

SECTION 3. SIC AND NAICS CODES (40 CFR 122.21(f)(3))
3.1
SIC Code(s)
Description (optional)

R
4.2

Is the name you listed in Item 4.1 also the owner?

 Yes  No

4.3

Operator Status

 Public—federal
 Private

Operator Information
Continued

Operator Information

SECTION 4. OPERATOR INFORMATION (40 CFR 122.21(f)(4))
4.1
Name of Operator

4.4

Phone Number of Operator

4.5

Operator Address
Street or P.O. Box

 Public—state
 Other public (specify)_______________
 Other (specify) _______________

City or town

State

ZIP code

Email address of operator

Indian
Land

SECTION 5. INDIAN LAND (40 CFR 122.21(f)(5))
5.1

Is the facility located on Indian Land?

 Yes  No

EPA Form 3510-1 (revised )

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EPA Identification Number

NPDES Permit Number

Facility Name

Form Approved
OMB No.
Form Expires

Existing Environmental
Permits

SECTION 6. EXISTING ENVIRONMENTAL PERMITS (40 CFR 122.21(f)(6))
Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
6.1

 NPDES (discharges to surface  RCRA (hazardous wastes)
water)
_______________________

 Nonattainment program (CAA)

 NESHAPs (CAA)

 Ocean dumping (MPRSA)

 Dredge or fill (CWA Section 404)

 Other (specify)

___________________________

________________________
SECTION 7. MAP (40 CFR 122.21(f)(7))
Map

fluids)
________________________

____________________________

 PSD (air emissions)

________________________

7.1

 UIC (underground injection of

_______________________

____________________________

_________________________

Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)

Nature of Business

SECTION 8. NATURE OF BUSINESS (40 CFR 122.21(f)(8))
8.1
Describe the nature of your business.

 Yes  No  CAFO—Not Applicable (See requirements in Form 2B.)

R
 Yes  No  SKIP to Item 10.1.

9.2

Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
NPDES permitting authority to determine what specific information needs to be submitted and when.)

Cooling Water
Intake Structures

SECTION 9. COOLING WATER INTAKE STRUCTURES (40 CFR 122.21(f)(9))
9.1
Does your facility use cooling water?

Variance Requests

SECTION 10. VARIANCE REQUESTS (40 CFR 122.21(f)(10))
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
 Fundamentally different factors (CWA
 Water quality related effluent limitations (CWA Section
302(b)(2))
Section 301(n))
 Non-conventional pollutants (CWA
 Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))



Not applicable

EPA Form 3510-1 (revised )

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EPA Identification Number

NPDES Permit Number

Facility Name

Form Approved
OMB No.
Form Expires

SECTION 11. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))

Section 1: Activities Requiring an NPDES Permit



w/ attachments



Section 2: Name, Mailing Address, and Location



w/ attachments



Section 3: SIC Codes



w/ attachments



Section 4: Operator Information



w/ attachments



Section 5: Indian Land



w/ attachments



Section 6: Existing Environmental Permits



w/ attachments



Section 7: Map



w/ topographic
map



Section 8: Nature of Business



w/ attachments



Section 9: Cooling Water Intake Structures



w/ attachments



Section 10: Variance Requests



w/ attachments



Section 11: Checklist and Certification Statement



w/ attachments



 w/ additional attachments

11.2

In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2

Certification Statement

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.

Checklist and Certification Statement

11.1

Name (print or type first and last name)

Signature

Official title

Date signed

EPA Form 3510-1 (revised )

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Contains Nonbinding Recommendations
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United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2A
Revised

Water Permits Division

Application Form 2A
New and Existing Publicly
Owned Treatment Works

NPDES Permitting Program

Note: Complete this form if your facility is a new or existing publicly owned treatment works.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect information and
complete Form 2A to average between 5 and 25 hours, depending on the number of sections the
applicant must complete. The estimate includes time for reviewing instructions, searching existing data
sources, gathering and maintaining the needed data, and completing and reviewing the collection of
information. Send comments about the burden estimate or any other aspect of this collection of
information to the Chief, Information Policy Branch (PM-223), U.S. Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503,
marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2A—GENERAL INSTRUCTIONS
Form 2A. If you do not assert a claim of confidentiality at the time
you submit your information to the NPDES permitting authority,
EPA may make the information available to the public without
further notice to you. EPA will handle claims of confidentiality in
accordance with the Agency’s business confidentiality regulations
at Part 2 of Title 4 of the Code of Federal Regulations (CFR).

Who Must Complete Form 2A?
All new and existing publicly owned treatment works (POTWs) and
other dischargers designated by the National Pollutant Discharge
Elimination System (NPDES) permitting authority must complete
Form 2A. Note that you may wish to consult the “General
Instructions” of NPDES Application Form 1 to determine if your
treatment works is required to submit any additional NPDES
application forms.

Completion of Forms
Form 2A is divided into six major sections. It also contains five
effluent monitoring tables (Tables A through E) and an industrial
discharge information table (Table F), all located at the end of the
form. Note that not all applicants are required to complete each
section of the form or all of the tables. The questions on the form
will direct you to the items and tables you must complete.

At the state level, either the U.S. Environmental Protection Agency
(EPA) or an approved state agency administers the NPDES permit
program. If you are located in a jurisdiction in which an EPA
regional office administers the NPDES permit program, you should
use Form 2A and all other applicable forms described in these
instructions. If you are located in a jurisdiction where a state
administers the NPDES permit program, contact the state to
determine the forms you should complete. States often develop
their own application forms rather than use the federal forms. See
http://www.epa.gov/npdes/npdes-state-program-information for a
list of states that have approved NPDES permit programs and
those that do not.

Exhibit 2A–1 (see end of this section) provides contact information
for each of EPA’s 10 regional offices. Since the exhibit’s content is
subject to change, consult EPA’s website for the latest information:
http://www.epa.gov/aboutepa#regional.
Where to File Your Completed Form


If you are in a jurisdiction where EPA is the NPDES permitting
authority (i.e., the state is not an NPDES-authorized state),
mail the completed application forms to the EPA regional office
that covers the state in which your facility is located (see
Exhibit 2A–1).



If you are in a jurisdiction with an approved state NPDES
permit program, file according to the instructions on the state
forms.

When to File Your Completed Form

If you have previously submitted information that answers a specific
question to EPA or an approved state NPDES agency, you may
either repeat the information in the space provided or attach a copy
of the previous submission.
Note for New Dischargers
Provide all information available to you at the time you
complete Form 2A. If you do not have information to respond
to an item because your facility has yet to discharge, write or
type “data are not available” next to the item on the form. Note
that you are required to submit actual data no later than
24 months after your facility commences to discharge.

Form 2A must be submitted at least 180 days before your present
NPDES permit expires or, if you are a new discharger, at least
180 days before the date on which the discharge is to commence,
unless the NPDES permitting authority has granted permission for a
later date.

Fees

EPA does not require applicants to pay a fee for applying for
NPDES permits. However, states that administer the NPDES permit
program may charge fees. Consult with state officials for further
information.
Public Availability of Submitted Information
EPA will make information from NPDES permit application forms
available to the public for inspection and copying upon request. You
may not claim any information on Form 2A (or related attachments)
as confidential.
You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by

The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
Definitions
The legal definitions of all key terms used in the various NPDES
application forms are included in the “Glossary” at the end of these
instructions.

2A-1

Contains Nonbinding Recommendations
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FORM 2A—GENERAL INSTRUCTIONS CONTINUED
Exhibit 2A–1. Addresses of EPA Regional Contacts and Covered States
REGION 6
U.S. Environmental Protection Agency, Region 6
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733
Phone: (214) 665-2200; toll free: (800) 887-6063
Fax: (214) 665-7113
Website: http://www.epa.gov/aboutepa/epa-region-6-south-central
Covered states: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas

2A-2

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FORM 2A—LINE-BY-LINE INSTRUCTIONS
Section 1. Basic Application Information for All Applicants
Facility Information
Item 1.1. Enter the facility’s official or legal name. Do not use a
colloquial name. Provide the mailing address of the facility. Next,
give the name (first and last), title, work telephone number, and
email address of the person who is thoroughly familiar with the
operation of the facility and with the facts reported in this
application.

Discharge Points by Type
Item 1.11. Provide the facility’s total number of effluent discharge
points to waters of the United States by type (e.g., treated effluent,
untreated effluent, combined sewer overflows, bypasses, and
constructed emergency overflows).
Outfalls and Other Discharge or Disposal Methods
Outfalls Other Than to Waters of the United States
Item 1.12. Indicate whether the POTW discharges wastewater to
basins, ponds, or other surface impoundments that do not have
outlets for discharge to waters of the United States. If yes, continue
to Item 1.13. If no, skip to Item 1.14.

Include a complete location address for the facility if different from
the mailing address. 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 Routes 425 and 22”).

Item 1.13. Specify the location of each surface impoundment, the
average daily volume discharged to each surface impoundment in
gallons per day (gpd), and whether the discharge is continuous or
intermittent.

Item 1.2. Indicate whether the application is for a facility that has
not yet commenced discharge. If yes, be advised that you are
required to submit actual data no later than 24 months after your
facility commences to discharge.

Item 1.14. Indicate if the facility applies wastewater to land. If yes,
continue to Item 1.15. If no, skip to Item 1.16.

Applicant Information
Item 1.3. Indicate if the applicant is different from the entity listed
under Item 1.1. If so, specify the applicant name and address.
Provide the name (first and last) of a contact, including his/her title,
telephone number, and email address.

Item 1.15. Provide the location of each land application site; the
size of each land application site (in acres); the average daily
volume applied to each land application site (in gpd), and whether
the land application is continuous or intermittent.

Item 1.4. Indicate if the applicant is the facility’s owner, operator, or
both.
Item 1.5. Specify whether the NPDES permitting authority should
send correspondence to the facility or the applicant.

Item 1.16. Note whether the facility’s effluent is transported to
another facility for treatment prior to discharge. If yes, continue to
Item 1.17. If no, skip to Item 1.21.
Item 1.17. Describe the means by which the effluent is transported,
such as by tank truck or pipe.

Existing Environmental Permits
Item 1.6. Indicate all environmental permits or construction
approvals received or applied for (including dates) under the noted
programs. Print or type the corresponding permit number for each.

Item 1.18. Specify whether the facility’s effluent is transported by a
party other than the applicant. If yes, continue to Item 1.19. If no,
skip to Item 1.20.
Item 1.19. Provide the name, mailing address, contact person,
phone number, and email address of the entity that transports the
discharge.

Collection System and Population Served
Item 1.7. Specify the municipalities served by the treatment works,
including unincorporated connector districts. For each municipality,
indicate the population served, the percentage of each collection
system type if known (e.g., separate sanitary or combined storm
and sanitary), and collection system ownership status. Finally,
indicate the total percentage of sewer line each type comprises.

Item 1.20. Provide the name, mailing address, contact person,
phone number, email address, and NPDES permit number (if any)
of the receiving facility. Also specify the average daily flow rate from
the facility into the receiving facility in mgd.
Item 1.21. Indicate if wastewater is disposed of in a manner other
than those already mentioned in Items 1.14 through 1.21 that do
not have outlets to waters of the United States, such as
underground percolation and underground injections. If yes,
continue to Item 1.22. If no, skip to Item 1.23.

Do not report privately owned collection systems discharging
industrial waste to the treatment works in Item 1.7. Those facilities
must be reported on Table F.
Indian Country
Item 1.8. Indicate if the POTW is located in Indian Country.

Item 1.9. Note whether the treatment works discharges to a
receiving stream that flows through Indian Country.
Design and Actual Flow Rates
Item 1.10. Provide the facility’s design flow rate in million gallons
per day (mgd). Next, specify the facility’s actual annual average
daily flow rate and maximum daily flow rate for each of the previous
three years (in mgd).

Item 1.22. Provide a description of the disposal method, including
the location and size of each disposal site; the annual average daily
discharge volume (in gpd), and whether disposal through this
method is continuous or intermittent.
Variance Requests
Item 1.23. If known at the time of application, check all of the
authorized variances that you plan to request or renew. Note that
you are not being asked to submit any other information at this
time. Contact your NPDES permitting authority to determine the

2A-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED
website at http://nationalmap.gov/. (For a map from this site, use
the traditional 7.5-minute quadrangle format. If none is available,
use a USGS 15-minute series map.) You may also use a plat or
other appropriate map. Briefly describe land uses in the map area
(e.g., residential, commercial). An example of an acceptable
location map is shown as Exhibit 2A–2 at the end of these
instructions. Note: Exhibit 2A–2 is provided for illustration only; it
does not show an actual facility. Note that you have completed your
topographic map and attached it to the application.

specifics of what you should provide and when. The ability to
request a variance is not limited to the time of application, and an
applicant may request a variance consistent with statutory and
regulatory requirements.
Contractor Information
Item 1.24. Indicate if any of the operational or maintenance
activities associated with wastewater treatment and effluent quality
of the POTW are the responsibility of a contractor. If yes, continue
to Item 1.25. If no, skip to Section 2.

Flow Diagram
Item 2.4. Provide a process flow diagram or schematic showing the
processes of the treatment plant, including all bypass piping and all
backup power sources or redundancy in the system. This includes
a water balance showing all treatment units, including disinfection
(e.g., chlorination and dechlorination), and showing daily average
flow rates at influent and discharge points, and approximate daily
flow rates between treatment units. Also provide a narrative
description of the diagram/schematic. Answer “Yes” to Item 2.4
once you have completed and attached your diagram to the
application.

Item 1.25. Provide a listing of all contractors (by company name).
For each, specify the mailing address, a contact name, telephone
number, and email address. Also summarize the operational and
maintenance responsibilities of each contractor.

Section 2. Additional Information
Outfalls to Waters of the United States
Design Flow
Item 2.1. Indicate whether the treatment works has a design flow
greater than or equal to 0.1 mgd. If yes, continue to Item 2.2. If no,
skip to Section 3.

Scheduled Improvements and Schedules of Implementation
Item 2.5. Indicate whether any improvements to the facility are
scheduled. If yes, list and briefly describe each scheduled
improvement and continue to Item 2.6. If no, skip to Section 3.

Inflow and Infiltration
Item 2.2. Specify the POTW’s current average daily volume of
inflow and infiltration (in gpd) and steps the facility is taking to
minimize inflow and infiltration.

Topographic Map
Item 2.3. Prepare a topographic map (or other map if a topographic
map is unavailable) extending at least one mile beyond property
boundaries of the treatment plant, including all unit processes and
showing the following: (1) treatment plant area and unit processes;
(2) major pipes or other structures through which wastewater enters
the treatment plant and the pipes or other structures through which
treated wastewater is discharged from the treatment plant (include
outfalls from bypass piping, if applicable); (3) each well where fluids
from the treatment plant are injected underground; (4) wells,
springs, and other surface water bodies listed in public records or
otherwise known to the applicant within ¼ mile of the treatment
works’ property boundaries; (5) sewage sludge management
facilities (including onsite treatment, storage, and disposal sites);
and (6) location at which waste classified as hazardous under the
Resource Conservation and Recovery Act (RCRA) enters the
treatment plant by truck, rail, or dedicated pipe.
On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude to the nearest second. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS).
On all maps of rivers, show the direction of the current. In tidal
waters, show the directions of ebb and flow tides.
You may develop your map by going to USGS’s National Map

Item 2.6. For each scheduled improvement, indicate the outfall
number of each outfall affected and the scheduled or actual dates
of completion for the following: (1) commencement of construction,
(2) completion of construction, (3) commencement of discharge,
and (4) attainment of operational level.
Item 2.7. Note whether the appropriate permits/clearances
concerning other federal/state requirements have been obtained
and briefly explain your response.
Section 3. Information on Effluent Discharges
Description of Outfalls
Item 3.1. Provide a description of each of the POTW’s wastewater
discharge outfalls. The application form provides reporting space
for three outfalls. If your facility has more than this number, attach
additional sheets as necessary.
For each outfall, provide the outfall number. Indicate the state,
county, and city or town where each outfall is located. Note the
distance from shore in feet and the depth below the surface in feet.
Specify the average daily flow rate through the outfall in mgd. Also
specify the latitude and longitude of each outfall to the nearest
second. Latitude and longitude coordinates may be obtained in a
variety of ways, including use of hand held devices (e.g., a GPS
enabled smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., USGS). The location of each outfall (i.e.,
where the coordinates are collected) shall be the point where the
discharge is released into a water of the United States. For further
guidance, refer to http://www.epa.gov/geospatial/latitudelongitudedata-standard.

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FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED
Seasonal or Periodic Discharge Data
Item 3.2. Indicate whether any of the outfalls described under
Item 3.1 have seasonal or periodic discharges. If yes, continue to
Item 3.3. If no, skip to Item 3.4.

completing Items 3.10 to 3.26 and Tables A through E.

Item 3.5. Briefly describe the diffuser type at each applicable
outfall.

Treatment Description

Item 3.12. For each applicable outfall, note the number of acute
and chronic WET tests conducted since the last permit reissuance
of the facility’s discharges or of the receiving water near the
discharge points.
Item 3.13. Note whether the POTW has a design flow greater than
or equal to 0.1 mgd. If yes, continue to Item 3.14. If no, skip to Item
3.16.
Item 3.14 and Table B. Answer whether the treatment works uses
chlorine for disinfection, uses it elsewhere in the treatment process,
or otherwise has reasonable potential to discharge chlorine in its
effluent. If yes, complete Table B including chlorine. If no, complete
Table B, omitting chlorine.

Waters of the United States
Item 3.6. Note whether the POTW discharges or plans to discharge
wastewater to waters of the United States from one or more
discharge points. If yes, continue to Item 3.7. If no, skip to
Section 6.
Receiving Water Description
Item 3.7. Provide receiving water and related information in the
table provided on the form (if known): (1) name of receiving water,
(2) name of watershed/river/stream system and U.S. Soil
Conservation Service 14-digit watershed code, (3) name of state
management/river basin and U.S. Geological Survey (USGS) 8-digit
hydrologic unit code, (4) acute and chronic critical low flow in cubic
feet per second (cfs) and total hardness of receiving stream at
critical low flow, in milligrams per liter (mg/L) of calcium carbonate,
if applicable.

Item 3.11. Answer whether the POTW has conducted any whole
effluent toxicity (WET) tests during the 4.5 years prior to the date of
the application on any of the facility’s discharges or on any
receiving water near the discharge points. If yes, continue to Item
3.12. If no, skip to Item 3.13.

Item 3.3. Specify the following for each applicable outfall:
(1) number of times per year discharge occurs, (2) average duration
of each discharge, (3) average flow of each discharge in mgd, and
(4) months in which discharge occurs.
Diffuser Type
Item 3.4. Note whether any of the outfalls listed under Item 3.1 are
equipped with a diffuser. If yes, continue to Item 3.5. If no, skip to
Item 3.6.

Item 3.10 and Table A. All applicants that discharge wastewater to
waters of the United States must provide effluent data for Table A
parameters. Respond “Yes” to Item 3.10 when you have completed
Table A and attached it to your application.

Item 3.8. Specify the highest level of treatment provided for
discharges from each outfall (e.g., primary, equivalent to
secondary, secondary, or advanced). Also indicate the following
design removals (in percent) for the following parameters for each
outfall: (1) biochemical oxygen demand (BOD5 or CBOD5), (2) total
suspended solids (TSS), (3) phosphorus (if applicable), (4) nitrogen
(if applicable), and (5) any other removals that an advanced
treatment system is designed to achieve.
Item 3.9. Provide a description of the type(s) of disinfection used for
wastewater discharged through each outfall. Indicate the seasons
the disinfection type is used. Note whether the POTW dechlorinates
if disinfection is accomplished through chlorination. Otherwise,
check “Not Applicable.”
Effluent Testing Data and Tables A through E
Items 3.10 to 3.26. These items require you to collect and report
data for the parameters and pollutants listed in Tables A through E,
located at the end of Form 2A. The instructions for completing the
tables are table-specific, as are the criteria for determining who
should complete them.
Important note: Read the “General Instructions for Reporting,
Sampling, and Analysis” later in these instructions before

Item 3.15. Answer “Yes” when you have completed monitoring for
all applicable Table B parameters and attached the results to your
application.
Item 3.16 and Screen for Tables C through E. Indicate whether
one or more of the conditions apply to your POTW. If yes, continue
to Item 3.17. If no, skip to Section 4.
Item 3.17 and Table C. Answer “Yes” to indicate you have
completed monitoring for all applicable Table C pollutants and
attached the results to your application package.
Item 3.18 and Table D. Answer “Yes” to indicate you have
completed monitoring for applicable Table D pollutants required by
your NPDES permitting authority and attached the results to your
application package, or “No” if the NPDES permitting authority has
not required additional sampling for the pollutants in Table D.
Item 3.19 and Additional Screen for Table E. Answer whether the
POTW conducted either (1) a minimum of four quarterly WET tests
for one year preceding this permit application or (2) at least four
annual WET tests in the past 4.5 years. If yes, continue to Item
3.20. If no, complete tests and Table E and then skip to Item 3.26.
Item 3.20 and Additional Screen for Table E. Report whether you
have previously submitted the results of the WET tests indicated in
Item 3.19 to your NPDES permitting authority. If yes, continue to
Item 3.21. If no, provide the results in Table E and skip to Item 3.26.

Item 3.21. Report the dates the testing data were submitted to your
NPDES permitting authority and provide a summary of the results.
Item 3.22. Regardless of how you may have provided the results of
previously conducted WET analyses to your NPDES permitting
authority, indicate if any of the tests resulted in toxicity. If yes,

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FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED
continue to Item 3.23. If no, skip to Item 3.26.
pretreatment program, which is defined at 40 CFR 403.3 as a
program administered by a POTW that meets the criteria
Item 3.23. Describe the cause(s) of toxicity.
established in 40 CFR 403.8 and 403.9 and that has been
Item 3.24. Indicate if the POTW has conducted a toxicity reduction
approved by the NPDES permitting authority.
evaluation. If yes, continue to Item 3.25. If no, skip to Item 3.26.
Item 4.4. Answer whether you have submitted either of the
Item 3.25. Provide details of any toxicity reduction evaluations
following to the NPDES permitting authority that contains
performed.
information substantially identical to that required in Table F: (1) a
pretreatment program annual report submitted within one year of
Item 3.26. Answer “Yes” when you have completed Table E for all
the application or (2) a pretreatment program. If yes, continue to
applicable outfalls and attached the results to the application
Item 4.5. If no, skip to Item 4.6.
package, or answer “No” if the item is not applicable because you
previously submitted WET data to your NPDES permitting authority. Item 4.5. Identify the title and date of the pretreatment program
annual report or pretreatment program referenced in Item 4.4 and
Section 4. Industrial Discharges, Table F, and Hazardous
skip to Item 4.7.
Wastes
Item 4.1. Indicate if the POTW receives discharges from significant Item 4.6 and Table F. Complete Table F by providing the following
industrial users (SIUs) or non-significant categorical industrial users information for each SIU that discharges to the POTW: (1) name
and mailing address; (2) description of all industrial processes that
(NSCIUs), including SIUs and NSCIUs that truck or haul waste. If
affect or contribute to each SIU’s discharge; (3) a list of the principal
yes, continue to Item 4.2. If no, skip to Item 4.7.
products and raw materials that affect or contribute to the SIU’s
1. SIUs are defined as:
discharge; (4) average daily volume of wastewater discharged by
each SIU, indicating the amount attributable to process flow and
a. All industrial users subject to categorical pretreatment
non-process flow; (5) whether the SIU is subject to local limits;
standards under 40 CFR 403.6 and 40 CFR Chapter I,
(6) whether the SIU is subject to categorical standards and the
Subchapter N (CIUs); and
categories/subcategories under which the SIU is subject; and
b. Any other industrial user per 40 CFR 403.3 that:
(7) whether any problems (e.g., upsets, pass-through interference)
i. Discharges an average of 25,000 gpd or more of
have occurred at the POTW that can be attributed to the SIU in the
process wastewater to the treatment works (with
past 4.5 years. Answer “Yes” to Item 4.6 when you have completed
certain exclusions); or
and attached Table F to the application package.
ii. Contributes a process wastestream that makes up
Note: SIUs include users that truck or haul industrial waste to the
5 percent or more of the average dry weather
POTW. Information for these users must be provided in Table F.
hydraulic or organic capacity of the treatment plant;
or
Item 4.7. Indicate if the POTW receives or has been notified that it
will receive by truck, rail, or dedicated pipe any wastes that are
iii. Is designated as an SIU by the control authority.
regulated as RCRA hazardous wastes pursuant to 40 CFR 261. If
2. The control authority may determine that an Industrial User
yes, continue to Item 4.8. If no, skip to Item 4.9.
subject to categorical Pretreatment Standards under 40 CFR
Item 4.8. For each hazardous waste received, provide the
403.6 and 40 CFR Chapter I, Subchapter N is a NSCIU rather
hazardous waste number, the method by which the waste is
than a SIU on a finding that the Industrial User never
received (e.g., by truck, dedicated pipe, rail, etc.), and the amount
discharges more than 100 gpd of total categorical wastewater
of waste received annually (specify units).
(excluding sanitary, non-contact cooling and boiler blowdown
wastewater, unless specifically included in the Pretreatment
Item 4.9. Answer whether the POTW receives, or has been notified
Standard) and the following conditions are met:
that it will receive, wastewaters that originate from remedial
a. The Industrial User, prior to the control authority's finding, activities, including those undertaken pursuant to Comprehensive
Environmental Response, Compensation, and Liability Act
has consistently complied with all applicable categorical
(CERCLA) and Sections 3004(u) or 3008(h) of RCRA. If yes,
Pretreatment Standards and Requirements;
continue to Item 4.10. If no, skip to Section 5.
b. The Industrial User annually submits the certification
statement required in 40 CFR 403.12(q) together with any Item 4.10. Answer whether the POTW receives (or expects to
receive) less than 15 kilograms per month of non-acute hazardous
additional information necessary to support the
wastes as specified at 40 CFR 261.30(d) and 261.33(e). If yes, skip
certification statement; and
to Section 5. If no, continue to Item 4.11.
c. The Industrial User never discharges any untreated
Item 4.11. In an attachment to the application, provide an
concentrated wastewater.
identification and description of the site(s) or facility(ies) at which
Item 4.2. Indicate the number of SIUs and NSCIUs that discharge
the wastewater originates; the identities of the wastewater’s
to the POTW.
hazardous constituents, as listed in Appendix VII of 40 CFR 261, if
known; and the extent of treatment, if any, the wastewater receives
Item 4.3. Answer whether the POTW has an approved
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Contains Nonbinding Recommendations
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General Instructions for Reporting, Sampling, and Analysis

General Items
Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit
number, facility name, and applicable outfall number at the top of
each page of the tables and any associated attachments.
You may report some or all of the required data by attaching
separate sheets of paper instead of completing Tables A through
E for each of your outfalls, so long as the sheets contain all of the
required information and are similar in format to Tables A through
E. For example, you may be able to print a report in a compatible
format from the data system used in your analysis of metals
completed under Table C.

The method ML is above the water quality criterion, but the
amount of the pollutant or pollutant parameter in the facility’s
discharge is high enough that the method detects and
quantifies the level of the pollutant or pollutant parameter in
the discharge.



The method has the lowest ML of the analytical methods
approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O, for the measured pollutant or
pollutant parameter.

Note for new dischargers. Provide all information available to
you at the time you complete Form 2A. If you do not have
information to respond to an item because your facility has yet to
discharge, write or type “data are not available” next to the item
on the form. Note that you are required to submit actual data no
later than 24 months after your facility commences discharge.



Important note: Read these instructions before completing
Tables A through E and Section 3 of Form 2A.

Reporting of Effluent Data
Where effluent data are requested, do not provide information on
CSOs. The latter information is requested instead under Section 5
of Form 2A.

Provide data for each outfall through which effluent is discharged.
When an applicant has two or more outfalls with substantially
identical effluents, the NPDES permitting authority may allow the
applicant to test only one outfall and report that quantitative data
as applying to the substantially identical outfall. If the permitting
authority grants your request, attach a separate sheet to the
application form identifying the outfall tested and describing why
the other outfall(s) are substantially identical.

At a minimum, effluent testing data must be based on at least
three samples taken within 4.5 years prior to the date of the
permit application. Samples must be representative of the
seasonal variation in the discharge from each outfall. Existing
data may be used, if available, in lieu of sampling done solely for
the purpose of this application.

All existing data for pollutants specified in Tables A through D that
is collected within 4.5 years of the application must be included in
the pollutant data summary that you submit. If, however, you
sampled for a specific pollutant on a monthly or more frequent
basis, it is only necessary, for such pollutant, to summarize all
data collected within 1 year of the application.
Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical
methods approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O. A method is “sufficiently sensitive”
when:


When there is no analytical method that has been approved under
40 CFR 136; required under 40 CFR chapter I, subchapter N or O,
and is not otherwise required by the NPDES permitting authority,
you may use any suitable method but shall provide a description
of the method. When selecting a suitable method, other factors
such as a method’s precision, accuracy, or resolution, may be
considered when assessing the performance of the method.
Effluent monitoring data must comply with the QA/QC
requirements of 40 CFR 136 (and other appropriate QA/QC
requirements for standard methods for analytes not addressed by
40 CFR 136).
Clearly specify the units of measure on Tables A through E for
each parameter/pollutant analyzed. Values should be reported as
concentration or mass, except for flow, temperature, pH, color,
and fecal coliform organisms, unless otherwise requested or
required by the NPDES permitting authority. Flow, temperature,
pH, color, and fecal coliform organisms must be reported as mgd,
degrees Celsius (°C), standard units, color units, and most
probable number per 100 milliliters (MPN/100 mL), respectively.
Use the following abbreviations in the columns requiring “units” in
Tables A through D.
Concentration

Mass

ppm = parts per million

lbs = pounds

mg/L = milligrams per liter

ton = tons (English tons)

ppb = parts per billion

mg = milligrams

µg/L = micrograms per liter

g = grams
kg = kilograms
T = tonnes (metric tons)

MPN = most probable number
per 100 milliliters

The method minimum level (ML) is at or below the level of
the applicable water quality criterion for the measured
pollutant or pollutant parameter.
2A-7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued
Grab samples must be used for pH, temperature, cyanide, total
phenols, residual chlorine, oil and grease, fecal coliform (including
E. coli), and volatile organic compounds. For all other pollutants,
24-hour composite samples must be used. For a composite
sample, only one analysis of the composite of aliquots is required.

times, and the collection of duplicate samples—must be followed.
The time when you sample should be representative of your normal
operation, to the extent feasible, with your treatment system
operating properly with no system upsets. Collect samples from the
center of the flow channel, where turbulence is at a maximum, at a
site specified in your present NPDES permit, or at any site
adequate for the collection of a representative sample.

The effluent monitoring data provided must include at least the
following for each parameter: (1) the maximum daily discharge
based upon actual sample values, (2) average daily discharge for
all samples, expressed as concentration or mass, and the number
of samples used to obtain this value, (3) the analytical method
used, and (4) the threshold level (i.e., method detection limit,
minimum level, or other designated method endpoints) for the
analytical method used.

Further Requirements for Table E, Whole Effluent Toxicity
Testing

Sampling

Applicants must conduct tests with multiple species (no less than
two species; e.g., fish, invertebrate, plant) and test for acute or
chronic toxicity, depending on the range of receiving water dilution.
See 40 CFR 122.21(j)(5)(v) for further details.

The collection of samples for the reported analyses should be
supervised by a person experienced in performing sampling of
domestic wastewater. You may contact your NPDES permitting
authority for detailed guidance on sampling techniques and for
answers to specific questions. See Exhibit 2A–1 for contact
information. Any specific requirements in the analytical methods—
for example, for sample containers, sample preservation, holding

Metals must be reported as “total recoverable metal,” unless all
approved analytical methods for the metal inherently measure only
its dissolved form (e.g., hexavalent chromium) or otherwise directed
by the NPDES permitting authority.

Each applicant required to perform WET testing must provide
results of a minimum of four quarterly tests for a year, from the year
preceding the permit application, or the results from four tests
performed at least annually in the 4.5-year period prior to the
application, provided the results show no appreciable toxicity using
a safety factor determined by the NPDES permitting authority.

WET testing must be conducted using methods approved under
40 CFR 136. West coast facilities in Washington, Oregon,
California, Alaska, Hawaii, and the Pacific Territories are exempted
from 40 CFR 136 chronic methods and must use alternative
guidance as directed by the NPDES permitting authority.

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FORM 2A—LINE-BY-LINE INSTRUCTIONS CONTINUED

watershed (14-digit) code, if known; (3) name of the state
management/river basin and the USGS 8-digit hydrologic
cataloging unit code, if known; and (4) a description of any known
water quality impacts on the receiving water caused by the CSO
(e.g., permanent or intermittent beach closings, permanent or
intermittent shellfish bed closings, fish kills, fish advisories, other
recreational loss, or exceedance of any applicable state water
quality standard).
Section 6. Checklist and Certification Statement
Item 6.1. Review the checklist provided. In Column 1, mark the
sections of Form 2A that you have completed and are submitting
with your application. In Column 2, indicate for each section
whether you are submitting attachments.
Item 6.2. The Clean Water Act provides for severe penalties for
submitting false information on this application form. CWA Section
309(c)(2) 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 AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A. For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) 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 (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END
Submit your completed Form 2A and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

or will receive before entering the POTW. Answer “Yes” to Item
4.11 when you have completed and attached the information to the
application package.
Section 5. Combined Sewer Overflows
CSO Map and Diagram
Item 5.1. Indicate if the treatment works has a combined sewer
system. If yes, continue to Item 5.2. If no, skip to Section 6.
Item 5.2. Attach a CSO system map to the application. The map
should indicate: (1) all CSO discharge points, (2) sensitive use
areas potentially affected by CSOs (e.g., beaches, drinking water
supplies, shellfish beds, sensitive aquatic ecosystems, and
outstanding national resource waters), and (3) waters supporting
threatened and endangered species potentially affected by CSOs.
Answer “Yes” to Item 5.2 when you have completed the map and
attached it to the application package.
Item 5.3. Prepare a diagram of the CSO collection system. The
diagram should show the following: (1) the location of major sewer
trunk lines, both combined and separate sanitary; (2) the locations
of points where separate sanitary sewers feed into the combined
sewer system; (3) in-line and off-line storage structures; (4) the
locations of flow-regulating devices; and (5) the locations of pump
stations. Answer “Yes” to Item 5.3 when you have completed the
diagram and attached it to the application package.
CSO Outfall Description
Item 5.4. Provide the following information for each CSO outfall:
(1) outfall number; (2) state, county, city or town and ZIP code in
which the outfall is located; (3) latitude and longitude of the outfall,
to the nearest second, (4) distance of the outfall from shore and
depth of the outfall below water surface. Latitude and longitude
coordinates may be obtained in a variety of ways, including use of
hand held devices (e.g., a GPS enabled smartphone), internet
mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., USGS). The location of each CSO
outfall (i.e., where the coordinates are collected) shall be the point
where the discharge is released into a water of the United States.
CSO Monitoring
Item 5.5. Indicate whether the POTW has monitored any of the
following items in the past year for each of its CSO outfalls:
(1) rainfall, (2) CSO flow volume, (3) CSO pollutant concentrations;
(4) receiving water quality, (5) CSO frequency, and (6) number of
storm events.
CSO Events in Past Year
Item 5.6. For each CSO outfall, record (1) the number of CSO
events in the past year, (2) the average duration in hours per event,
(3) the average volume per CSO event in million gallons, and
(4) the minimum rainfall that caused a CSO event in inches of
rainfall in the past year. Note whether your responses for sub-items
(2) through (4) above are based on actual or estimated data.
CSO Receiving Waters
Item 5.7. For each CSO outfall, record the following receiving water
information: (1) name of receiving water; (2) name of
watershed/stream system and the U.S. Soil Conservation Service

2A-9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2A–2. Example Topographic Map

2A-10

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2A—GLOSSARY
Note: This glossary includes terms used in the various NPDES application forms, including Form 2A. The definitions are from the NPDES
regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms, contact
your NPDES permitting authority.
ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (other than an aquatic animal production facility) where the
following conditions are met;


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



Crops, vegetation, forage growth, or post-harvest residues are not sustained in the normal growing season over any portion of the lot
or facility.

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.
APPROVED PROGRAM or APPROVED STATE means a State or interstate program which has been approved or authorized by EPA
under part 123.

AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month,
calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured during that
month.
AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week,
calculated as the sum of all daily discharges measured during a calendar week divided by the number of daily discharges measured during
that week.
BEST MANAGEMENT PRACTICES (BMPs) 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. BMPs 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.

BIOSOLIDS (see sewage sludge).

LARGE CONCENTRATED ANIMAL FEEDING OPERATION (LARGE CAFO) means an AFO that stables or confines as many as or
more than the numbers of animals specified in any of the following categories:
1. 700 mature dairy cows, whether milked or dry;
2. 1,000 veal calves;
3. 1,000 cattle other than mature dairy cows or veal calves. Cattle includes but is not limited to heifers, steers, bulls and cow/calf
pairs;
4. 2,500 swine each weighing 55 pounds or more;
5. 10,000 swine each weighing less than 55 pounds;
6. 500 horses;
7. 10,000 sheep or lambs;
2A-11

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Draft Application Forms - Not for Implementation

FORM 2A—GLOSSARY CONTINUED
8.
9.
10.
11.
12.
13.
B.

55,000 turkeys;
30,000 laying hens or broilers, if the AFO uses a liquid manure handling system;
125,000 chickens (other than laying hens), if the AFO uses other than a liquid manure handling system;
82,000 laying hens, if the AFO uses other than a liquid manure handling system;
30,000 ducks (if the AFO uses other than a liquid manure handling system); or
5,000 ducks (if the AFO uses a liquid manure handling system).

Closed ponds which discharge only during periods of excess runoff; or

Facilities which produce less than 45,454 harvest weight kilograms (approximately 100,000 pounds) of aquatic animals per year.

CWA means the Clean Water Act (formerly referred to as the Federal Water Pollution Control Act or Federal Water Pollution Control Act
Amendments of 1972) Public Law 92–500, as amended by Public Law 95–217, Public Law 95–576, Public Law 96–483 and Public Law
97–117, 33 U.S.C. 1251 et seq.
CWA AND REGULATIONS means the Clean Water Act (CWA) and applicable regulations promulgated thereunder. In the case of an
approved State program, it includes State program requirements.
2A-12

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FORM 2A—GLOSSARY CONTINUED
DAILY DISCHARGE means the “discharge of a pollutant” measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling. For pollutants with limitations expressed in units of mass, the “daily discharge” is
calculated as the total mass of the pollutant discharged over the day. For pollutants with limitations expressed in other units of
measurement, the “daily discharge” is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the “discharge of a pollutant.”
DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an authorized representative. When there
is no “approved State program,” and there is an EPA administered program, “Director” means the Regional Administrator. When there is
an approved State program, “Director” normally means the State Director. In some circumstances, however, EPA retains the authority to
take certain actions even when there is an approved State program. (For example, when EPA has issued an NPDES permit prior to the
approval of a State program, EPA may retain jurisdiction over that permit after program approval, see § 123.1.) In such cases, the term
“Director” means the Regional Administrator and not the State Director.
DISCHARGE (OF A POLLUTANT) means:
Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or



DISCHARGE MONITORING REPORT means the EPA uniform national form, including any subsequent additions, revisions, or
modifications for the reporting of self-monitoring results by permittees. DMRs must be used by “approved States” as well as by EPA. EPA
will supply DMRs to any approved State upon request. The EPA national forms may be modified to substitute the state agency name,
address, logo, and other similar information, as appropriate, in place of EPA's.
DRAFT PERMIT means a document prepared under § 124.6 indicating the Director's tentative decision to issue or deny, modify, revoke
and reissue, terminate, or reissue a “permit.” A notice of intent to terminate a permit, and a notice of intent to deny a permit, as discussed
in § 124.5, are types of “draft permits.” A denial of a request for modification, revocation and reissuance, or termination, as discussed in
§ 124.5, is not a “draft permit.” A “proposed permit” is not a “draft permit.”
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 “contiguous zone,” or the ocean.

EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administrator under section 304(b) of the CWA to adopt or
revise “effluent limitations.”
ENVIRONMENTAL PROTECTION AGENCY (EPA) means the United States Environmental Protection Agency.
FACILITY or ACTIVITY means any NPDES “point source” or any other facility or activity (including land or appurtenances thereto) that is
subject to regulation under the NPDES program.



All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same.

INDIAN TRIBE means any Indian Tribe, band, group, or community recognized by the Secretary of the Interior and exercising
governmental authority over a Federal Indian reservation.
INDIRECT DISCHARGE means a nondomestic discharger introducing “pollutants” to a “publicly owned treatment works.”

2A-13

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FORM 2A—GLOSSARY CONTINUED
LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(4)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census (Appendix F of 40 CFR 122); or
(ii) Located in the counties listed in appendix H of 40 CFR 122, except municipal separate storm sewers that are located in the
incorporated places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraphs (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(D) The nature of the receiving waters; and
(E) Other relevant factors; or

MEDIUM MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(7)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 100,000 or more but less than 250,000, as determined by the 1990 Decennial
Census by the Bureau of the Census (appendix G of 40 CFR 122); or
(ii) Located in the counties listed in appendix I of 40 CFR 122, except municipal separate storm sewers that are located in the incorporated
places, townships or towns within such counties; or

(iii) Owned or operated by a municipality other than those described in paragraph (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraph (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(C) The quantity and nature of pollutants discharged to waters of the United States;
(D) The nature of the receiving waters; or
(E) Other relevant factors; or
(iv) The Director may, upon petition, designate as a medium municipal separate storm sewer system, municipal separate storm sewers
located within the boundaries of a region defined by a storm water management regional authority based on a jurisdictional, watershed, or
other appropriate basis that includes one or more of the systems described in paragraphs (i), (ii), (iii) of this section.

2A-14

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FORM 2A—GLOSSARY CONTINUED
MUNICIPALITY means a city, 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 the CWA.
MUNICIPAL SEPARATE STORM SEWER (defined at § 122.26(b)(8)) means a conveyance or system of conveyances (including roads
with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels, or storm drains):


Owned or operated by a State, city, town, borough, county, parish, district, association, or other public body (created by or pursuant to
State law) having jurisdiction over disposal of sewage, industrial wastes, stormwater, or other wastes, including special districts under
State law such as a sewer district, flood control district or drainage district, or similar entity, or an Indian tribe or an authorized Indian
tribal organization, or a designated and approved management agency under section 208 of the CWA that discharges to waters of the
United States.



Designed or used for collecting or conveying stormwater.



Which is not a combined sewer; and



Which is not part of a POTW as defined at 40 CFR 122.2.

MUNICIPAL SLUDGE (see sewage sludge)



That did not commence the “discharge of pollutants” at a particular “site” prior to August 13, 1979;



Which is not a “new source;” and



Which has never received a finally effective NPDES permit for discharges at that “site.”



This definition includes an “indirect discharger” which commences discharging into “waters of the United States” after August 13, 1979. It
also means any existing mobile point source (other than an offshore or coastal oil and gas exploratory drilling rig or a coastal oil and gas
developmental drilling rig) such as a seafood processing rig, seafood processing vessel, or aggregate plant, that begins discharging at a
“site” for which it does not have a permit; and any offshore or coastal mobile oil and gas exploratory drilling rig or coastal mobile oil and gas
developmental drilling rig that commences the discharge of pollutants after August 13, 1979, at a “site” under EPA’s permitting jurisdiction
for which it is not covered by an individual or general permit and which is located in an area determined by the Regional Administrator in
the issuance of a final permit to be an area of biological concern. In determining whether an area is an area of biological concern, the
Regional Administrator shall consider the factors specified in 40 CFR 125.122(a)(1) through (10).
An offshore or coastal mobile exploratory drilling rig or coastal mobile developmental drilling rig will be considered a “new discharger” only
for the duration of its discharge in an area of biological concern.
NEW SOURCE means any building, structure, facility, or installation from which there is or may be a “discharge of pollutants,” the
construction of which commenced:
After promulgation of standards of performance under section 306 of the CWA which are applicable to such source, or



OWNER OR OPERATOR means the owner or operator of any “facility or activity” subject to regulation under the NPDES program.

PERMIT means an authorization, license, or equivalent control document issued by EPA or an “approved State” to implement the
requirements of this part and parts 123 and 124. “Permit” includes an NPDES “general permit” (§ 122.28). Permit does not include any
permit which has not yet been the subject of final agency action, such as a “draft permit” or a “proposed permit.”

PESTICIDE DISCHARGES TO WATERS OF THE UNITED STATES FROM PESTICIDE APPLICATION means the application of
biological pesticides, and the application of chemical pesticides that leave a residue, from point sources to waters of the United States. In
the context of this definition of pesticide discharges to waters of the United States from pesticide application, this does not include
agricultural storm water discharges and return flows from irrigated agriculture, which are excluded by law (33 U.S.C. 1342(l); 33 U.S.C.
1362(14)).
PESTICIDE RESIDUE for the purpose of determining whether a NPDES permit is needed for discharges to waters of the United States
from pesticide application, means that portion of a pesticide application that is discharged from a point source to waters of the United
States and no longer provides pesticidal benefits. It also includes any degradates of the pesticide.
2A-15

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FORM 2A—GLOSSARY CONTINUED
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, landfill leachate collection system, vessel or
other floating craft from which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff. (See § 122.3).
POLLUTANT means dredged spoil, solid waste, incinerator residue, filter backwash, sewage, garbage, sewage sludge, munitions,
chemical wastes, biological materials, radioactive materials (except those regulated under the Atomic Energy Act of 1954, as amended (42
U.S.C. 2011 et seq.)), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste
discharged into water. It does not mean:


Sewage from vessels; or



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.
PROPOSED PERMIT means a state NPDES “permit” prepared after the close of the public comment period (and, when applicable, any
public hearing and administrative appeals) which is sent to EPA for review before final issuance by the State. A “proposed permit” is not a
“draft permit.”
PUBLICLY OWNED TREATMENT WORKS or POTW (defined at § 403.3) means a treatment works as defined by CWA Section 212,
which is owned by a state or municipality (as defined by CWA Section 502(4)). This definition includes any devices or systems used in the
storage, treatment, recycling, and reclamation) of municipal sewage or industrial wastes of a liquid nature. This definition also includes
sewers, pipes, and other conveyances only if they convey wastewater to a POTW. The term also means the municipality as defined in
CWA Section 502(4), which has jurisdiction over the indirect discharges to and the discharges from such a treatment works.

SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.

SEWAGE SLUDGE means any solid, semi-solid, or liquid residue removed during the treatment of municipal waste water or domestic
sewage. Sewage sludge includes, but is not limited to, solids removed during primary, secondary, or advanced waste water treatment,
scum, septage, portable toilet pumpings, type III marine sanitation device pumpings (33 CFR 159), and sewage sludge products. Sewage
sludge does not include grit or screenings, or ash generated during the incineration of sewage sludge.

SlLVICULTURAL POINT SOURCE (defined at § 122.27) means any discernible, 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 non-point 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 (see 33 CFR 209.120 and part 233).
2A-16

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FORM 2A—GLOSSARY CONTINUED
SITE means the land or water area where any “facility or activity” is physically located or conducted, including adjacent land used in
connection with the facility or activity.
SLUDGE-ONLY FACILITY means any “treatment works treating domestic sewage” whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d) of the CWA
which govern minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.
STATE means any of the 50 States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Commonwealth of the Northern Mariana Islands, the Trust Territory of the Pacific Islands, or an Indian Tribe as defined in
these regulations which meets the requirements of § 123.31 of this chapter.
STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an “approved program,” or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, “State Director”
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.

STORMWATER (or STORM WATER) (defined at § 122.26(b)(13)) means stormwater runoff, snow melt runoff, and surface runoff and
drainage.

4.
5.
6.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2A—GLOSSARY CONTINUED
Steam electric power generating facilities, including coal handling sites;
Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221–25), 43, 44, 45, and 5171 which have
vehicle maintenance shops, equipment cleaning operations, or airport deicing operations. Only those portions of the facility that are
either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication),
equipment cleaning operations, airport deicing operations, or which are otherwise identified under paragraphs 1–7 or 9–11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system, used in the
storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved
pretreatment program under 40 CFR 403. Not included are farm lands, domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility, or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing, grading and excavation, except operations that result in the disturbance of less than five acres
of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34
(except 3441), 35, 36, 37 (except 373), 38, 39, and 4221–25.

7.
8.

UPSET (defined at § 122.41(n)) 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.
VARIANCE means any mechanism or provision under section 301 or 316 of the CWA or under 40 CFR 125, or in the applicable “effluent
limitations guidelines” which allows modification to or waiver of the generally applicable effluent limitation requirements or time deadlines of
the CWA. This includes provisions which allow the establishment of alternative limitations based on fundamentally different factors or on
sections 301(c), 301(g), 301(h), 301(i), or 316(a) of the CWA.
WATERS OF THE UNITED STATES as defined at § 122.2.

WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test.

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NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2A
NPDES

NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS
SECTION 1. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
1.1
Facility name
Mailing address (street or P.O. box)

Facility Information

City or town
Contact name (first and last)

Title

State

ZIP code

Phone number

Email address

 Same as mailing address

Location address (street, route number, or other specific identifier)
City or town

State

Is this application for a facility that has yet to commence discharge?
 Yes  See instructions on data submission
 No
requirements for new dischargers.

1.3

Is applicant different from entity listed under Item 1.1 above?



Yes

1.2

ZIP code



No  SKIP to Item 1.4.

Applicant address (street or P.O. box)
City or town

Applicant Information

Applicant name

Contact name (first and last)

1.4

Owner



Phone number

Email address

Operator



Both

To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
and applicant
 Facility
 Applicant
 Facility
(they are one and the same)
Indicate below any existing environmental permits. (Check all that apply and print or type the corresponding permit
number for each.)

D
Existing Environmental Permits

1.6

ZIP code

Is the applicant the facility’s owner, operator, or both? (Check only one response.)



1.5

Title

State




NPDES (discharges to surface
water)
_________________________
PSD (air emissions)



_________________________
Ocean dumping (MPRSA)
_________________________

EPA Form 3510-2A (Revised )

Existing Environmental Permits



RCRA (hazardous waste)



_________________________
Nonattainment program (CAA)



UIC (underground injection
control)
_______________________
NESHAPs (CAA)



_______________________
Other (specify)



_________________________
Dredge or fill (CWA Section
404)
_________________________

_______________________

Page 1

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NPDES Permit Number
Facility Name

EPA Identification Number

Provide the collection system information requested below for the treatment works.
Municipality
Population
Collection System Type
Served
Served
(indicate percentage)
_____ % separate sanitary sewer
_____ % combined storm and sanitary sewer
Unknown

_____ % separate sanitary sewer
_____ % combined storm and sanitary sewer
Unknown

_____ % separate sanitary sewer
_____ % combined storm and sanitary sewer
Unknown

_____ % separate sanitary sewer
_____ % combined storm and sanitary sewer
Unknown

Total
Population
Served

Ownership Status














1.9

Yes
 No
Provide design and actual flow rates in the designated spaces.

Annual Average Flow Rates (Actual)
Last Year

Two Years Ago

mgd

Maximum Daily Flow Rates (Actual)
Last Year

Two Years Ago

mgd
This Year
mgd
This Year

mgd

Provide the total number of effluent discharge points to waters of the United States by type.
Total Number of Effluent Discharge Points by Type

Discharge Points
by Type

mgd

1.11

Design Flow Rate

mgd

Design and Actual
Flow Rates



Does the facility discharge to a receiving water that flows through Indian Country?



1.10

Yes

Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain
Maintain

Indian Country

1.8














Combined Storm and
Sanitary Sewer

Separate Sanitary Sewer System
Total percentage of each type of
sewer line (in miles)
Is the treatment works located in Indian Country?

Own
Own
Own
Own
Own
Own
Own
Own
Own
Own
Own
Own

Collection System and Population Served

1.7

Form Approved
OMB No.
Form Expires

Treated Effluent

EPA Form 3510-2A (Revised )

Untreated Effluent

Combined Sewer
Overflows

Bypasses

Constructed
Emergency
Overflows

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NPDES Permit Number
Facility Name

Form Approved
OMB No.
Form Expires

Outfalls Other Than to Waters of the United States
1.12 Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets for
discharge to waters of the United States?
 Yes
 No  SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume
Continuous or Intermittent
Location
Discharged to Surface
(check one)
Impoundment
 Continuous
gpd
 Intermittent
 Continuous
gpd
 Intermittent
 Continuous
gpd
 Intermittent
1.14 Is wastewater applied to land?
 Yes
 No  SKIP to Item 1.16.
1.15 Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Continuous or
Average Daily Volume
Location
Size
Intermittent
Applied
(check one)
 Continuous
acres
gpd
 Intermittent
 Continuous
acres
gpd
 Intermittent
 Continuous
acres
gpd
 Intermittent
1.16 Is effluent transported to another facility for treatment prior to discharge?
No  SKIP to Item 1.21.
 Yes

1.17 Describe the means by which the effluent is transported (e.g., tank truck, pipe).

Outfalls and Other Discharge or Disposal Methods

EPA Identification Number

Is the effluent transported by a party other than the applicant?
 Yes
 No  SKIP to Item 1.20.

1.19

Provide information on the transporter below.

1.18

Entity name

Transporter Data
Mailing address (street or P.O. box)

City or town

State

Contact name (first and last)

Title

Phone number

Email address

EPA Form 3510-2A (Revised )

ZIP code

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NPDES Permit Number
Facility Name

EPA Identification Number

In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Mailing address (street or P.O. box)
City or town

State

Contact name (first and last)

Title

Phone number

Email address

NPDES number of receiving facility (if any)
1.21

Average daily flow rate



No  SKIP to Item 1.23.

Yes

Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal
Annual Average
Location of
Size of
Method
Daily Discharge
Disposal Site
Disposal Site
Description
Volume

Variance
Requests

Continuous or Intermittent
(check one)

 Continuous
 Intermittent
 Continuous
acres
gpd
 Intermittent
 Continuous
acres
gpd
 Intermittent
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)? (Check all that apply.
Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
into marine waters (CWA
quality related effluent limitation (CWA Section
 Discharges
 Water
Section 301(h))
302(b)(2))
acres

1.23

mgd

Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do not
have outlets to waters of the United States (e.g., underground percolation, underground injection)?


1.22

 None

ZIP code

Outfalls and Other Discharge or Disposal Methods Continued

1.20

Form Approved
OMB No.
Form Expires

Not applicable



gpd

1.24

Contractor Information

1.25

Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works
the responsibility of a contractor?
 Yes
 No SKIP to Section 2.
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Mailing address
(street or P.O. box)
City, state, and ZIP
code
Contact name (first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor

EPA Form 3510-2A (Revised )

Page 4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires


2.2

No  SKIP to Section 3.

Provide the treatment works’ current average daily volume of inflow
and infiltration.

Average Daily Volume of Inflow and Infiltration

gpd

Indicate the steps the facility is taking to minimize inflow and infiltration.

Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)


2.4



Yes

2.3

Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for specific requirements.)


2.5



Yes

Are improvements to the facility scheduled?



Yes



No  SKIP to Section 3.

Briefly list and describe the scheduled improvements.
1.
2.

3.
4.

2.6

Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Affected
Scheduled
Begin
End
Begin
Outfalls
Improvement
Construction
Construction
Discharge
(list outfall
(from above)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
number)

Scheduled Improvements and Schedules of Implementation



Yes

Flow
Topographic
Inflow and Infiltration Design Flow
Diagram
Map

SECTION 2. ADDITIONAL INFORMATION (40 CFR 122.21(j)(1) and (2))
Outfalls to Waters of the United States
2.1
Does the treatment works have a design flow greater than or equal to 0.1 mgd?

Attainment of
Operational
Level
(MM/DD/YYYY)

1.
2.
3.
4.

2.7

Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.



Yes



None required or applicable

Explanation:

EPA Form 3510-2A (Revised )

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 3. INFORMATION ON EFFLUENT DISCHARGES (40 CFR 122.21(j)(3) to (5))
3.1
Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number ______

Outfall Number _____

Outfall Number ______

Description of Outfalls

State
County
City or town
Distance from shore

ft.

Depth below surface

ft.

mgd

Average daily flow rate

Latitude

Do any of the outfalls described under Item 3.1 have seasonal or periodic discharges?


3.3



Outfall Number _____

Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
mgd
discharge
Months in which discharge
occurs
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?



3.5

No  SKIP to Item 3.4.

If so, provide the following information for each applicable outfall.
Outfall Number _____

3.4

Yes



Outfall Number _____

mgd

No  SKIP to Item 3.6.

Briefly describe the diffuser type at each applicable outfall.
Outfall Number _____

Outfall Number _____

Waters of
the U.S.

Diffuser Type

Yes

3.2

Seasonal or Periodic Discharge Data

Longitude

3.6

Does the treatment works discharge or plan to discharge wastewater to waters of the United States from one or more
discharge points?



Yes

EPA Form 3510-2A (Revised )



No  SKIP to Section 6.

Page 6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

3.7

Form Approved
OMB No.
Form Expires

Provide the receiving water and related information (if known) for each outfall.
Outfall Number _____

Outfall Number _____

Receiving water name

Receiving Water Description

Name of watershed, river,
or stream system
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
Critical low flow (chronic)

cfs

mg/L of
Total hardness at critical
mg/L of
CaCO3
CaCO3
low flow
Provide the following information describing the treatment provided for discharges from each outfall.
Highest Level of
Treatment (check all that
apply per outfall)

mg/L of
CaCO3

Outfall Number _____

 Primary
 Equivalent to
secondary
 Secondary
 Advanced
 Other (specify)
__________________

 Primary
 Equivalent to
secondary
 Secondary
 Advanced
 Other (specify)
___________________

 Primary
 Equivalent to
secondary
 Secondary
 Advanced
 Other (specify)
_________________

Design Removal Rates by
Outfall
BOD5 or CBOD5

TSS

Treatment Description

cfs

3.8

cfs

Phosphorus
Nitrogen

Other (specify)

______________________

EPA Form 3510-2A (Revised )

 Not applicable

 Not applicable
%

 Not applicable

 Not applicable
%

 Not applicable

 Not applicable
%

%
%
 Not applicable

Page 7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Treatment Description Continued

3.9

Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.

Outfall Number _____

Disinfection type
Seasons used
Dechlorination used?

3.12

Not applicable
Yes





Not applicable
Yes

No
No
No
Have you completed monitoring for all Table A parameters and attached the results to the application package?
 Yes
 No
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility’s
discharges or on any receiving water near the discharge points?
 Yes
 No  SKIP to Item 3.13.
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility’s
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number _____
Outfall Number ______
Outfall Number _____
Acute

Chronic

Acute

Chronic

Acute

Chronic

Number of tests of discharge
water
Number of tests of receiving
water
Does the treatment works have a design flow greater than or equal to 0.1 mgd?
 Yes
 No  SKIP to Item 3.16.
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
 Yes  Complete Table B, including chlorine.
 No  Complete Table B, omitting chlorine.

3.13





3.11





3.10

3.14

3.15

Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
 Yes
 No

Effluent Testing Data

Form Approved
OMB No.
Form Expires

3.16

3.17

3.18

Does one or more of the following conditions apply?
 The facility has a design flow greater than or equal to 1 mgd.
 The POTW has an approved pretreatment program or is required to develop such a program.
 The NPDES permitting authority has informed the POTW that it must sample for the parameters in Table C, must
sample other additional parameters (Table D), or submit the results of WET tests for acute or chronic toxicity for
each of its discharge outfalls (Table E).
Tables C, D, and E as
 Yes  Complete
 No  SKIP to Section 4.
applicable.
Have you completed monitoring for all applicable Table C pollutants and attached the results to this application
package?
 Yes
 No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
attached the results to this application package?
additional sampling required by NPDES
 Yes
 No
permitting authority.

EPA Form 3510-2A (Revised )

Page 8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

3.19

3.20
3.21

Form Approved
OMB No.
Form Expires

Has the POTW conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
or (2) at least four annual WET tests in the past 4.5 years?
tests and Table E and SKIP to
 Yes
 No  Complete
Item 3.26.
Have you previously submitted the results of the above tests to your NPDES permitting authority?
Provide results in Table E and SKIP to
 Yes
 No  Item
3.26.
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
Summary of Results

3.23

3.24
3.25

Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
 Yes
 No  SKIP to Item 3.26.
Describe the cause(s) of the toxicity:

3.22

Effluent Testing Data Continued

(MM/DD/YYYY)

Has the treatment works conducted a toxicity reduction evaluation?
 Yes

Provide details of any toxicity reduction evaluations conducted.

Have you completed Table E for all applicable outfalls and attached the results to the application package?
applicable because previously submitted
 Yes
 Not
information to the NPDES permitting authority.
SECTION 4. INDUSTRIAL DISCHARGES AND HAZARDOUS WASTES (40 CFR 122.21(j)(6) and (7))
4.1
Does the POTW receive discharges from SIUs or NSCIUs?
 Yes
 No  SKIP to Item 4.7.
4.2
Indicate the number of SIUs and NSCIUs that discharge to the POTW.
Number of SIUs
Number of NSCIUs
Industrial Discharges and Hazardous Wastes

3.26

No  SKIP to Item 3.26.

4.3

Does the POTW have an approved pretreatment program?



4.4

Yes



Have you submitted either of the following to the NPDES permitting authority that contains information substantially
identical to that required in Table F: (1) a pretreatment program annual report submitted within one year of the
application or (2) a pretreatment program?



Yes



No  SKIP to Item 4.6.

4.5

Identify the title and date of the annual report or pretreatment program referenced in Item 4.4. SKIP to Item 4.7.

4.6

Have you completed and attached Table F to this application package?



Yes

EPA Form 3510-2A (Revised )



Page 9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Does the POTW receive, or has it been notified that it will receive, by truck, rail, or dedicated pipe, any wastes that are
regulated as RCRA hazardous wastes pursuant to 40 CFR 261?


4.8



Yes

If yes, provide the following information:

Truck
Dedicated pipe




Rail




Truck
Dedicated pipe




Rail
Other (specify)
________________
________________




Truck
Dedicated pipe

Other (specify)
________________
________________




Yes



No  SKIP to Section 5.

Does the POTW receive (or expect to receive) less than 15 kilograms per month of non-acute hazardous wastes as
specified in 40 CFR 261.30(d) and 261.33(e)?



Yes  SKIP to Section 5.



Have you reported the following information in an attachment to this application: identification and description of the
site(s) or facility(ies) at which the wastewater originates; the identities of the wastewater’s hazardous constituents; and
the extent of treatment, if any, the wastewater receives or will receive before entering the POTW?

4.11




Units

Rail
Other (specify)
________________
________________
Does the POTW receive, or has it been notified that it will receive, wastewaters that originate from remedial activities,
including those undertaken pursuant to CERCLA and Sections 3004(7) or 3008(h) of RCRA?


4.10

Annual
Amount of
Waste
Received

Waste Transport Method
(check all that apply)

Industrial Discharges and Hazardous Wastes Continued

Hazardous Waste
Number

4.9

No  SKIP to Item 4.9.

4.7

Form Approved
OMB No.
Form Expires



Yes



No  SKIP to Section 6.



Yes

CSO Map and Diagram

SECTION 5. COMBINED SEWER OVERFLOWS (40 CFR 122.21(j)(8))
Does the treatment works have a combined sewer system?
5.1
5.2

Have you attached a CSO system map to this application? (See instructions for map requirements.)



5.3

Yes



Have you attached a CSO system diagram to this application? (See instructions for diagram requirements.)



Yes

EPA Form 3510-2A (Revised )



Page 10

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

5.4

For each CSO outfall, provide the following information. (Attach additional sheets as necessary.)
CSO Outfall Number ____

CSO Outfall Number _____

Distance from shore

ft.

Depth below surface

ft.

CSO Outfall Description

City or town
State and ZIP code
County
Latitude
Longitude

CSO Outfall Number ____

CSO Outfall Number _____

Rainfall

 Yes  No

CSO flow volume

 Yes  No

CSO pollutant
concentrations

 Yes  No

Receiving water quality

 Yes  No

CSO frequency

 Yes  No

Number of storm events

 Yes  No

CSO Outfall Number ____

events

hours

Provide the following information for each of your CSO outfalls.

5.6

Did the POTW monitor any of the following items in the past year for its CSO outfalls?

CSO Monitoring

5.5

Number of CSO events in
the past year
Average duration per
event

CSO Events in Past Year

Form Approved
OMB No.
Form Expires

Average volume per event
Minimum rainfall causing
a CSO event in last year

EPA Form 3510-2A (Revised )

 Actual or  Estimated
million gallons
 Actual or  Estimated
inches of rainfall
 Actual or  Estimated

Page 11

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

5.7

Form Approved
OMB No.
Form Expires

Provide the information in the table below for each of your CSO outfalls.
CSO Outfall Number ____

CSO Outfall Number ____

Receiving water name

AF









w/ Table A
w/ Table B



Section 3: Information on
Effluent Discharges



Section 4: Industrial
Discharges and Hazardous
Wastes



Section 5: Combined Sewer
Overflows

Checklist and Certification Statement

CSO Receiving Waters

Name of watershed/
stream system
U.S. Soil Conservation
 Unknown
 Unknown
 Unknown
Service 14-digit
watershed code
(if known)
Name of state
management/river basin
U.S. Geological Survey
 Unknown
 Unknown
 Unknown
8-Digit Hydrologic Unit
Code (if known)
Description of known
water quality impacts on
receiving stream by CSO
(see instructions for
examples)
SECTION 6. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
Section 1: Basic Application
 Information for All Applicants  w/ variance request(s)
 w/ additional attachments
 w/ topographic map
 w/ process flow diagram
2: Additional
 Section
Information
 w/ additional attachments

Section 6: Checklist and
Certification Statement
Certification Statement



6.2

w/ Table C
w/ SIU and NSCIU attachments






w/ Table D



w/ additional attachments

w/ Table E
w/ additional attachments
w/ Table F

w/ additional attachments
w/ CSO map
w/ CSO system diagram
w/ attachments

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.
Name (print or type first and last name)
Official title
Signature

EPA Form 3510-2A (Revised )

Date signed

Page 12

EPA Identification Number

NPDES Permit Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

TABLE A. EFFLUENT PARAMETERS FOR ALL POTWS
Maximum Daily Discharge
Pollutant
Value
Units

Outfall Number

Average Daily Discharge
Value

Units

Number of
Samples

Form Approved
OMB No.
Form Expires

Analytical
Method1

ML or MDL
(include units)

Biochemical oxygen demand

 BOD5 or  CBOD5

 ML
 MDL

Fecal coliform

 ML
 MDL

(report one)

Design flow rate
pH (minimum)

pH (maximum)
Temperature (winter)
Temperature (summer)
Total suspended solids (TSS)

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

EPA Form 3510-2A (Revised )

Page 13

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Identification Number

NPDES Permit Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number

TABLE B. EFFLUENT PARAMETERS FOR ALL POTWS WITH A FLOW EQUAL TO OR GREATER THAN 0.1 MGD
Maximum Daily Discharge
Average Daily Discharge
Pollutant
Value
Units
Value
Units

Number of
Samples

Form Approved
OMB No.
Form Expires

Analytical
Method1

ML or MDL
(include units)
 ML
 MDL

Chlorine
(total residual, TRC)2

 ML
 MDL

Dissolved oxygen

 ML
 MDL

Ammonia (as N)

Nitrate/nitrite

Kjeldahl nitrogen
Oil and grease
Phosphorus
Total dissolved solids

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
2 Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are not
required to report data for chlorine.

EPA Form 3510-2A (Revised )

Page 15

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant

Value

Units

Average Daily Discharge
Value

Units

Number of
Samples

Analytical
Method1

ML or MDL
(include units)

Metals, Cyanide, and Total Phenols

Hardness (as CaCO3)
Antimony, total recoverable
Arsenic, total recoverable
Beryllium, total recoverable

Cadmium, total recoverable
Chromium, total recoverable
Copper, total recoverable
Lead, total recoverable
Mercury, total recoverable
Nickel, total recoverable

Silver, total recoverable
Thallium, total recoverable
Zinc, total recoverable
Cyanide

Total phenolic compounds

Selenium, total recoverable

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

Volatile Organic Compounds
Acrolein

Acrylonitrile
Benzene

Bromoform
EPA Form 3510-2A (Revised )

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
Page 17

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant

Value

Units

Average Daily Discharge
Value

Units

Number of
Samples

Carbon tetrachloride
Chlorobenzene

Chlorodibromomethane
Chloroethane
2-chloroethylvinyl ether

Chloroform
Dichlorobromomethane
1,1-dichloroethane
1,2-dichloroethane
trans-1,2-dichloroethylene
1,1-dichloroethylene

1,3-dichloropropylene
Ethylbenzene
Methyl bromide
Methyl chloride

Methylene chloride

1,2-dichloropropane

1,1,2,2-tetrachloroethane
Tetrachloroethylene
Toluene

1,1,1-trichloroethane
1,1,2-trichloroethane

EPA Form 3510-2A (Revised )

Analytical
Method1

ML or MDL
(include units)
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

Page 18

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant

Value

Units

Average Daily Discharge
Value

Units

Number of
Samples

Vinyl chloride
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

Base-Neutral Compounds

Acenaphthene

Pentachlorophenol

2,4,6-trichlorophenol

Acenaphthylene
Anthracene
Benzidine

ML or MDL
(include units)
 ML
 MDL
 ML
 MDL

Trichloroethylene

Phenol

Analytical
Method1

Benzo(a)anthracene
Benzo(a)pyrene

3,4-benzofluoranthene
EPA Form 3510-2A (Revised )

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
Page 19

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant

Value

Units

Average Daily Discharge
Value

Units

Number of
Samples

Benzo(ghi)perylene
Benzo(k)fluoranthene

Bis (2-chloroethoxy) methane
Bis (2-chloroethyl) ether
Bis (2-chloroisopropyl) ether

Bis (2-ethylhexyl) phthalate
4-bromophenyl phenyl ether
Butyl benzyl phthalate
2-chloronaphthalene
4-chlorophenyl phenyl ether
Chrysene

di-n-octyl phthalate
Dibenzo(a,h)anthracene
1,2-dichlorobenzene
1,3-dichlorobenzene

1,4-dichlorobenzene

di-n-butyl phthalate

3,3-dichlorobenzidine
Diethyl phthalate

Dimethyl phthalate
2,4-dinitrotoluene
2,6-dinitrotoluene

EPA Form 3510-2A (Revised )

Analytical
Method1

Page 20

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Contains Nonbinding Recommendations
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Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWS
Maximum Daily Discharge
Pollutant

Value

Units

Average Daily Discharge
Value

Units

Number of
Samples

Analytical
Method1

ML or MDL
(include units)

1,2-diphenylhydrazine
Fluoranthene

Fluorene
Hexachlorobenzene
Hexachlorobutadiene

Hexachlorocyclo-pentadiene
Hexachloroethane
Indeno(1,2,3-cd)pyrene
Isophorone
Naphthalene
Nitrobenzene

N-nitrosodimethylamine
N-nitrosodiphenylamine
Phenanthrene
Pyrene

1,2,4-trichlorobenzene

N-nitrosodi-n-propylamine

 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL
 ML
 MDL

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
1

EPA Form 3510-2A (Revised )

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EPA Identification Number

NPDES Permit Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number

TABLE D. ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING AUTHORITY
Maximum Daily Discharge
Average Daily Discharge
Pollutant
(list)
Value
Units
Value
Units

Number of
Samples

Form Approved
OMB No.
Form Expires

Analytical
Method1

ML or MDL
(include units)

 No additional sampling is required by NPDES permitting authority.

1 Sampling

shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required
under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2A (Revised )

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EPA Identification Number

NPDES Permit Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.
Test Information
Test Number _____

 Grab
 24-hour composite

 Before Disinfection
 After Disinfection
 After Dechlorination

 Before disinfection
 After disinfection
 After dechlorination

 Acute
 Chronic
 Both

Sample Location
Check one:

Test species
Age at initiation of test
Outfall number
Date sample collected
Date test started
Duration
Toxicity Test Methods
Test method number
Manual title
Edition number and year of publication
Page number(s)
Sample Type
Check one:

Test Number _____

Point in Treatment Process
Describe the point in the treatment process
at which the sample was collected for each
test.

Toxicity Type
Indicate for each test whether the test was
performed to asses acute or chronic toxicity,
or both. (Check one response.)

EPA Form 3510-2A (Revised )

 Acute
 Chronic
 Both

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Contains Nonbinding Recommendations
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Facility Name

NPDES Permit Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.
Test Number _____

Source of Dilution Water
Indicate the source of dilution water. (Check
one response.)

If laboratory water, specify type.
If receiving water, specify source.
Type of Dilution Water
Indicate the type of dilution water. If salt
water, specify “natural” or type of artificial
sea salts or brine used.

Acute Test Results
Percent survival in 100% effluent
LC50
95% confidence interval
Control percent survival

EPA Form 3510-2A (Revised )

 Static
 Static-renewal
 Flow-through

 Laboratory water
 Receiving water

 Fresh water
 Salt water (specify)

 pH
 Salinity
 Temperature

Parameters Tested
Check the parameters tested.

 Laboratory water
 Receiving water

Percentage Effluent Used
Specify the percentage effluent used for all
concentrations in the test series.

 Static
 Static-renewal
 Flow-through

response.)

Test Number _____

Test Type
Indicate the type of test performed. (Check one

Test Number _____

 Ammonia
 Dissolved oxygen

 pH
 Salinity
 Temperature

 Fresh water
 Salt water (specify)

 Ammonia
 pH
 Dissolved oxygen  Salinity
 Temperature

 Ammonia
 Dissolved oxygen

%
%

Page 26

EPA Identification Number

NPDES Permit Number

Contains Nonbinding Recommendations
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Facility Name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE E. EFFLUENT MONITORING FOR WHOLE EFFLUENT TOXICITY
The table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.
Test Number _____

Test Number _____

Chronic Test Results
NOEC
IC25
Control percent survival
Other (describe)

Quality Control/Quality Assurance
Is reference toxicant data available?

 Yes
 Yes

 No
 No

 Yes
 Yes

 No
 No

%
%
%

 Yes
 Yes

 No
 No

Was reference toxicant test within
acceptable bounds?
What date was reference toxicant test run
(MM/DD/YYYY)?
Other (describe)

%
%
%

Acute Test Results Continued
Other (describe)

EPA Form 3510-2A (Revised )

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Contains Nonbinding Recommendations
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NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE F. INDUSTRIAL DISCHARGE INFORMATION
Response space is provided for three SIUs. Copy the table to report information for additional SIUs.
SIU ____

SIU ____

Name of SIU
Mailing address (street or P.O. box)

City, state, and ZIP code

List the principal products and raw materials that
affect or contribute to the SIU’s discharge.

Indicate the average daily volume of wastewater
discharged by the SIU.

How much of the average daily volume is
attributable to process flow?

Description of all industrial processes that affect
or contribute to the discharge.

How much of the average daily volume is
attributable to non-process flow?

 Yes

Is the SIU subject to local limits?

Is the SIU subject to categorical standards?

EPA Form 3510-2A (Revised )

 Yes

gpd

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

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NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE F. INDUSTRIAL DISCHARGE INFORMATION
Response space is provided for three SIUs. Copy the table to report information for additional SIUs.
SIU ____

SIU ____

 No

 Yes

 No

 Yes

 No

Has the POTW experienced problems (e.g.,
upsets, pass-through interferences) in the past 4.5
years that are attributable to the SIU?
If yes, describe.

Under what categories and subcategories is the
SIU subject?

EPA Form 3510-2A (Revised )

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United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2B
Revised

Water Permits Division

Application Form 2B

Concentrated Animal Feeding
Operations and Concentrated
Aquatic Animal Production
Facilities

NPDES Permitting Program

Note: Complete this form and Form 1 if your facility is a new or existing concentrated animal feeding
operation or concentrated aquatic animal production facility.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency (EPA) estimates the average burden for concentrated animal
feeding operation respondents to collect information and complete Form 2B to be 9.5 hours (9 hours to
complete and submit the application and 0.5 hours to complete and submit a nutrient management plan).
EPA estimates the average burden for concentrated aquatic animal production respondents to collect
information and complete Form 2B to be 6 hours. These estimates include time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing
and reviewing the collection of information. Send comments about the burden estimates or any other
aspect of this collection of information to the Chief, Information Policy Branch (PM-223), U.S.
Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the
Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW,
Washington, DC 20503, marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2B—INSTRUCTIONS
General Instructions
Who Must Complete Form 2B?
You must complete Form 2B if you answered “Yes” to Item 1.2.1 on
Form 1—that is, if you are a concentrated animal feeding operation
(CAFO) or a concentrated aquatic animal production (CAAP)
facility.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2B) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1–1 of Form 1’s “General
Instructions” to identify your NPDES permitting authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2B (or related attachments) as
confidential.

Definitions
The legal definitions of all key terms used in these instructions and
Form 2B are in the “Glossary” at the end of the “General
Instructions” in Form 1.
Line-by-Line Instructions
Section 1. General Information
Item 1.1. Mark whether your facility/business type is a CAFO or a
CAAP.


For a CAFO, you must complete Sections 1 through 6 and
Section 8.



For a CAAP, you must complete Sections 1, 7, and 8.

Section 2. CAFO Owner/Operator Contact Information
Item 2.1. Provide the name, title, telephone number, and email
address of the owner/operator of the facility/business.

You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2B. Note that NPDES authorities will deny claims for treating any
effluent data as confidential. If you do not assert a claim of
confidentiality at the time you submit your information to the
NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will handle
claims of confidentiality in accordance with the Agency’s business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).

Item 1.2. Indicate whether your facility is an existing or proposed
facility. Mark “Proposed Facility” if your facility is presently not in
operation or is expanding to meet the definition of a CAFO in
accordance with the regulations at 40 CFR 122.23.

Item 2.2. Provide the complete mailing address of the
owner/operator of the facility/business.
Section 3. CAFO Location and Contact Information
Item 3.1. Provide the legal name and location (complete mailing
address) of the facility. Also indicate whom the NPDES permitting
authority should contact about the application, including a
telephone number and email address.

Item 3.2. Provide the latitude and longitude of the entrance to the
production area (i.e., the part of the operation that includes the
animal confinement area, the manure storage area, the raw
materials storage area, and the waste containment areas). Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS). For
further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.

Completion of Forms
Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.

Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 2B and any attachments. If your facility is new
(i.e., not yet constructed), write or type “New Facility” in the space
provided for the EPA Identification Number and NPDES permit
number. If you do not know your EPA Identification Number,
contact your NPDES permitting authority. See Exhibit 1–1 of the
“General Instructions” of Form 1 for contact information.

Item 3.3. If the facility uses a contract grower, provide the name
and complete mailing address of the integrator.

Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter “NA” for “not applicable” to
show that you considered the item and determined a response was
not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.

Section 4. CAFO Topographic Map
Item 4.1. Provide a topographic map of the geographic area in
which the facility is located, showing the specific location of the
production area(s). You are not required to provide the topographic
map required by Section 7 of Form 1.
On each map, include the map scale, a meridian arrow showing
north, and latitude and longitude to the nearest second. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),

2B-1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2B—INSTRUCTIONS CONTINUED
geographic information systems (e.g., ArcView), or paper maps
Item 6.3. Indicate if a nutrient management plan is being
from trusted sources (e.g., USGS).
implemented at the CAFO. If not land applying, describe the
alternative uses of the manure, litter, and wastewater (e.g.,
On all maps of rivers, show the direction of the current. In tidal
composting, pelletizing, energy generation).
waters, show the directions of ebb and flow tides.

Item 5.1. Provide the maximum number of each type of animal in
open confinement or housed under roof (either partially or totally)
that are held at your facility for a total of 45 days or more in any 12month period. Provide the total number of animals confined at the
facility.

Note: A permit application is not complete until a nutrient
management plan is submitted to the NPDES permitting authority.
Section 7. CAAP Facility Characteristics
Item 7.1. Indicate if the CAAP facility is located on land. If the
facility is located in water (e.g., a net pen or submerged cage
system), check “No” and skip to Item 7.3. If yes, continue to Item
7.2.
Item 7.2. Provide the maximum daily and maximum average
monthly discharge at the CAAP facility by outfall number. Outfall
numbers should correspond with the outfall numbers provided on
the map submitted in Section 7 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 average monthly flow is the average of
measured daily flow over the calendar month of highest flow.

Item 5.2. Identify the applicable types of containment and storage
for manure, litter, and process wastewater at the facility and
indicate the capacity of storage in days and gallons or tons.

Item 6.4. Indicate the date of the last review or revision of the
nutrient management plan.

You may develop your map by going to the United States USGS’s
National Map website at http://nationalmap.gov/. (For a map from
this site, use the traditional 7.5-minute quadrangle format. If none is
available, use a USGS 15-minute series map.) You may also use a
plat or other appropriate map. Briefly describe land uses in the map
area (e.g., residential, commercial.). Note that you have completed
your topographic map and attached it to the application.
Section 5. CAFO Characteristics
Supply all information in Section 5 if you checked “Existing facility”
in response to Item 1.2.

Item 7.3. Indicate the number of ponds, raceways, net pens,
submerged cages, or similar structures at your facility that result in
discharges to waters of the United States. Describe each type and
provide the name of the associated receiving water and intake
water source.

Item 5.3. Indicate the total number of acres that are drained and
collected in the containment and storage structure(s).

Item 5.4. Specify the tons of manure or litter and the gallons of
process wastewater generated at the facility on an annual basis.

Item 5.5. Indicate whether the manure, litter, and/or process
wastewater is land applied. If yes, continue to Item 5.6. If no, skip to
Item 5.8.
Item 5.6. Indicate the number of acres of land under the control of
the applicant that are available for land application of the manure,
litter, or process wastewater.

For each species, provide the total harvestable weight in pounds
(lbs.) for a typical calendar year. Also indicate the maximum weight
present at any one time at your facility.

Item 5.7. Check any of the identified best management practices
that are being implemented at the facility to control runoff and
protect water quality.

Item 5.8. Indicate if the manure, litter, and/or process wastewater is
transferred to any other persons. If yes, continue to Item 5.9. If no,
skip to Item 5.10.
Item 5.9. Specify the tons of manure or litter or the gallons of
process wastewater transferred annually to other people.
Item 5.10. Describe any alternative uses of manure, litter, or
process wastewater, if any (e.g., composting, pelletizing, energy
generation).
Section 6. CAFO Nutrient Management Plans
Item 6.1. Indicate if you have submitted a nutrient management
plan that satisfies the requirements at 40 CFR 122.42(e) and, if
applicable, the requirements at 40 CFR 412.4(c).

Item 7.4. List the species of fish or aquatic animals held and fed at
your facility. Distinguish between cold-water and warm-water
species. The names of fish species should be proper, common, or
scientific names as given in Special Publication 34 of the American
Fisheries Society, Common and Scientific Names of Fishes from
the United States, Canada, and Mexico.

Item 7.5. Indicate the maximum monthly pounds of food given at
your facility. Also indicate the month given. The amounts should be
representative of your normal operations.
Section 8. Checklist and Certification Statement
Item 8.1. Review the checklist provided. In Column 1, mark the
sections of Form 2B that you have completed and are submitting
with your application. For each section in Column 2, indicate
whether you are submitting attachments.
Item 8.2. The Clean Water Act provides for severe penalties for
submitting false information on this application form. CWA Section
309(c)(2) 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.”

Item 6.2. If you have not yet submitted a nutrient management
plan, explain why not.
2B-2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2B—INSTRUCTIONS CONTINUED
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:

For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) 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 (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END

Submit your completed Form 1, Form 2B, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

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EPA Identification Number

NPDES Permit Number

Form Approved
OMB No.
Form Expires

Facility Name

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2B
NPDES

General
Information

CONCENTRATED ANIMAL FEEDING OPERATIONS and
CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITIES
SECTION 1. GENERAL INFORMATION (40 CFR 122.21(I)(1))
1.1
Indicate the facility/business type. (Check only one response.)
 CAFO  Complete Sections 1 through 6 and Section 8.


1.2

CAAP  Complete Sections 1, 7, and 8.

Indicate the operational status of the facility. (Check one.)



Existing facility

Proposed facility

2.2

Phone number

Email address

CAFO Owner/Operator
Contact Information

SECTION 2. CAFO OWNER/OPERATOR CONTACT INFORMATION (40 CFR 122.21(f)(2) and (4) and 122.21(i)(1)(i))
Owner/Operator Contact
2.1
Name (first and last)
Title

Owner/Operator Mailing Address
Street or P.O. box
City or town

State

Zip code

Address (street, route number, or other specific identifier)

City or town

CAFO Location and Contact Information

SECTION 3. CAFO LOCATION AND CONTACT INFORMATION (40 CFR 122.21(i)(1)(ii and iii))
3.1
CAFO Location and Contact
Name

Facility contact name

3.2

County

State

Zip code

Phone number

Email address

Latitude/Longitude of Entrance to Production Area (see instructions)
Latitude

EPA Form 3510-2B (revised )

Longitude

Page 1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

NPDES Permit Number

CAFO Location and Contact
Information Continued

EPA Identification Number

3.3

Facility Name

Form Approved
OMB No.
Form Expires

Integrator Name and Address
Name
Street address
City or town

State

Zip code



Yes  SKIP to Section 5.

CAFO
Topographic
Map

SECTION 4. CAFO TOPOGRAPHIC MAP (40 CFR 122.21(i)(1)(iv))
Have you attached a topographic map containing all required information to this application? (See instructions for
4.1
specific requirements.)



SECTION 5. CAFO CHARACTERISTICS (40 CFR 122.21(i)(1)(v-ix))
5.1
Provide information on the type and number of animals in the table below.
Number in Open
Confinement

Number
Housed
Under Roof

Mature dairy
cows

5.2

Dairy heifers
Veal calves

Cattle (not dairy
or veal calves)
Swine
(55 lbs. or more)
Swine
(under 55 lbs.)
Horses

Turkeys

Number in Open
Confinement

Number
Housed
Under Roof

Sheep or
lambs
Chickens
(broilers)
Chickens
(layers)
Ducks

Other
(specify)
Other
(specify)
Other
(specify)

Total Animals

Indicate the type of containment and storage, total number of days, and total capacity for manure, litter, and
process wastewater storage in the table below.
Type of Containment
and Storage

5.3

Animal Type


















CAFO Characteristics

Animal Type

Total Number of
Days

Total
Capacity
(specify gallons
or tons)

Type of
Containment and
Storage



Anaerobic lagoon



Belowground
storage tanks



Evaporation



Roofed
storage shed



Aboveground
storage tanks



Concrete pad



Storage pond



Impervious
soil pad



Underfloor pit



Other
(specify)

Total Number of
Days

Total
Capacity
(specify gallons
or tons)

Indicate the total number of acres drained and collected in the containment and storage structure(s) reported under
Item 5.2.
____________ acres

EPA Form 3510-2B (revised )

Page 2

Contains Nonbinding Recommendations
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NPDES Permit Number

EPA Identification Number

Facility Name

Form Approved
OMB No.
Form Expires

Manure, Litter, and/or Process Wastewater Production and Use
5.4
How many tons of manure or litter and gallons of process wastewater are generated annually at the CAFO?
Manure

tons

Litter

tons

Process wastewater
Is manure, litter, and/or process wastewater generated at the CAFO land applied?



5.7

Setbacks





Grass filter

Conservation tillage

Constructed wetlands

Terrace

Other (specify)

Is manure, litter, and/or process wastewater transferred to any other persons?



Yes



No  SKIP to Item 5.10.

How many tons of manure or litter and gallons of process wastewater, produced by the CAFO, are transferred
annually to other people?
Manure

tons

Litter

tons

5.9

No  SKIP to Item 5.8.

How many acres of land under the control of the applicant are available for applying the CAFO’s manure, litter,
or process wastewater?
______________ acres
Check all land application best management practices that are being implemented.
 Buffers
 Infiltration field




5.8



CAFO Characteristics Continued

5.6

Yes

5.5

gallons

Process wastewater

Describe alternative use(s) of manure, litter, or process wastewater, if any.

5.10

gallons

CAFO Nutrient Management Plans

SECTION 6. CAFO NUTRIENT MANAGEMENT PLANS (40 CFR 122.21(i)(1)(x))
6.1
Has the applicant attached a nutrient management plan that satisfies the requirements at 40 CFR 122.42(e)
and, if applicable, the requirements at 40 CFR 412.4(c)? Note: A permit application is not complete until a
nutrient management plan is submitted to the NPDES permitting authority.
 Yes  SKIP to Item 6.3.
 No
6.2

Explain why a nutrient management plan is not attached to the application.

6.3

Is a nutrient management plan being implemented at the CAFO?
 Yes
 No

6.4

What was the date of the last review
or revision of the nutrient
management plan?

EPA Form 3510-2B (revised )

Date _________________________________

Page 3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

NPDES Permit Number

EPA Identification Number

Facility Name

SECTION 7. CAAP FACILITY CHARACTERISTICS (40 CFR 122.21(i)(2))
7.1
Is the CAAP facility located on land?
 Yes

Provide the maximum daily and maximum average monthly discharge at CAAP by outfall.
Discharge

Outfall
Number

7.3

No  SKIP to Item 7.3.

Maximum Daily Discharge

Maximum Average Monthly Discharge

gpd

7.2



Form Approved
OMB No.
Form Expires

Indicate the type and number of discharge structures at the CAAP. Provide a brief description of each structure.
Also note the name of the receiving water and the source of the intake water for each structure.
Number of Each

Receiving Water
Name

Description

Source of Intake
Water

Structure
Type

Raceways
Net pens

Not applicable

Submerged
cages
Similar
structures

Not applicable

(specify)
_____________

CAAP Facility Characteristics

Ponds

7.4

List the cold-water and/or warm-water aquatic species raised/produced in the table below. For each species
listed, indicate the total yearly and maximum harvestable weight (in pounds).

Species

Cold Water Species
Harvestable Weight
Total Yearly
Maximum

7.5

Species

Warm Water Species
Harvestable Weight
Total Yearly
Maximum

lbs.

Indicate the calendar month of maximum feeding and the total mass of food fed (in pounds) during that month.
Month of Maximum Feeding

Total Mass of Food Fed

lbs.

EPA Form 3510-2B (revised )

Page 4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

NPDES Permit Number

EPA Identification Number

Facility Name

Form Approved
OMB No.
Form Expires

Section 1: General Information



w/ attachments



Section 2: CAFO Owner/Operator Contact Information



w/ attachments



Section 3: CAFO Location and Contact Information

w/ attachments



Section 4: CAFO Topographic Map



Section 5: CAFO Characteristics



Section 6: CAFO Nutrient Management Plans



Section 7: CAAP Facility Characteristics











Section 8: Checklist and Certification Statement



w/ attachments

w/ topographic map
w/ additional attachments
w/ attachments

w/ nutrient management plan
w/ attachments

8.2



w/ attachments

Certification Statement

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.
Name (print or type first and last name)
Official title

Checklist and Certification Statement

SECTION 8. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
8.1
In Column 1, below, mark the sections of Form 2B that you have completed and are submitting with your
application. For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting
authority. Note that not all applicants are required to provide attachments.
Column 1
Column 2

Date signed

Signature

EPA Form 3510-2B (revised )

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2C
Revised

Water Permits Division

Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Silvicultural Operations

NPDES Permitting Program

Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect information and
complete Form 2C to be 33 hours. 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 about the burden estimate or any other aspect of this
collection of information to the Chief, Information Policy Branch (PM-223), U.S. Environmental
Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW,
Washington, DC 20503, marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2C—INSTRUCTIONS
Who Must Complete Form 2C?
You must complete Form 2C if you answered “Yes” to Item 1.2.2 on
Form 1—that is, if you are an existing manufacturing, commercial,
mining, or silvicultural facility that currently discharges process
wastewater.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2C) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1–1 of Form 1’s “General
Instructions” to identify your NPDES permitting authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2C (or related attachments) as
confidential.

Completion of Forms

Line-by-Line Instructions
Section 1. Outfall Location
Item 1.1. Identify each of the facility’s outfall structures by number.
For each outfall, specify the latitude and longitude to the nearest
15 seconds and name of the receiving water. The application form
provides reporting space for three outfalls. If your facility has more
than this number, attach additional sheets as necessary. The
location of each outfall (i.e., where the coordinates are collected)
shall be the point where the discharge is released into a water of
the United States. Latitude and longitude coordinates may be
obtained in a variety of ways, including use of hand held devices
(e.g., a GPS enabled smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS).For
further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.

You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2C. Note that NPDES authorities will deny claims for treating any
effluent data as confidential. If you do not assert a claim of
confidentiality at the time you submit your information to the
NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will handle
claims of confidentiality in accordance with the Agency’s business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).

Definitions
The legal definitions of all key terms used in these instructions and
Form 2C are in the “Glossary” at the end of the “General
Instructions” in Form 1.

General Instructions

Section 2. Line Drawing
Item 2.1. Attach a line drawing showing water flow through your
facility, from intake to discharge. Indicate the sources of intake
water (e.g., city, well, stream, other); operations contributing
wastewater to the effluent including process and production areas,
sanitary flows, cooling water, and stormwater runoff; and treatment
units labeled to correspond to the more detailed descriptions under
Section 3. You may group similar operations into a single unit.
Construct a water balance on the line drawing by showing average
flows (specify units) between intakes, operations, treatment units,
and outfalls. Show all significant losses of water to products, the
atmosphere, and discharge. You should use actual measurements
wherever available; otherwise use your best estimate. If you cannot
determine a water balance for your activities (such as mining
activities), provide a pictorial description of the nature and amount
of any sources of water and any collection and treatment measures.
An example of an acceptable line drawing is provided in Exhibit
2C–1 at the end of these instructions.

Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 2C and any attachments. If you do not know
your EPA Identification Number, contact your NPDES permitting
authority. See Exhibit 1–1 of Form 1’s “General Instructions” for
contact information. Additionally, for Tables A through E, provide
the applicable outfall number at the top of each page.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter “NA” for “not applicable” to
show that you considered the item and determined a response was
not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.

Section 3. Average Flows and Treatment
Item 3.1. For each outfall identified under Item 1.1, provide the
following information: (1) all processes, operations, or production
areas that contribute wastewater to the effluent for the outfall,
including process wastewater, sanitary wastewater, cooling water,
and stormwater runoff; (2) average flow of wastewater contributed
by each operation in million gallons per day (mgd); (3) a description
of the treatment unit (including size of each treatment unit, flow rate
through each treatment unit, retention time, etc.); (4) the applicable
treatment code(s) from Exhibit 2C–2 (see end of instructions); and
(5) the ultimate disposal of any solid or fluid wastes that are not
discharged to the receiving water. You may describe processes,
operations, or production areas in general terms (e.g., “dye-making
reactor” or “distillation tower”). You may estimate the average flow
of point sources composed of stormwater; however, you must

2C-1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED
indicate the basis of the rainfall event and the method of estimation. Item 5.3. Indicate if the limitations in the applicable ELGs are
Add additional sheets as necessary.
expressed in terms of production or other measure of operation. For
Item 3.2. Answer whether you are applying for an NPDES permit to operational parameter, it is expressed in terms of production (e.g.,
“pounds of biological oxygen demand per cubic foot of logs from
operate a privately owned treatment works. If yes, continue to Item
which bark is removed,” or “pounds of total suspended solids per
3.3. If no, skip to Section 4.
megawatt hour of electrical energy consumed by smelting
Item 3.3. Attach a list to your application that includes the identity of furnace”). An example of an ELG not expressed in terms of a
each user of the treatment works, then answer “Yes” to Item 3.3.
measure of operation is one that limits the concentration of
pollutants. If yes, continue to Item 5.4. If no, skip to Section 6.
Section 4. Intermittent Flows
Item 5.4. Indicate the operations, products, or materials produced
Item 4.1. Answer “Yes” or “No” to indicate whether any of the
at the facility for each outfall. For each operation, product, or
discharges you described in Sections 1 and 3 of Form 2C are
material produced, denote the quantity produced per day using the
intermittent or seasonal, except for stormwater runoff, spillage, or
measurement units specified in the applicable ELG. The NPDES
leaks. An intermittent discharge is one that is not continuous. A
permitting authority will use the production information to apply
continuous discharge is one that occurs without interruption during
ELGs to your facility. You may not claim that the production
the operating hours of the facility, except for infrequent shutdowns
information you submit is confidential. You do not need to indicate
for maintenance, process changes, or other similar activities. A
how you calculated the reported information. The production figures
discharge is seasonal if it occurs only during certain parts of the
provided must be based on a reasonable measure of actual daily
year. If yes, continue to Item 4.2. If no, skip to Section 5.
production, not on design capacity or on predictions of future
Item 4.2. By relevant outfall number, identify each operation that
operations. To obtain alternate limits under 40 CFR 122.45(b)(2)(ii),
has intermittent or seasonal discharges. Indicate the average
you must define your maximum production capability and
frequency (days per week and months per year), the long-term
demonstrate to the NPDES permitting authority that your actual
average and maximum daily flow rates in mgd, and the duration of
production is substantially below maximum production capability
the intermittent or seasonal discharges. Base your answers on
and that there is a reasonable potential for an increase above
actual data if available. Otherwise, provide your best estimate.
actual production during the duration of the permit.
Report the average of all daily values measured during days when
Section 6. Improvements
the discharge occurred for “Long-Term Average,” and report the
highest daily value for “Maximum Daily.”
Item 6.1. Indicate if you are required by any federal, state, or local
authority to meet an implementation schedule for constructing,
Section 5. Production
upgrading, or operating wastewater treatment equipment or
Item 5.1. Indicate whether any effluent limitation guidelines (ELGs)
practices or any other environmental programs that could affect the
promulgated under Section 304 of the Clean Water Act (CWA)
discharges described in your application. The requirements include,
apply to your facility. If yes, continue to Item 5.2. If no, skip to
but are not limited to, permit conditions, administrative enforcement
Section 6. All ELGs promulgated by EPA appear in the Federal
orders, enforcement compliance schedule letters, stipulations, court
Register and are published annually in 40 CFR Subchapter N. An
orders, and grant or loan conditions. If yes, continue to Item 6.2. If
ELG applies if you have any operations contributing process
no, skip to Item 6.3.
wastewater in any subcategory covered by a Best Practicable
Item 6.2. Briefly identify and describe each applicable project (e.g.,
Control Technology Currently Available (BPT), Best Conventional
consent decree, enforcement order, or permit condition). For each
Pollutant Control Technology (BCT), or Best Available Technology
condition, specify the affected outfall number(s), the source(s) of
Economically Achievable (BAT) guideline. If you are unsure
the discharge, the projected final compliance date, and the
whether you are covered by a promulgated ELG, consult your
required final compliance date.
NPDES permitting authority (see Exhibit 1–1 of the “General
Instructions” of Form 1). You must check “Yes” if an applicable ELG Item 6.3. OPTIONAL ITEM. If desired, attach descriptions of any
has been promulgated, even if the ELG is being contested in court. additional water pollution control programs (or other environmental
If you believe that a promulgated ELG has been remanded for
projects that could affect your discharges) that are now underway
reconsideration by a court and does not apply to your operations,
or planned. Indicate in your attachments whether each program is
you may answer “No” to Item 5.1 and skip to Section 6.
actually underway or is planned, and indicate your actual or

Applicable ELGs

Item 5.2. Complete Item 5.2 by indicating the applicable ELG
category, ELG subcategory, and corresponding regulatory citation.
See the example below.
5.2

ELG Category
Pulp, Paper,
and
Paperboard
Point Source
Category

ELG
Subcategory
Secondary Fiber
Non-Deink
Subcategory

Regulatory
Citation
40 CFR 430,
Subpart J

planned schedule for construction.
Section 7. Effluent and Intake Characteristics
Items 7.1 to 7.17. These items require you to collect and report
data for the parameters and pollutants listed in Tables A through E,
located at the end of Form 2C. The instructions for completing the
tables are table-specific in addition to the criteria for determining
who should complete them. In general, the following conditions
apply:

2C-2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED
Pollutants/Parameters
Conventional and nonconventional pollutants

Toxic metals, cyanide, total
phenols, and organic toxic
pollutants
Certain conventional and
non-conventional pollutants

D
E

Certain hazardous
substances and asbestos
2,3,7,8-tetrachlorodibenzop-dioxin (2,3,7,8-TCDD)

Item 7.5. Because you indicated in Item 7.4 that the facility’s
processes contribute wastewater that falls into one or more of the
primary industry categories, check “Testing Required” for all toxic
metals, cyanide, and total phenols in Section 1 of Table B. Answer
“Yes” to Item 7.5 once you have completed this task.

Who Completes?
All applicants from all outfalls unless a
waiver is obtained from the NPDES
permitting authority.
Applicants in the primary industry
categories listed in Exhibit 2C-3 at the
end of these instructions.
Applicants subject to ELGs that limit
pollutants directly or indirectly and
applicants who believe pollutants may
be present in their facility’s discharge.
Applicants who believe pollutants may
be present in their facility’s discharge.
Applicants that use or manufacture the
pollutant or believe the pollutant may
be present in the facility’s discharge.

Item 7.6. Because you indicated in Item 7.4 that the facility’s
processes contribute wastewater that falls into one or more of the
primary industry categories, list the primary industry categories
applicable to your facility. Next, review Exhibit 2C-3 to determine
whether testing is required and for which GC/MS fraction(s): volatile
compounds, acid compounds, base/neutral compounds, and
pesticides. Check the applicable boxes for each GC/MS fraction
requiring testing.

Important note: Read the “General Instructions for Reporting,
Sampling, and Analysis” on pages 2C-5 and 2C-6 before
completing Section 7 and Tables A through E.

Item 7.8 and Sections 1 through 5 of Table B. For all other cases
(secondary industries, nonprocess wastewater outfalls, and
nonrequired GC/MS fractions) and remaining pollutants, check
“Believed Present” or “Believed Absent” in Sections 1 through 5 of
Table B to indicate whether you have reason to believe that any of
the pollutants listed are discharged from your outfalls. Answer “Yes”
to Item 7.8 after you have completed this step.

Item 7.1 and Table A. All applicants must report at least one
analysis for each conventional and non-conventional pollutant listed
in Table A for each outfall (one table per outfall). This includes
outfalls discharging only noncontact cooling water or stormwater
runoff. However, at your request, the NPDES permitting authority
may waive the requirement to test for one or more of the listed
pollutants for specific outfalls, upon a determination that available
information is adequate to support issuance of your NPDES permit
with less stringent reporting requirements. You may also request a
waiver from your NPDES permitting authority for one or more of the
Table A pollutants for your industry category or subcategory.
Indicate whether you are requesting a waiver in response to Item
7.1. If yes, continue to Item 7.2. If no, skip to Item 7.3.

Item 7.7. For each of the required GC/MS fractions, check “Testing
Required” for each of the pollutants in the required fraction in
Sections 2 through 5 of Table B. Answer “Yes” to Item 7.7 once you
have completed this task.

Table
A

Item 7.2. Specify the outfalls for which you are requesting a waiver.
Next, indicate on Table A for the applicable outfalls the pollutants
for which the waiver is being requested. Attach your waiver request
and supporting information to your completed Form 2C.

Item 7.3. Test your effluent from each outfall for each pollutant
listed in Table A for which you have not requested a waiver. You
may also conduct optional tests of your intake water for the Table A
pollutants. See the “General Instructions for Reporting, Sampling,
and Analysis” on pages 2C-5 and 2C-6 for further information.
Item 7.4 and Table B. This item asks whether any of the facility’s
processes that contribute wastewater fall into one or more of the
primary industry categories listed in Exhibit 2C-3. If you are
applying for a permit for a privately owned treatment works,
determine your testing requirements based on the industrial
categories of your contributors. This exercise is simply to determine
your testing requirements only. You are not giving up your right to
challenge your inclusion in the category determined for testing (e.g.,
for deciding whether an ELG is applicable) before your permit is
issued. If yes, continue to Item 7.5. If no, skip to Item 7.8.
Complete a separate Table B for each outfall. Section 1 of Table B
lists toxic metals, cyanide, and total phenols. Sections 2 through 5
of Table B list the pollutants in each of the gas
chromatography/mass spectrometry (GC/MS) fractions. Note that
inclusion of total phenols in Section 1 of Table B does not mean
that EPA is classifying the group as toxic pollutants.

Item 7.9 and Section 1 of Table B. For each pollutant you know or
have reason to believe is present in your discharge from each
applicable outfall in concentrations of 10 parts per billion (ppb) or
greater, you must report quantitative data. For every pollutant
expected to be discharged in concentrations less than 10 ppb, you
must submit quantitative data or briefly describe the reasons the
pollutant is expected to be discharged. For pollutants in intake
water, see the discussion under “General Instructions for Reporting,
Sampling, and Analysis” below. Answer “Yes” to Item 7.9 once you
have completed Section 1 of Table B.

Item 7.10. This item asks if you qualify as a “small business.” If so,
you are exempt from submitting quantitative data for the organic
toxic pollutants on Table B (Sections 2 through 5). You still must
indicate, though, whether you believe any of the pollutants listed in
Sections 1 through 5 are present in your discharge per the
Instructions at Item 7.8 above.
You can qualify as a small business in two ways: (1) 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. (2) 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 that is the
source of the discharge. The data should not be limited to
production or sales for the process or processes that contribute to
the discharge, unless those are the only processes at your facility.

2C-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED

If you qualify as a small business according to the criteria above,
answer “Yes” to Item 7.10. Check the box at the top of Table B to
show that you are not required to submit quantitative data for the
organic toxic pollutants (Sections 2 through 5 of Table B), then
skip to Item 7.12. Otherwise, answer “No” and continue to Item
7.11.

Item 7.15. Answer “Yes” to this Item when you have completed
Table D.
Under 40 CFR 117.12(a)(2), certain discharges of hazardous substances
(listed in Exhibit 2C-4 at the end of these instructions) may be exempted from
the requirements of Section 311 of the 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 can 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.
Exemptions are allowed from the requirements of CWA Section 311.
Applications for exemptions must set forth the following information:
1. The substance and the amount of each substance that may be discharged.
2. The origin and source of the discharge of the substance.
3. The treatment 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 that is
additionally capable of treating the amount of the substance identified
under paragraph 1 above; or
c. Any combination of the above.

Item 7.11 and Sections 2 through 5 of Table B. Unless you
qualify as a small business (see Item 7.10), you must provide
quantitative data for all pollutants for which you marked “Testing
Required” in Sections 2 through 5 of Table B. You must also
provide quantitative data for all pollutants you marked as “Believed
Present” in Sections 2 through 5 of Table B if you discharge those
pollutants in concentrations of 10 ppb or greater, except for
acrolein, acrylonitrile, 2,4-dinitrophenol, and 2-methyl-4,6dinitrophenol. If you discharge any of the four latter pollutants in
concentrations of 100 ppb or greater, you must report quantitative
data. If you discharge the pollutants in Sections 2 through 5 of
Table B less than these thresholds (i.e., <100 ppb for acrolein,
acrylonitrile, 2,4-dinitrophenol, and 2-methyl-4,6-dinitrophenol and
<10 ppb for all others), you must submit quantitative data or briefly
describe the reasons the pollutant is in your discharge.

Item 7.14 and Table D. For each outfall, indicate if you believe that
any pollutant listed in Table D is “Believed Present” or “Believed
Absent” in your facility’s effluent. Check the boxes in the applicable
columns on Table D next to each pollutant. For every pollutant
believed present, you must briefly describe the reasons the
pollutant is expected to be discharged and report any quantitative
data you have for that pollutant. Note that you are not required to
perform analytical tests for any of the Table D pollutants at this time.
However, if you have prior test results, you must report them.

For sales data, in situations involving intra-corporate 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 online from
the U.S. Department of Commerce, Bureau of Economic Analysis
at http://bea.gov/national/pdf/SNTables.pdf.

For pollutants in intake water, see the discussion under “General
Instructions for Reporting, Sampling, and Analysis” on pages
2C-5 and 2C-6 for further information.

Once you have completed these tasks, answer “Yes” to Item 7.11.

Item 7.12 and Table C. For each outfall (including outfalls
containing only noncontact cooling water or stormwater runoff),
indicate whether you know or have reason to believe that any of
the pollutants listed on Table C are present in your discharge. If
so, mark the box in the “Believed Present” column for each
applicable pollutant. If not, mark the box in the “Believed Absent”
column for each applicable pollutant. Answer “Yes” to Item 7.12
once you have completed the required task for each outfall.

Item 7.13 and Table C. You are required to report quantitative
data for any Table C pollutants that are directly limited in an
applicable ELG or are indirectly limited in an applicable ELG
through an expressed limitation on an indicator (e.g., use of total
suspended solids (TSS) as an indicator to control the discharge
of iron and aluminum). For all other pollutants that you marked as
“Believed Present,” you must either report quantitative data or
briefly describe the reasons the pollutant is expected to be
discharged.
For pollutants in intake water, see the discussion under “General
Instructions for Reporting, Sampling, and Analysis” on pages
2C-5 and 2C-6 for further information.
Answer “Yes” to Item 7.13 when you have fully completed the
tasks associated with Table C and Items 7.12 and 7.13 above.

See 40 CFR 117.12(a)(2) and (c) or contact your NPDES permitting authority
for further information on exclusions from CWA Section 311.

Item 7.16. Indicate whether:


Your facility uses or manufactures 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-trichlorophenyl)
phosphorothioate (Ronnel); 2,4,5,-trichlorophenol (TCP); or
hexachlorophene (HCP).



You know or have reason to believe that 2.3.7,8tetrachlorodibenzo-p-dioxin (TCDD) is or may be present in an
effluent.

If yes, continue to Item 7.17. If no, skip to Section 8.
Item 7.17 and Table E. If you answered “Yes” to Item 7.16, you
must report qualitative data, generated using a screening procedure
not calibrated with analytical standards, for TCDD. Your screening
analyses must be performed using gas chromatography with an
electron capture detector. A TCDD standard for quantitation is not
required. Describe the results of your screening analysis (e.g., “no
measurable baseline deflection at the retention time of TCDD” or “a
measurable peak within the tolerances of the retention time of
TCDD.”) on Table E. The NPDES permitting authority may require
you to perform a quantitative analysis if you report a positive result.
Answer “Yes” to Item 7.17 when you have completed Table E.
2C-4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis
Important note: Read these instructions before completing Tables
A through E and Section 7 of Form 2C.

All reporting of values for metals must be in terms of “total
recoverable metal,” unless:

General Items



An applicable, promulgated ELG specifies the limitation for
the metal in dissolved, valent, or total form;



All approved analytical methods for the metal inherently
measure only its dissolved form (e.g., hexavalent chromium);
or



The permitting authority has determined that in establishing
case-by-case limitations it is necessary to express the
limitations of the metal in dissolved, valent, or total form to
carry out the provisions of the CWA.

You may report some or all of the required data by attaching
separate sheets of paper instead of completing Tables A through E
for each of your outfalls so long as the sheets contain all of the
required information and are similar in format to Tables A through
E. For example, you may be able to print a report in a compatible
format from the data system used in your GC/MS analysis
completed under Table B.

If you measure only one daily value, complete the “Maximum Daily
Discharge” columns of the tables and enter “1” in the “Number of
Analyses” columns. The NPDES permitting authority may require
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.

Table A requires you to report at least one analysis for each
pollutant listed. Tables B through D require you to report analytical
data in two ways. For some pollutants, you may be required to
check the box in the “Testing Required” column and test and report
the levels of the pollutants in your discharge whether or not you
expect them to be present in your discharge. For all other
pollutants, you must check the box in either the “Believed Present”
or “Believed Absent” columns based on your best estimate and test
for those you believe to be present (with some exceptions). Base
your determination that a pollutant is present in or absent from your
discharge on your 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.

Note that you are not required to complete the “Maximum Monthly
Discharge” and the “Long-Term Average Daily Discharge” columns
of Tables A through C; however, these fields should be completed
if data are available.

Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit number,
facility name, and applicable outfall number at the top of each page
of the tables and any associated attachments.

If you would expect a pollutant to be present solely because of its
presence in your intake water, you must mark “Believed Present”
but you are not required to analyze for that pollutant. Instead, mark
an “X” in the long-term average value of the “Intake” column;
optionally, you may instead provide intake data.
Reporting of Effluent Data

Report sampling results for all pollutants in Tables A through C as
concentration and total mass, except for flow, temperature, pH,
color, and fecal coliform organisms. If you are reporting
quantitative data under Table D, report concentration only.

Flow, temperature, pH, color, and fecal coliform organisms must be
reported as mgd, degrees Celsius (°C), standard units, color units,
and most probable number per 100 milliliters (MPN/100 mL),
respectively. Use the following abbreviations in the columns
requiring “units” in Tables A through D.
Concentration

Mass

ppm = parts per million

lbs = pounds

mg/L = milligrams per liter

ton = tons (English tons)

ppb = parts per billion

mg = milligrams

µg/L = micrograms per liter

g = grams
kg = kilograms
T = tonnes (metric tons)

MPN = most probable number per
100 milliliters

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.
When an applicant has two or more outfalls with substantially
identical effluents, the NPDES permitting authority may allow the
applicant to test only one outfall and report those quantitative data
as applying to the substantially identical outfall. If the permitting
authority grants your request, attach a separate sheet to the
application form identifying the outfall tested and describing why the
other outfall(s) are substantially identical.
Reporting of Intake Data
You are not required to report data under the “Intake” columns of
Tables A through C unless you wish to demonstrate your eligibility
for a “net” effluent limitation for one or more pollutants in Tables A
through C (i.e., 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 of your intake
water and discuss the requirements for a net limitation with your
NPDES permitting authority. If your water is treated before use, test
the water after it has been treated.

2C-5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued
Sampling

Aliquots may be collected manually or automatically. For “GC/MS
Fraction—Volatile Compounds” in Table B, aliquots must be
combined in the laboratory immediately before analysis. Four
(rather than eight) aliquots or grab samples should be collected for
this fraction. These four samples should be collected during actual
hours of discharge over a 24-hour period and need not be flow
proportioned. Only one analysis is required.

The collection of samples for the reported analyses should be
supervised by a person experienced in performing sampling of
industrial wastewater. You may contact your NPDES permitting
authority for detailed guidance on sampling techniques and for
answers to specific questions. See Exhibit 1–1 of Form 1 for
contact information. Any specific requirements in the applicable
analytical methods—for example, sample containers, sample
preservation, holding times, and the collection of duplicate
samples—must be followed.

Use of Historical Data

Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical
methods approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O. A method is “sufficiently sensitive”
when:

Grab samples must be used for pH, temperature, cyanide, total
phenols, residual chlorine, oil and grease, fecal coliform (including
E. coli), and enterococci (previously known as fecal streptococcus
at 40 CFR 122.26(d)(2)(iii)(A)(3)), and volatile organic compounds.

Analysis

Existing data may be used, if available, in lieu of sampling
conducted solely for the purposes of this application, provided that:
all data requirements are met; sampling was performed, collected,
and analyzed no more than 4.5 years prior to submission; all data
are representative of the discharge; and all available representative
data are considered in the values reported.

For all other pollutants, a 24-hour composite sample, using a
minimum of four grab samples, must be used unless specified
otherwise at 40 CFR 136. However, a minimum of one grab
sample may be taken for effluents from holding ponds or other
impoundments with a retention period greater than 24 hours.

For stormwater discharges, a minimum of one to four grab
samples must be taken, depending on the duration of the
discharge. One grab sample must be taken in the first hour (or
less) of discharge, with one more grab sample (up to a minimum of
four) taken in each succeeding hour of discharge for discharges
lasting four hours or more.

Except for stormwater discharges, the NPDES permitting authority
may waive composite sampling requirements for any outfall for
which you demonstrate that use of an automatic sampler is
infeasible and that the minimum of four grab samples will be
representative of your discharge. Results of analyses of individual
grab samples for any parameter may be averaged to obtain the
daily average. Grab samples that are not required to be analyzed
immediately may be composited in the laboratory, if the container,
preservation, and holding time requirements are met and if sample
integrity is not compromised during compositing. See Table II at 40
CFR 136.3 for further information.
A grab sample is an individual sample of at least 100 milliliters
collected at a randomly chosen time over a period not exceeding
15 minutes.
A composite sample is a combination of at least eight 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.



The method minimum level (ML) is at or below the level of the
applicable water quality criterion for the measured pollutant or
pollutant parameter.



The method has the lowest ML of the analytical methods
approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O for the measured pollutant or
pollutant parameter.

Consistent with 40 CFR 136, you may provide matrix- or samplespecific MLs rather than the published levels. Further, where you
can demonstrate that, despite a good faith effort to use a method
that would otherwise meet the definition of “sufficiently sensitive,”
the analytical results are not consistent with the quality assurance
(QA)/quality control (QC) specifications for that method, then the
NPDES permitting authority may determine that the method is not
performing adequately and the NPDES permitting authority should
select a different method from the remaining EPA-approved
methods that is sufficiently sensitive consistent with 40 CFR
122.21(e)(3)(i). Where no other EPA-approved methods exist, you
must select a method consistent with 40 CFR 122.21(e)(3)(ii).
When there is no analytical method that has been approved under
40 CFR 136; required under 40 CFR chapter I, subchapter N or O,
and is not otherwise required by the NPDES permitting authority,
you may use any suitable method but shall provide a description of
the method. When selecting a suitable method, other factors such
as a method’s precision, accuracy, or resolution, may be
considered when assessing the performance of the method.

2C-6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED
Section 8. Used or Manufactured Toxics

Section 12. Checklist and Certification Statement

Item 8.1. Indicate if any pollutant listed in Table B is used or
manufactured in your facility as an intermediate or final product or
byproduct. If yes, continue to Item 8.2. If no, skip to Section 9.

Item 12.1. Review the checklist provided. In Column 1, mark the
sections of Form 2C that you have completed and are submitting
with your application. In Column 2, indicate for each section
whether you are submitting attachments.

Section 9. Biological Toxicity Tests
Item 9.1. Indicate if 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 three years. If yes, continue to Item 9.2. If
no, skip to Section 10.

FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A.

For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) 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 (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END

Item 9.2. Identify the tests known to have been performed and the
purposes of each. For each test, check “Yes” or “No” to indicate if
you have submitted the test results to the NPDES permitting
authority and the date the results were submitted. The NPDES
permitting authority may ask you to provide additional details after
reviewing your application.

Item 12.2. The CWA provides for severe penalties for submitting
false information on this application form. Section 309(c)(2) of the
CWA 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.”

Item 8.2. List the applicable toxic pollutants. Note that the NPDES
permitting authority may waive or modify the requirement if you
demonstrate that it would be unduly burdensome to identify each
toxic pollutant and the permitting authority has adequate
information to issue you a permit. You may not claim this
information as confidential. Note that you do not need to distinguish
between use or production of the pollutants or list amounts.

Section 10. Contract Analyses

Item 10.1. Indicate if any of the analyses reported in Section 7 were
performed by a contract laboratory or consulting firm. If yes,
continue to Item 10.2. If no, skip to Section 11.

Item 10.2. Identify each laboratory or firm used in the table
provided. For each, provide the name, address, and phone number
of the laboratory or firm and the pollutants analyzed.
Section 11. Additional Information

Item 11.1. In addition to the information reported on the application
form, the NPDES permitting authority may request additional
information reasonably required to assess the discharges of the
facility and to determine whether to issue an NPDES permit. The
additional information may include additional quantitative data and
bioassays to assess the relative toxicity of discharges to aquatic life
and requirements to determine the cause of the toxicity. Indicate
under Item 11.1 whether the NPDES permitting authority has
requested additional information from you. If yes, continue to Item
11.2. If no, skip to Section 12.
Item 11.2. List the items requested and attach the required
information to the application.

2C-7

Submit your completed Form 1, Form 2C, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2C–1. Example Line Drawing

2C-8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2C–2. Codes for Treatment Units and Disposal of Wastes Not Discharged
PHYSICAL TREATMENT PROCESSES
1–M ................ Grit removal
1–N ................ Microstraining
1–O ................ Mixing
1–P................. Moving bed filters
1–Q ................ Multimedia filtration
1–R ................ Rapid sand filtration
1–S................. Reverse osmosis (hyperfiltration)
1–T ................. Screening
1–U ................ Sedimentation (settling)
1–V................. Slow sand filtration
1–W................ Solvent extraction
1–X................. Sorption

CHEMICAL TREATMENT PROCESSES
2–G ................ Disinfection (ozone)
2–H ................ Disinfection (other)
2–I .................. Electrochemical treatment
2–J ................. Ion exchange
2–K................. Neutralization
2–L ................. Reduction

1–A ................ Ammonia stripping
1–B ................ Dialysis
1–C ................ Diatomaceous earth filtration
1–D ................ Distillation
1–E ................ Electrodialysis
1–F................. Evaporation
1–G ................ Flocculation
1–H ................ Flotation
1–I .................. Foam fractionation
1–J ................. Freezing
1–K ................ Gas–phase separation
1–L ................. Grinding (comminutors)

2–A ................ Carbon adsorption
2–B ................ Chemical oxidation
2–C ................ Chemical precipitation
2–D ................ Coagulation
2–E ................ Dechlorination
2–F................. Disinfection (chlorine)

BIOLOGICAL TREATMENT PROCESSES
3–E................. Pre-aeration
3–F ................. Spray irrigation/land application
3–G ................ Stabilization ponds
3–H ................ Trickling filtration

WASTEWATER DISPOSAL PROCESSES
4–C ................ Reuse/recycle of treated effluent
4–D ................ Underground injection

3–A ................ Activated sludge
3–B ................ Aerated lagoons
3–C ................ Anaerobic treatment
3–D ................ Nitrification–denitrification

4–A ................ Discharge to surface water
4–B ................ Ocean discharge to outfall

5–A ................ Aerobic digestion
5–B ................ Anaerobic digestion
5–C ................ Belt filtration
5–D ................ Centrifugation
5–E ................ Chemical conditioning
5–F................. Chlorine treatment
5–G ................ Composting
5–H ................ Drying beds
5–I .................. Elutriation
5–J ................. Flotation thickening
5–K ................ Freezing
5–L ................. Gravity thickening

SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–M ................ Heat drying
5–N ................ Heat treatment
5–O ................ Incineration
5–P................. Land application
5–Q ................ Landfill
5–R ................ Pressure filtration
5–S................. Pyrolysis
5–T ................. Sludge lagoons
5–U ................ Vacuum filtration
5–V................. Vibration
5–W................ Wet oxidation

2C-9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2C–3. Testing Requirements for Organic Toxic Pollutants Industry Categories*
GC/MS FRACTION†
Acid
Base/Neutral

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

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 (all subparts except D and F) .....
Gum and wood chemicals, Subpart D (tall oil rosin) .............
Gum and wood chemicals, Subpart F (rosin-based
derivatives) ...........................................................................
Inorganic chemicals manufacturing ......................................
Iron and steel manufacturing ................................................
Leather tanning and finishing
Mechanical products manufacturing .....................................
Nonferrous metals manufacturing .........................................
Ore mining, Subpart B (base and precious metals) ..............
Organic chemicals manufacturing ........................................
Paint and ink formulation ......................................................
Pesticides .............................................................................
Petroleum refining.................................................................
Pharmaceutical preparations ................................................
Photographic equipment and supplies..................................
Plastic and synthetic materials manufacturing ......................
Plastic processing .................................................................
Printing and publishing .........................................................
Pulp and paperboard mills ....................................................
Rubber processing................................................................
Soap and detergent manufacturing ......................................
Steam electric power plants..................................................
Textile mills (except Subpart C, Greige Mills) .......................
Timber products processing .................................................

Volatile

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

Pesticide

INDUSTRY CATEGORY

X
X
X

X
X

X
X
X

* See note at conclusion of 40 CFR 122, Appendix D (1983) for explanation of effect of suspensions on testing requirements for primary
industry categories.
† The pollutants in each fraction are listed in Table B.
X = Testing is required.
= Testing is not required.

2C-10

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2C–4. Hazardous Substances
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 fluorite
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

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

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
68. Calcium carbide
69. Calcium chromate
70. Calcium cyanide
71. Calcium dodecylbenzenesulfonate
72. Calcium hypochlorite

2C-11

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2C–4. Hazardous Substances
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 fluoride
296. Zirconium sulfate
297. Zirconium tetrachloride

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 (2,4,5-trichlorophenoxyacetic 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 (2,4,5-trichlorophenoxy 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

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

2C-12

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2C
NPDES

EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS

Outfall Location

SECTION 1. OUTFALL LOCATION (40 CFR 122.21(g)(1))
1.1
Provide information on each of the facility’s outfalls in the table below.
Outfall
Receiving Water Name
Latitude
Number

Longitude



Yes



Line
Drawing

SECTION 2. LINE DRAWING (40 CFR 122.21(g)(2))
2.1
Have you attached a line drawing to this application that shows the water flow through your facility with a water
balance? (See instructions for drawing requirements. See Exhibit 2C–1 at end of instructions for example.)
SECTION 3. AVERAGE FLOWS AND TREATMENT (40 CFR 122.21(g)(3))

For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number** __________
Operations Contributing to Flow
Operation
Average Flow

Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Table 2C-1
retention time, etc.)

mgd
mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Average Flows and Treatment

3.1

EPA Form 3510-2C (Revised )

Page 1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

3.1
cont.

Form Approved
OMB No.
Form Expires

**Outfall Number** __________
Operations Contributing to Flow
Operation

Average Flow
mgd
mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Average Flows and Treatment Continued

Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Table 2C-1
retention time, etc.)

**Outfall Number** __________
Operations Contributing to Flow

Average Flow

Operation

mgd
mgd
mgd
Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Table 2C-1
retention time, etc.)

mgd

System
Users

3.2

Are you applying for an NPDES permit to operate a privately owned treatment works?



3.3

Yes
 No  SKIP to Section 4.
Have you attached a list that identifies each user of the treatment works?
 Yes
 No

EPA Form 3510-2C (Revised )

Page 2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 4. INTERMITTENT FLOWS (40 CFR 122.21(g)(4))
4.1
Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?



days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

days/week

months/year

mgd

days

Intermittent Flows

4.2

Yes
 No  SKIP to Section 5.
Provide information on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if necessary.
Frequency
Flow Rate
Outfall
Operation
Duration
Average
Average
Long-Term
Maximum
Number
(list)
Days/Week
Months/Year
Average
Daily

SECTION 5. PRODUCTION (40 CFR 122.21(g)(5))
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
5.2

Yes

No  SKIP to Section 6.

Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory

Regulatory Citation

Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?

5.3

Production-Based Limitations



Applicable ELGs



5.4

Yes



No  SKIP to Section 6.

Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall
Operation, Product, or Material
Quantity per Day
Number

EPA Form 3510-2C (Revised )

Unit of
Measure

Page 3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 6. IMPROVEMENTS (40 CFR 122.21(g)(6))
6.1
Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?

6.3

Briefly identify each applicable project in the table below.
Affected
Brief Identification and Description of
Outfalls
Project
(list outfall
number)

No  SKIP to Item 6.3.
Final Compliance Dates

Source(s) of
Discharge

Required

Projected

6.2



Yes

Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)



Yes



Upgrades and Improvements



Not applicable

SECTION 7. EFFLUENT AND INTAKE CHARACTERISTICS (40 CFR 122.21(g)(7))

See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non-Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
 Yes
 No  SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.

Outfall Number _____

7.3

Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
requested and attached the results to this application package?
a waiver has been requested from my NPDES
 Yes
 No;
permitting authority for all pollutants at all outfalls.
Table B. Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility’s processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)

Effluent and Intake Characteristics

Outfall Number _____



7.5



No  SKIP to Item 7.8.

Have you checked “Testing Required” for all toxic metals, cyanide, and total phenols in Section 1 of Table B?



7.6

Yes
Yes



List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Required GC/MS Fraction(s)
Primary Industry Category
(Check applicable boxes.)

EPA Form 3510-2C (Revised )

 Volatile

 Acid

 Base/Neutral

 Pesticide

 Volatile

 Acid

 Base/Neutral

 Pesticide

 Volatile

 Acid

 Base/Neutral

 Pesticide

Page 4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

7.7

Have you checked “Testing Required” for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
 Yes
 No

7.8

Have you checked “Believed Present” or “Believed Absent” for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
 Yes
 No
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are “Believed Present” in your discharge?
 Yes
 No
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
that you qualify at the top of Table B,
 Yes  Note
 No
then SKIP to Item 7.12.

7.9

7.10

Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
pollutants you have indicated are “Believed Present” in your discharge?
 Yes
 No
Table C. Certain Conventional and Non-Conventional Pollutants
7.12 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed on Table C
for all outfalls?
 Yes
 No
7.13 Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
“Believed Present”?
 Yes
 No
Table D. Certain Hazardous Substances and Asbestos
7.14 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed in Table D for
all outfalls?
 Yes
 No
7.15 Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
 Yes
 No
Table E. 2,3,7,8-Tetrachlorodibenzo-p-Dioxin (2,3,7,8-TCDD)
7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?

7.11

Effluent and Intake Characteristics Continued

Form Approved
OMB No.
Form Expires



7.17



Yes  Complete Table E.

No  SKIP to Section 8.

Have you completed Table E by reporting qualitative data for TCDD?
 Yes
 No

Used or Manufactured
Toxics

SECTION 8. USED OR MANUFACTURED TOXICS (40 CFR 122.21(g)(9))
8.1
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
 Yes
 No  SKIP to Section 9.
8.2
List the pollutants below.
1.

EPA Form 3510-2C (Revised )

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

Biological Toxicity Tests

SECTION 9. BIOLOGICAL TOXICITY TESTS (40 CFR 122.21(g)(11))
9.1
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?


9.2



Yes

No  SKIP to Section 10.

Identify the tests and their purposes below.
Test(s)

Purpose of Test(s)

Submitted to NPDES
Permitting Authority?



Yes



Yes



Yes



Date Submitted



Yes

No  SKIP to Section 11.

Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1
Laboratory Number 2
Name of laboratory/firm

Contract Analyses

10.2

SECTION 10. CONTRACT ANALYSES (40 CFR 122.21(g)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?

Laboratory Number 3

Laboratory address

Phone number

Pollutant(s) analyzed

Additional Information

SECTION 11. ADDITIONAL INFORMATION (40 CFR 122.21(g)(13))
11.1 Has the NPDES permitting authority requested additional information?



11.2

Yes



No  SKIP to Section 12.

List the information requested and attach it to this application.
1.

EPA Form 3510-2C (Revised )

Page 6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 12. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
12.1 In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to complete all sections or provide attachments.
Column 1
Column 2



Section 1: Outfall Location



w/ attachments



Section 2: Line Drawing



w/ line drawing



w/ additional attachments



Section 3: Average Flows and
Treatment



w/ attachments



w/ list of each user of
privately owned treatment
works



Section 4: Intermittent Flows



w/ attachments



Section 5: Production



w/ attachments



w/ attachments



w/ request for a waiver and
supporting information
w/ small business exemption
request



w/ other attachments



w/ Table A



w/ Table B



w/ Table C



w/ Table D



w/ Table E



w/ analytical results as an
attachment



w/ attachments



Section 8: Used or Manufactured
Toxics
Section 9: Biological Toxicity
Tests



w/ attachments



Section 10: Contract Analyses



w/ attachments



Section 11: Additional Information



w/ attachments



w/ attachments



Section 6: Improvements

Section 7: Effluent and Intake
Characteristics

Checklist and Certification Statement



w/ optional additional
sheets describing any
additional pollution control
plans
w/ explanation for identical
outfalls

Section 12: Checklist and
Certification Statement
Certification Statement



12.2

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 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.
Name (print or type first and last name)
Official title

Signature

EPA Form 3510-2C (Revised )

Date signed

Page 7

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE A. CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(iii))1
Intake

Effluent
Pollutant

Waiver
Requested

Units
(specify)

(if applicable)

(Optional)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

Long-Term
Average Daily
Discharge

(required)

(if available)

Number of
Analyses



Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.

Biochemical oxygen demand
(BOD5)



Chemical oxygen demand
(COD)



Total organic carbon (TOC)



Total suspended solids (TSS)



Ammonia (as N)



Flow

Concentration
Mass



Rate



°C



°C

pH (minimum)



Standard units

s.u.

pH (maximum)



Standard units

s.u.

Temperature (winter)
Temperature (summer)

Number of
Analyses

Mass

Concentration

Long-Term
Average Value

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
1

EPA Form 3510-2C (Revised )

Page 8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)



Believed
Present

Units

Believed
Absent

(specify)

Intake

Effluent

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires

Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.

Section 1. Toxic Metals, Cyanide, and Total Phenols



1.2

Arsenic, total
(7440-38-2)



1.3

Beryllium, total
(7440-41-7)



1.4

Cadmium, total
(7440-43-9)



1.5

Chromium, total
(7440-47-3)



1.6

Copper, total
(7440-50-8)

1.7

Lead, total
(7439-92-1)

1.8

Mercury, total
(7439-97-6)

1.9



Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Antimony, total
(7440-36-0)

1.1



Nickel, total
(7440-02-0)



1.10

Selenium, total
(7782-49-2)



1.11

Silver, total
(7440-22-4)



EPA Form 3510-2C (Revised )

Page 10

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Testing
Required

Pollutant/Parameter

Believed
Present

Units

Believed
Absent

(specify)

Intake

Effluent

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

(and CAS Number, if available)

Form Approved
OMB No.
Form Expires

Concentration



Mass
Concentration
Zinc, total
1.13



(7440-66-6)
Mass
Concentration
Cyanide, total
1.14



(57-12-5)
Mass
Concentration
1.15 Phenols, total



Mass
Section 2. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)
Acrolein
(107-02-8)



2.2

Acrylonitrile
(107-13-1)



2.3

Benzene
(71-43-2)

2.4

Bromoform
(75-25-2)

2.5

Carbon tetrachloride
(56-23-5)

2.6



Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

2.1

Thallium, total
1.12
(7440-28-0)



Chlorobenzene
(108-90-7)



2.7

Chlorodibromomethane
(124-48-1)



2.8

Chloroethane
(75-00-3)



EPA Form 3510-2C (Revised )

Page 11

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

2.9

2-chloroethylvinyl ether
(110-75-8)

Units

Believed
Absent



(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

2.11

Dichlorobromomethane
(75-27-4)



2.12

1,1-dichloroethane
(75-34-3)



2.13

1,2-dichloroethane
(107-06-2)



2.14

1,1-dichloroethylene
(75-35-4)



2.15

1,2-dichloropropane
(78-87-5)



2.16

1,3-dichloropropylene
(542-75-6)

2.17

Ethylbenzene
(100-41-4)

2.18

Methyl bromide
(74-83-9)

2.19



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



Long-Term
Average
Daily
Discharge

(optional)

2.10 Chloroform (67-66-3)

Believed
Present

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



Methyl chloride
(74-87-3)



2.20

Methylene chloride
(75-09-2)



2.21

1,1,2,2- tetrachloroethane
(79-34-5)



EPA Form 3510-2C (Revised )

Page 12

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Units

Believed
Absent






(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

2.23

Toluene
(108-88-3)



2.24

1,2-trans-dichloroethylene
(156-60-5)



2.25

1,1,1-trichloroethane
(71-55-6)



2.26

1,1,2-trichloroethane
(79-00-5)



2.27

Trichloroethylene
(79-01-6)



2.28

Vinyl chloride
(75-01-4)



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



Long-Term
Average
Daily
Discharge

(optional)

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Tetrachloroethylene
2.22
(127-18-4)

Believed
Present

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires

Section 3. Organic Toxic Pollutants (GC/MS Fraction—Acid Compounds)
3.1

2-chlorophenol
(95-57-8)

3.2

2,4-dichlorophenol
(120-83-2)

3.3



2,4-dimethylphenol
(105-67-9)



3.4

4,6-dinitro-o-cresol
(534-52-1)



3.5

2,4-dinitrophenol
(51-28-5)



EPA Form 3510-2C (Revised )

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 13

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Testing
Required

Pollutant/Parameter

Believed
Present

Believed
Absent

Units
(specify)

Intake

Effluent

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

(and CAS Number, if available)

Form Approved
OMB No.
Form Expires

Concentration
3.6



Mass
Concentration
4-nitrophenol
3.7



(100-02-7)
Mass
Concentration
p-chloro-m-cresol
3.8



(59-50-7)
Mass
Concentration
Pentachlorophenol
3.9



(87-86-5)
Mass
Concentration
Phenol
3.10



(108-95-2)
Mass
Concentration
2,4,6-trichlorophenol
3.11



(88-05-2)
Mass
Section 4. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds)
Concentration
Acenaphthene
4.1



(83-32-9)
Mass
Concentration
Acenaphthylene
4.2



(208-96-8)
Mass
Concentration
Anthracene
4.3



(120-12-7)
Mass
Concentration
Benzidine
4.4



(92-87-5)
Mass
Concentration
Benzo (a) anthracene
4.5



(56-55-3)
Mass
Concentration
Benzo (a) pyrene
4.6



(50-32-8)
Mass

2-nitrophenol
(88-75-5)

EPA Form 3510-2C (Revised )

Page 14

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Units

Believed
Absent

(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

4.7



4.8

Benzo (ghi) perylene
(191-24-2)



4.9

Benzo (k) fluoranthene
(207-08-9)



4.10

Bis (2-chloroethoxy) methane
(111-91-1)



4.11

Bis (2-chloroethyl) ether
(111-44-4)



4.12

Bis (2-chloroisopropyl) ether
(102-80-1)



4.13

Bis (2-ethylhexyl) phthalate
(117-81-7)



4.14

4-bromophenyl phenyl ether
(101-55-3)

4.15

Butyl benzyl phthalate
(85-68-7)

4.16

2-chloronaphthalene
(91-58-7)

4.17



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



Long-Term
Average
Daily
Discharge

(optional)

3,4-benzofluoranthene
(205-99-2)

Believed
Present

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



4-chlorophenyl phenyl ether
(7005-72-3)



4.18

Chrysene
(218-01-9)



4.19

Dibenzo (a,h) anthracene
(53-70-3)



EPA Form 3510-2C (Revised )

Page 15

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Units

Believed
Absent

(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)



4.21

1,3-dichlorobenzene
(541-73-1)



4.22

1,4-dichlorobenzene
(106-46-7)



4.23

3,3-dichlorobenzidine
(91-94-1)



4.24

Diethyl phthalate
(84-66-2)



4.25

Dimethyl phthalate
(131-11-3)



4.26

Di-n-butyl phthalate
(84-74-2)



4.27

2,4-dinitrotoluene
(121-14-2)

4.28

2,6-dinitrotoluene
(606-20-2)

4.29

Di-n-octyl phthalate
(117-84-0)

4.30



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



Long-Term
Average
Daily
Discharge

(optional)

1,2-dichlorobenzene
4.20
(95-50-1)

Believed
Present

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



1,2-Diphenylhydrazine
(as azobenzene) (122-66-7)



4.31

Fluoranthene
(206-44-0)



4.32

Fluorene
(86-73-7)



EPA Form 3510-2C (Revised )

Page 16

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Units

Believed
Absent






(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

4.34

Hexachlorobutadiene
(87-68-3)



4.35

Hexachlorocyclopentadiene
(77-47-4)



4.36

Hexachloroethane
(67-72-1)



4.37

Indeno (1,2,3-cd) pyrene
(193-39-5)



4.38

Isophorone
(78-59-1)



4.39

Naphthalene
(91-20-3)



4.40

Nitrobenzene
(98-95-3)

4.41

N-nitrosodimethylamine
(62-75-9)

4.42

N-nitrosodi-n-propylamine
(621-64-7)

4.43



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



Long-Term
Average
Daily
Discharge

(optional)

Hexachlorobenzene
4.33
(118-74-1)

Believed
Present

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



N-nitrosodiphenylamine
(86-30-6)



4.44

Phenanthrene
(85-01-8)



4.45

Pyrene
(129-00-0)



EPA Form 3510-2C (Revised )

Mass
Page 17

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Believed
Present

Units

Believed
Absent

1,2,4-trichlorobenzene
4.46



(120-82-1)
Section 5. Organic Toxic Pollutants (GC/MS Fraction—Pesticides)
5.1

Aldrin
(309-00-2)



5.2

α-BHC
(319-84-6)



5.3

β-BHC
(319-85-7)



5.4

γ-BHC
(58-89-9)



5.5

δ-BHC
(319-86-8)



5.6

Chlordane
(57-74-9)



5.7

4,4’-DDT
(50-29-3)

5.8

4,4’-DDE
(72-55-9)

5.9

4,4’-DDD
(72-54-8)



5.10

Dieldrin
(60-57-1)



5.11

α-endosulfan
(115-29-7)



Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value



(specify)

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



EPA Form 3510-2C (Revised )

Page 18

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

β-endosulfan
5.12
(115-29-7)

Believed
Present






Endosulfan sulfate
(1031-07-8)



5.14

Endrin
(72-20-8)



5.15

Endrin aldehyde
(7421-93-4)



5.16

Heptachlor
(76-44-8)



(specify)

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Heptachlor epoxide
5.17 (1024-57-3)



PCB-1242
5.18 (53469-21-9)



PCB-1221
5.20 (11104-28-2)



PCB-1232
5.21 (11141-16-5)



(if available)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

PCB-1254
5.19 (11097-69-1)



Long-Term
Average
Daily
Discharge

(optional)

5.13

Units

Believed
Absent

Intake

Effluent

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Form Approved
OMB No.
Form Expires



PCB-1248
5.22 (12672-29-6)



PCB-1260
5.23 (11096-82-5)



PCB-1016
5.24 (12674-11-2)



EPA Form 3510-2C (Revised )

Page 19

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Testing
Required

Pollutant/Parameter
(and CAS Number, if available)

Believed
Present

Believed
Absent

Intake

Effluent

Maximum
Daily
Discharge

Maximum
Monthly
Discharge

(required)

(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Toxaphene
5.25 (8001-35-2)

Units
(specify)

Form Approved
OMB No.
Form Expires

Concentration



Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2C (Revised )

Page 20

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Believed
Absent

Units
(specify)

Maximum Daily
Discharge
(required)

Outfall Number

Form Approved
OMB No.
Form Expires

Intake

Effluent

(Optional)

Maximum
Monthly
Discharge

Long-Term
Average Daily
Discharge

(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses

Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the “Presence or Absence” column of Table C for
each pollutant.



Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the “Presence or Absence” column of Table C for
each pollutant.



Chlorine, total
residual



Color



Fecal coliform



Fluoride
(16984-48-8)



Nitrate-nitrite



Nitrogen, total
organic (as N)



Oil and grease



Phosphorus (as
P), total (7723-14-0)



(as SO4)
10. Sulfate
(14808-79-8)



11. Sulfide (as S)








Bromide
(24959-67-9)



EPA Form 3510-2C (Revised )

Page 21

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Units

Believed
Absent

(specify)

Maximum Daily
Discharge



13. Surfactants



total
14. Aluminum,
(7429-90-5)



15. Barium, total



16. Boron, total



total
17. Cobalt,
(7440-48-4)



18. Iron, total



19. Magnesium, total
(7439-95-4)



Molybdenum,
20. total



(7440-39-3)

(7440-42-8)

(7439-89-6)

(7439-98-7)




21. Manganese, total



22. Tin, total



(7440-31-5)

23. Titanium, total
(7440-32-6)

Maximum
Monthly
Discharge

Long-Term
Average Daily
Discharge

(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses



Mass

Concentration
Mass
Concentration
Mass
Concentration
Mass

(7439-96-5)

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration

(Optional)



(14265-45-3)

Intake

Effluent

12. Sulfite (as SO3)

Form Approved
OMB No.
Form Expires

(required)

Outfall Number

EPA Form 3510-2C (Revised )

Page 22

EPA Identification Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

NPDES Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Believed
Absent

Units
(specify)

Maximum Daily
Discharge
(required)

Form Approved
OMB No.
Form Expires

Intake

Effluent

(Optional)

Maximum
Monthly
Discharge

Long-Term
Average Daily
Discharge

(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses

24. Radioactivity

Outfall Number

Concentration
Mass
Concentration
Beta, total


Mass
Concentration
Radium, total


Mass
Concentration
Radium 226, total


Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).



Alpha, total

EPA Form 3510-2C (Revised )

Page 23

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number

Asbestos



Acetaldehyde



Allyl alcohol



Allyl chloride



Amyl acetate



Aniline



Benzonitrile



Benzyl chloride



Butyl acetate



10. Butylamine



11. Captan



15. Chlorpyrifos



16. Coumaphos



17. Cresol



18. Crotonaldehyde



19. Cyclohexane



13. Carbofuran

14. Carbon disulfide

12. Carbaryl

(specify units)

Available Quantitative Data

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent

Form Approved
OMB No.
Form Expires

EPA Form 3510-2C (Revised )

Page 25

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number



21. Diazinon



22. Dicamba



23. Dichlobenil



24. Dichlone



25. 2,2-dichloropropionic acid



26. Dichlorvos



27. Diethyl amine



28. Dimethyl amine



29. Dintrobenzene



30. Diquat



35. Ethylene diamine



36. Ethylene dibromide



37. Formaldehyde



38. Furfural



32. Diuron

34. Ethion

33. Epichlorohydrin

31. Disulfoton

(specify units)

20. 2,4-D (2,4-dichlorophenoxyacetic acid)

Available Quantitative Data

Form Approved
OMB No.
Form Expires

EPA Form 3510-2C (Revised )

Page 26

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number



40. Isoprene



41. Isopropanolamine



42. Kelthane



43. Kepone



44. Malathion



45. Mercaptodimethur



46. Methoxychlor



47. Methyl mercaptan



48. Methyl methacrylate



49. Methyl parathion



53. Monomethyl amine



54. Naled



55. Naphthenic acid



56. Nitrotoluene



57. Parathion



51. Mexacarbate

52. Monoethyl amine

50. Mevinphos

(specify units)

39. Guthion

Available Quantitative Data

Form Approved
OMB No.
Form Expires

EPA Form 3510-2C (Revised )

Page 27

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number



59. Phosgene



60. Propargite



61. Propylene oxide



62. Pyrethrins



63. Quinoline



64. Resorcinol



65. Strontium



66. Strychnine



67. Styrene



2,4,5-T (2,4,5-trichlorophenoxyacetic
acid)

68.

69. TDE (tetrachlorodiphenyl ethane)
70.

2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]

71. Trichlorofon

(specify units)

58. Phenolsulfonate

Available Quantitative Data

Form Approved
OMB No.
Form Expires

72. Triethanolamine



73. Triethylamine



74. Trimethylamine



75. Uranium



76. Vanadium
EPA Form 3510-2C (Revised )

Page 28

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

Outfall Number

77. Vinyl acetate



78. Xylene



79. Xylenol



80. Zirconium



Available Quantitative Data
(specify units)

Form Approved
OMB No.
Form Expires

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2C (Revised )

Page 29

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Identification Number

NPDES Number

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
Facility Name

2,3,7,8-TCDD



Results of Screening Procedure



Form Approved
OMB No.
Form Expires

TABLE E. 2,3,7,8-TETRACHLORODIBENZO-P-DIOXIN (2,3,7,8-TCDD) (40 CFR 122.21(g)(7)(viii))
Presence or
TCDD
Absence
Congeners
(check one)
Pollutant
Used or
Believed Believed
Manufactured Present
Absent

Outfall Number

EPA Form 3510-2C (Revised )

Page 31

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2D
Revised

Water Permits Division

Application Form 2D

New Manufacturing,
Commercial, Mining, and
Silvicultural Operations That
Have Not Yet Commenced
Discharge of Process
Wastewater

NPDES Permitting Program

Note: Complete this form and Form 1 if your facility is a new manufacturing, commercial, mining, or
silvicultural facility that has yet to commence discharge of process wastewater.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice
The U.S. Environmental Protection Agency estimates the average burden to complete Form 2D to
average 32 hours for some minor facilities and 46 hours for some major facilities, with a weighted
average for major and minor facilities of 33.2 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 about the burden estimate or
any other aspect of this collection of information to the Chief, Information Policy Branch (PM-223),
U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, and
to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street,
NW, Washington, DC 20503, marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2D—INSTRUCTIONS
General Instructions

Follow-up Requirements

Who Must Complete Form 2D?

Form 2D requires that you submit estimated data on your
effluent. Note that no later than 24 months after you commence
discharging from the proposed facility, you must complete and
submit Section 7 of NPDES Application Form 2C. However, you
need not complete those portions of Section 7 that require tests
you have already performed under the discharge monitoring
requirements of your NPDES permit. In addition, your NPDES
permitting authority may waive the requirements of Form 2C,
Section 7, if you make the demonstrations required under 40
CFR 122.22(g)(7)(i)(B) and 122.21(g)(9).

You must complete Form 2D if you answered “Yes” to Item 1.2.3 on
Form 1—that is, if you are a new manufacturing, commercial,
mining, or silvicultural facility that has yet to commence discharge
of process wastewater.
Where to File Your Completed Forms?
Submit your completed application package (Forms 1 and 2D) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1–1 of Form 1’s “General
Instructions” to identify your NPDES permitting authority.
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2D (or related attachments) as
confidential.

Public Availability of Submitted Information

Line-by-Line Instructions
Section 1. Expected Outfall Location
Item 1.1. Identify each of the facility’s outfall structures by
number. For each outfall, specify the latitude and longitude to the
nearest 15 seconds and name of the receiving water. The
application form provides reporting space for three outfalls. If
your facility has more than this number, attach additional sheets
as necessary. The location of each outfall (i.e., where the
coordinates are collected) shall be the point where the discharge
is released into a water of the United States. Latitude and
longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS).
For further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.

You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2D. Note that NPDES permitting authorities will deny claims for
treating any effluent data (estimated or actual) as confidential. If
you do not assert a claim of confidentiality at the time you submit
your information to the NPDES permitting authority, EPA may make
the information available to the public without further notice to you.
EPA will handle claims of confidentiality in accordance with the
Agency’s business confidentiality regulations at Part 2 of Title 40 of
the Code of Federal Regulations (CFR).
Completion of Forms

Definitions
The legal definitions of all key terms used in these instructions
and Form 2D are in the “Glossary” at the end of the “General
Instructions” in Form 1.

Provide your EPA Identification Number from the Federal Registry
Service and facility name at the top of each page of Form 2D and
any attachments. If you do not know your EPA Identification
Number, contact your NPDES permitting authority. See Exhibit 1–1
of Form 1’s “General Instructions” for contact information.
Additionally, for Tables A through E, provide the applicable outfall
number at the top of each page.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter “NA” for “not applicable” to
show that you considered the item and determined a response was
not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
2D-1

Section 2. Expected Discharge Date
Item 2.1. Report the expected date the facility will commence
discharging (month, day, and year).
Section 3. Average Flows and Treatment
Item 3.1. For each outfall, report the operations expected to
contribute wastewater to the effluent and an estimated average
flow from each. Briefly describe the planned wastewater
treatment for each operation or list the applicable treatment
code(s) from Exhibit 2D–1, located at the end of these
instructions. Finally, for each operation, note the ultimate
disposal of any solid or liquid wastes not expected to be
discharged.
Section 4. Line Drawing
Item 4.1. Attach a line drawing showing the expected water flow
through your facility, from intake to discharge. Indicate the
sources of intake water (e.g., city, well, stream, other); all
sources of wastewater contributing to the effluent, including
process and production areas, sanitary flows, cooling water, and

Contains Nonbinding Recommendations
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FORM 2D—INSTRUCTIONS CONTINUED

Applicable ELGs

stormwater runoff; and labeled treatment units. You may group
similar operations into a single unit.
Construct a water balance on the line drawing by showing average
flows (specify units) between intakes, operations, treatment units,
and outfalls. Show all significant losses of water to products, the
atmosphere, and discharge. You should use your best estimate. If
you cannot determine a water balance for your activities (such as
mining activities), provide a pictorial description of the nature and
amount of any sources of water and any collection and treatment
measures. An example of an acceptable line drawing is provided in
Exhibit 2D–2 at the end of these instructions.

ELG Category
Pulp, Paper,
and
Paperboard
Point Source
Category

ELG
Subcategory
Secondary
Fiber NonDeink
Subcategory

Regulatory
Citation
40 CFR 430,
Subpart J

Item 6.3. Indicate whether the limitations in the applicable ELGs
are expressed in terms of production (or other measure of
operation). An ELG is expressed in terms of production (or
another measure of operation) if the limitation is expressed as
mass of pollutant per operational parameter (e.g., “pounds of
biological oxygen demand per cubic foot of logs from which bark
is removed,” or “pounds of total suspended solids per megawatt
hour of electrical energy consumed by smelting furnace.”). An
example of an ELG not expressed in terms of a measure of
operation is one that limits the concentration of pollutants. If you
answer “No” to this item, skip to Section 7.

Section 5. Intermittent or Seasonal Flows
Item 5.1. Specify whether any of the expected discharges
described in Sections 1 and 3 will be intermittent or seasonal. If
yes, continue to Item 5.2. If no, skip to Section 6.

6.2

Item 6.4. For each applicable outfall to which an applicable
production-based ELG applies, list the estimated level of
production (projection of actual production level, not design), for
each of the first three years of operation. The estimated
production level 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,
you may report alternative production estimates, but you must
provide the basis for such alternatives. If known, report
quantities in units of measurements used in the applicable ELG.
If an ELG specifies a method for estimating production, you must
follow that method.

Item 5.2. List applicable outfalls that will have intermittent or
seasonal flows. For each, indicate the operations that will contribute
to the flow. For each operation, indicate the average days per week
and average months per year the discharge will occur, the
maximum daily flow rate, the maximum total volume, and the
duration of the discharge in days. The estimated flow rate and
volume should not include stormwater runoff, spillage, or leaks. 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
frequency is the average recurrence rate of the discharge (in days
per week and months per year). The duration is the average value
of the time duration during which the discharge occurs (in days).

The maximum daily flow rate is the highest daily value and should
be reported in million gallons per day (mgd). Maximum total volume
means the total volume of any one discharge within 24 hours and is
measured in units such as gallons.

Section 6. Production
Item 6.1. Indicate whether any effluent limitation guidelines (ELGs)
promulgated under Section 304 of the Clean Water Act (CWA)
apply to your facility. All ELGs promulgated by EPA appear in the
Federal Register and are published annually in 40 CFR
Subchapter N. An ELG applies if you have any operations
contributing process wastewater in any subcategory covered by
New Source Performance Standards (NSPS). If you are unsure
whether you are covered by a promulgated ELG, consult your
NPDES permitting authority (see Exhibit 1–1 of Form 1’s “General
Instructions”). You must check “Yes” if an applicable ELG has been
promulgated, even if the ELG is being contested in court. If you
believe that a promulgated ELG has been remanded for
reconsideration by a court and does not apply to your operations,
you may answer “No” to item 6.1 and skip to Section 7.
Item 6.2. Complete Item 6.2 by indicating the applicable ELG
category, ELG subcategory, and corresponding regulatory citation.
See the example below.

Section 7. Effluent Characteristics and Tables A through E
General Information. Section 7 requires you to report estimated
flow data for the parameters and pollutants listed in Tables A
through E, located at the end of Form 2D. You are not required
to conduct actual sampling and analysis at this time. If, however,
data from such analyses are available, you must report those
data. Note that no later than 24 months after you begin
discharging from the proposed facility, you must complete and
submit quantitative data for the pollutants and parameters in
Tables A through E. However, you need not report results for
tests you have already performed and reported under the
discharge monitoring requirements of your NPDES permit.
Complete a set of tables (Tables A through E) for each outfall at
your facility. Be sure to note the EPA Identification Number,
facility name, and outfall number at the top of each table page
and any associated attachments.
Tables A through D require you to report estimated effluent data,
with some exceptions, as discussed further below. Base your
estimates on available in-house or contractors’ engineering
reports or any other studies performed on the proposed facility.
Table E requires you to report quantitative data for the pollutants
listed, but only if it is already available.
Several tables require you to provide estimates for pollutants you
believe will be present in your discharge or will be limited directly
by an ELG or indirectly through promulgated limitations on an

2D-2

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Draft Application Forms - Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED

For those pollutants you believe will be present in the discharge,
you are to provide the maximum daily and average daily
concentration and total mass and the source of the information.
Use the following codes to report your source information:
Data Source
Engineering report
Actual data from pilot plants
Estimates from other engineering
reports
Data from other similar plants
Best professional estimates
Others

Code
1
1
2
3
4
5 and specify on
the table

To request a waiver, submit a written request to the NPDES
permitting authority in advance or with the permit application. The
written request should specify the parameters that should be waived
and for what outfall(s) and why. The NPDES permitting authority
may waive Table A requirements upon a determination that less
stringent reporting requirements are adequate to support issuance
of an NPDES permit. Attach a copy of any waiver approval notice(s)
received, if applicable, to this application.
Answer Item 7.1 by indicating if you are requesting a waiver for any
of your outfalls. If yes, continue to Item 7.2. Otherwise, complete
Table A by estimating your maximum daily and average daily
discharge. Provide the source(s) of your information. Also on
Table A, indicate whether you believe each of the parameters will
be present in the facility’s intake water. See “Reporting of Intake
Data” above for further information. Skip to Item 7.3.
Item 7.2. Indicate the outfalls for which you have requested a
waiver.
Item 7.3. Indicate if you have provided estimates or actual data for
all Table A parameters for each of your outfalls for which a waiver
has not been requested and attach the results to your application
package.

You may report some or all of your estimates (or actual data
when available) by attaching separate sheets of paper instead
of completing Tables A through E for each of your outfalls, so
long as the sheets contain all of the required information and
are similar in format to Tables A through E.

waiver for all pollutants for a given outfall, check the box indicating
this at the top of Table A.

indicator pollutant. 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,
intermediate and final products, byproducts, and any analyses of
any pollutant (you are required to report it).

Reporting of Intake Data

If you expect a pollutant to be present solely because of its
presence in your intake water, you must mark “Yes” under the
“Intake Water” column of Tables A through D. If you wish to
obtain credits for pollutants or parameters present in your
intake water, insert a separate sheet with a short statement of
why you believe you are eligible (see 40 CFR 122.45(g)).

Reporting of Effluent Data

Report all estimated pollutant or parameter levels as
concentration and as total mass, with the exception of discharge
flow, temperature, and pH.

Use the following abbreviations in the columns requiring “units”
in Tables A through E.
Concentration
ppm = parts per million

Mass
lbs = pounds

mg/L = milligrams per liter

ton = tons (English tons)

ppb = parts per billion

mg = milligrams

µg/L = micrograms per liter

g = grams

MPN = most probable number
per 100 milliliters

kg = kilograms
T = tonnes (metric tons)

Conventional and Non-Conventional Parameters
Item 7.1 and Table A. All applicants are required to complete
Table A for each outfall, including outfalls discharging only
noncontact cooling water or nonprocess water unless a waiver
has been received or requested from the NPDES permitting
authority. For each parameter listed on Table A, indicate
whether a waiver has been requested. If you have requested a

Certain Conventional and Non-Conventional Pollutants
Items 7.4 through 7.6 and Table B. Complete one table for each
outfall, including outfalls discharging only noncontact cooling water
or nonprocess wastewater. Check the box at the top of Table B if
you believe all pollutants listed will be absent in the discharge. If so,
you do not need to complete Table B for the noted outfall. (You still
need to complete Items 7.4 through 7.6.) Otherwise, for each
pollutant listed in Table B, indicate whether you expect it will be
present or absent in the discharge or whether the pollutant is limited
directly by an ELG or indirectly through promulgated limitations or
an indicator pollutant. (For example, total suspended solids is used
as an indicator to control the discharge of iron and aluminum.) Next,
provide an estimated maximum daily and average daily value,
including the source of the information. If you have quantitative data
available, report it. Also on Table B, indicate whether you believe
the listed pollutants will be present in the facility’s intake water. See
“Reporting of Intake Data” above for further information. Answer
“Yes” to Items 7.4 through 7.6 once you have completed the above
tasks.
Toxic Metals, Total Cyanide, and Total Phenols
Items 7.7 and 7.8 and Table C. Complete one table for each
outfall, including outfalls discharging only noncontact cooling water
or nonprocess wastewater. Check the box at the top of Table C if
you believe all pollutants listed will be absent in the discharge. If so,
you do not need to complete Table C for the noted outfall (unless
you have quantitative data available). You still need to respond to
Items 7.7 and 7.8, however. Otherwise, indicate whether you
believe each pollutant on Table C will be present or absent in your
discharge for each applicable outfall. For those pollutants you

2D-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED
2,4,5-trichlorophenoxy acetic acid (2,4,5-T) (CAS # 93-765).



2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4,5-TP)
(CAS # 93-72-1).



2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate (Erbon)
(CAS # 136-25-4).



0,0-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate
(Ronnel) (CAS # 299-84-3).



2,4,5-trichlorophenol (TCP) (CAS # 95-95-4).



Hexachlorophene (HCP) (CAS # 70-30-4).

Certain Hazardous Substances and Asbestos
Table E. Complete Table E for each outfall. Check the box at the
top of Table E if you believe all pollutants listed will be absent in the
discharge. Otherwise, for each pollutant listed in Table E, indicate
whether you believe it will be present or absent in the discharge. If
you have quantitative estimates available for any of the pollutants
listed, provide the maximum daily and average daily average value
and the source of the information. Also, on Table E, if you believe
the pollutant is or will be present in your facility’s intake water, state
so in the “Reason Pollutant Believed Present in Discharge” column.

The sales or production figures must be for the facility that will
be the source of the discharge. The data should not be limited
only to production or sales for the process or processes that will
contribute to the discharge, unless those are the only processes
at the facility.



believe will be present, provide an estimated maximum daily and
average daily value and source of the information. (Provide
quantitative data if you have them available.) Also, on Table C,
indicate whether you believe the pollutant is or will be present in
your facility’s intake water. See “Reporting of Intake Data” above
for more information. Answer “Yes” to Items 7.7 and 7.8 when
you have completed the above tasks.
Organic Toxic Pollutants
(Gas Chromatography/Mass Spectrometry or GC/MS
Fractions)
Item 7.9. Applicants are exempt from the reporting requirements
associated with Table D if they expect to have gross sales of
less than $100,000 per year for the next three years; also
exempt are coal mines with expected average production of less
than 100,000 tons of coal per year. If you believe you meet one
of these criteria, answer “Yes” to Item 7.9, check the small
business box at the top of Table D, and attach projected sales or
production figures. Skip to Item 7.12.

For sales data, where intra-corporate transfers of goods and
services will be involved, the transfer price per unit should
approximate market process 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. You may accomplish
this by using the gross national product price deflator (second
quarter of 1980 = 100). This index is available online from the
U.S. Department of Commerce, Bureau of Economic Analysis at
http://bea.gov/national/pdf/SNTables.pdf.

Item 7.10 and 7.11 and Table D. Complete one table for each
outfall, including outfalls discharging only noncontact cooling
water or nonprocess wastewater. Check the box at the top of
Table D if you believe all pollutants listed will be absent in the
discharge from the outfall. If so, you do not need to complete
Table D for the noted outfall (unless you have quantitative data
available). Otherwise, for each pollutant listed, indicate whether
you believe it will be present or absent in the discharge. For
those you believe will be present, provide an estimated
maximum daily and average daily value and the source of the
information. Also, on Table D, indicate whether you believe the
pollutant is or will be present in your facility’s intake water. See
“Reporting of Intake Data” above for further information. Finally,
answer “Yes” to Items 7.10 and 7.11 when you have completed
the above tasks.

2,3,7,8-Tetrachlorodibenzo-p-Dioxin (TCDD)
Item 7.12. Answer whether the facility uses or manufactures one
or more of the 2,3,7,8-TCDD congeners listed below or if you
know or have reason to believe that TCDD is or may be present
in effluent from any of your outfalls:

Item 7.13. Indicate whether, for each of your outfalls, you have
indicated whether you know or have reason to believe that any
pollutants listed in Table E are discharged.
Item 7.14. Indicate whether, for each of your outfalls, you have
completed and attached Table E to the application describing the
reasons the applicable pollutants are expected to be discharged
and providing quantitative data if available.
Under 40 CFR 117.12(a)(2), certain discharges of hazardous substances
(listed in Exhibit 2D-3 at the end of these instructions) may be exempted from
the requirements of Section 311 of the 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 can 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.
Exemptions are allowed from the requirements of CWA Section 311.
Applications for exemptions must set forth the following information:
1. The substance and the amount of each substance that may be discharged.
2. The origin and source of the discharge of the substance.
3. The treatment 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 that 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) or contact your NPDES permitting authority
for further information on exclusions from CWA Section 311.

Intake Credits
Item 7.15. Answer whether you are seeking to obtain credits for any
of the pollutants or parameters listed in Section 7 (Tables A through
E) in your intake water for any of the facility’s outfalls.

2D-4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED
Section 8. Engineering Report
Item 8.1. Indicate if any technical evaluations have been
conducted of your wastewater treatment, including engineering
reports or pilot plant studies. If yes, continue to Item 8.2. If no,
skip to Item 8.3.

FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A.

Item 8.2. Attach the technical evaluation(s) you considered when
responding to Item 8.1 and any related documentation, then
answer “Yes” to Item 8.2. The NPDES permit writer will use this
information to determine appropriate treatment methods and
associated permit conditions and limits.
Item 8.3. Answer “Yes” if you are aware of any existing plant(s)
that resemble your production processes, wastewater
constituents, or wastewater treatment. If you are unaware of such
plants, answer “No” and skip to Section 9.

Item 8.4. Provide the name and location of any existing plant(s)
that resemble(s) your production facility. You do not need to
conduct any studies to respond to this item.

For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer
means: (1) 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 decisionmaking functions for the corporation, or (2) 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.
B For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END
Submit your completed Form 1, Form 2D, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

Section 9. Other Information
Item 9.1. Indicate whether you have attached to the application
any optional information that you would like considered as part of
the application review process. These should be items beyond
those you have already noted as being included in the package.
Skip to Section 10 if you do not have further information to
provide.

Item 9.2. List the additional materials attached and note why you
think the NPDES permitting authority should consider them when
reviewing your application and developing your permit.
Section 10. Checklist and Certification Statement
Item 10.1. Review the checklist provided. In column 1, mark the
sections of Form 2D that you have completed and are submitting
with your application. For each section, indicate in column 2
whether you are submitting attachments.

Item 10.2. The CWA provides for severe penalties for submitting
false information on this application form. Section 309(c)(2) of the
CWA 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.”

2D-5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2D–1. Codes for Treatment Units and Disposal of Wastes Not Discharged
1.
1–A................. Ammonia stripping
1–B................. Dialysis
1–C ................ Diatomaceous earth filtration
1–D ................ Distillation
1–E................. Electrodialysis
1–F ................. Evaporation
1–G ................ Flocculation
1–H ................ Flotation
1–I .................. Foam fractionation
1–J ................. Freezing
1–K................. Gas-phase separation
1–L ................. Grinding (comminutors)
2.

CHEMICAL TREATMENT PROCESSES
2–G ................ Disinfection (ozone)
2–H ................ Disinfection (other)
2–I.................. Electrochemical treatment
2–J ................. Ion exchange
2–K ................ Neutralization
2–L................. Reduction

2–A................. Carbon adsorption
2–B................. Chemical oxidation
2–C ................ Chemical precipitation
2–D ................ Coagulation
2–E................. Dechlorination
2–F ................. Disinfection (chlorine)

PHYSICAL TREATMENT PROCESSES
1–M................ Grit removal
1–N ................ Microstraining
1–O ................ Mixing
1–P ................ Moving bed filters
1–Q ................ Multimedia filtration
1–R ................ Rapid sand filtration
1–S ................ Reverse osmosis (hyperfiltration)
1–T ................ Screening
1–U ................ Sedimentation (settling)
1–V ................ Slow sand filtration
1–W ............... Solvent extraction
1–X ................ Sorption

3–A................. Activated sludge
3–B................. Aerated lagoons
3–C ................ Anaerobic treatment
3–D ................ Nitrification–denitrification

BIOLOGICAL TREATMENT PROCESSES
3–E ................ Pre-aeration
3–F ................ Spray irrigation/land application
3–G ................ Stabilization ponds
3–H ................ Trickling filtration
4.

OTHER PROCESSES
4–C ............... Reuse/recycle of treated effluent
4–D ............... Underground injection

4–A................. Discharge to surface water
4–B................. Ocean discharge through outfall

SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–A................. Aerobic digestion
5–M................ Heat drying
5–B................. Anaerobic digestion
5–N ................ Heat treatment
5–C ................ Belt filtration
5–O ................ Incineration
5–D ................ Centrifugation
5–P ................ Land application
5–E................. Chemical conditioning
5–Q ................ Landfill
5–F ................. Chlorine treatment
5–R ................ Pressure filtration
5–G ................ Composting
5–S ................ Pyrolysis
5–H ................ Drying beds
5–T ................ Sludge lagoons
5–I .................. Elutriation
5–U ................ Vacuum filtration
5–J ................. Flotation thickening
5–V ................ Vibration
5–K................. Freezing
5–W ............... Wet oxidation
5–L ................. Gravity thickening

2D-6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2D–2. Example Line Drawing

2D-7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2D–3. Hazardous Substances
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 fluorite
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

2D-8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2D–3. Hazardous Substances
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 fluoride
296. Zirconium sulfate
297. Zirconium tetrachloride

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 (2,4,5-trichlorophenoxyacetic 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 (2,4,5-trichlorophenoxy
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

2D-9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2D
NPDES

NEW MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURAL OPERATIONS
THAT HAVE NOT YET COMMENCED DISCHARGE OF PROCESS WASTEWATER

SECTION 1. EXPECTED OUTFALL LOCATION (40 CFR 122.21(k)(1))
1.1 Provide information on each of the facility’s outfalls in the table below.
Outfall
Receiving Water
Latitude
Number
Name
Outfall Location

Longitude

Day

Year

Expected
Discharge
Date

SECTION 2. EXPECTED DISCHARGE DATE (40 CFR 122.21(k)(2))
2.1
Month

mgd
mgd
mgd
mgd
mgd

Treatment Units

Description
(include size, flow rate through each treatment unit,
retention time, etc.)

Code from
Exhibit 2D-1

Final Disposal of Solid or Liquid
Wastes Other Than by Discharge

Average Flows and Treatment

SECTION 3. AVERAGE FLOWS AND TREATMENT (40 CFR 122.21(k)(3)(i))
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets as
necessary.
**Outfall Number** _________
Operations Contributing to Flow
Operation
Average Flow

EPA Form 3510-2D (Revised )

Page 1

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

3.1

**Outfall Number** _________
Operations Contributing to Flow
Operation

Cont.

Average Flow
mgd
mgd
mgd
mgd
mgd

Treatment Units
Final Disposal of Solid or Liquid
Wastes Other Than by Discharge

Code from
Exhibit 2D-1

**Outfall Number** _________
Operations Contributing to Flow
Operation

Average Flows and Treatment Continued

Description
(include size, flow rate through each treatment unit,
retention time, etc.)

mgd
mgd
mgd
mgd
mgd

Treatment Units

Description
(include size, flow rate through each treatment unit,
retention time, etc.)

EPA Form 3510-2D (Revised )

Average Flow

Code from
Exhibit 2D-1

Final Disposal of Solid or Liquid
Wastes Other Than by Discharge

Page 2

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Line
Drawing

SECTION 4. LINE DRAWING (40 CFR 122.21(k)(3)(ii))
Have you attached a line drawing to this application that shows the water flow through your facility with a water
4.1
balance? (See instructions for drawing requirements. See Exhibit 2D–2 at end of instructions for example.)



Yes

SECTION 5. INTERMITTENT OR SEASONAL FLOWS (40 CFR 122.21(k)(3)(iii))
Except for stormwater runoff, leaks, or spills, are any expected discharges described in Sections 1 and 3 intermittent
5.1
or seasonal?



No  SKIP to Section 6.

Provide information on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if
necessary.
Frequency
Rate and Volume
Outfall Operations
Duration
Average
Average
Maximum Daily
Maximum Total
Number
(list)
Days/Week Months/Year
Discharge
Volume

Operations
(list)

months/year

mgd

gallons

days/week

months/year

mgd

gallons

days

days/week

months/year

mgd

gallons

days

Frequency
Average
Average
Days/Week Months/Year

Rate and Volume
Maximum Daily
Maximum Total
Discharge
Volume

Outfall
Number

days/week

Intermittent or Seasonal Flows

5.2



Yes

Outfall
Number

Operations
(list)

days

Duration

days/week

months/year

mgd

gallons

days

days/week

months/year

mgd

gallons

days

days/week

months/year

mgd

gallons

days

Frequency
Average
Average
Days/Week Months/Year

Duration

months/year

mgd

gallons

days

days/week

months/year

mgd

gallons

days

days/week

months/year

mgd

gallons

days

days/week

Rate and Volume
Maximum Daily
Maximum Total
Discharge
Volume

SECTION 6. PRODUCTION (40 CFR 122.21(k)(4))
6.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under CWA Section 304 apply to your facility?

Production



6.2

Yes



No  SKIP to Section 7.

Provide the following information on applicable ELGs.
ELG Category

EPA Form 3510-2D (Revised )

ELG Subcategory

Regulatory Citation

Page 3

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

6.3

Are the limitations in the applicable ELGs expressed in terms of production (or other measure of operation)?


6.4

Form Approved
OMB No.
Form Expires



Yes

No  SKIP to Section 7.

Provide an expected measure of average daily production expressed in terms and units of applicable ELGs.
Outfall
Number

Year

Expected Actual Average Daily Production for First Three Years
Quantity per Day
Operation, Product, or Material
(note basis if applicable)

Unit of Measure

Year 1

Production Continued

Year 2
Year 3

Year 2

Year 3

Year 1

Year 1
Year 2
Year 3

SECTION 7. EFFLUENT CHARACTERISTICS (40 CFR 122.21(k)(5))

See the instructions to determine the parameters and pollutants you are required to monitor and, in turn, the tables you must
complete. Note that not all applicants need to complete each table.
Table A. Conventional and Non-Conventional Parameters
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A parameters for any
7.1
of your outfalls?



No  SKIP to Item 7.3.

If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.

Outfall number ________
Outfall number ________
Outfall number ________
Have
you
have
provided
estimates
or
actual
data
for
all
Table
A
parameters
for
each
of your outfalls for which a
7.3
waiver has not been requested and attached the results to this application package?
No; a waiver has been requested from my
 Yes
 NPDES permitting authority for all parameters at
all outfalls.
Table B. Certain Conventional and Non-Conventional Pollutants
Have you checked “Believed Present” for all pollutants listed in Table B that are limited directly or indirectly by an
7.4
applicable ELG?
Yes

 No

Effluent Characteristics

7.2

Yes

7.5

Have you checked “Believed Present” or “Believed Absent” for all remaining pollutants listed in Table B?


7.6

Yes
 No
Have you provided estimated data for those Table B pollutants for which you have indicated are “Believed Present”
in your discharge?



Yes

EPA Form 3510-2D (Revised )



Page 4

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Table C. Toxic Metals, Total Cyanide, and Total Phenols
Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed on Table C
7.7
for all outfalls?
Yes

 No
7.8
Have you completed Table C by providing estimated data for pollutants you indicated are “Believed Present,”
including the source of the information, for each applicable outfall?



Yes



Table D. Organic Toxic Pollutants (GC/MS Fractions)
7.9
Do you qualify for a small business exemption under the criteria specified in the Instructions?
Yes  Note that you qualify at the top of
No

Table D, then SKIP to Item 7.12.
Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed on Table D
for all outfalls?

7.10

Yes
No

7.11 Have you completed Table D by providing estimated data for pollutants you indicated are “Believed Present,”
including the source of the information, for each applicable outfall?
Yes
No


2,3,7,8-Tetrachlorodibenzo-p-Dioxin (TCDD)
7.12 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the Instructions, or do you
know or have reason to believe that TCDD is or may be present in effluent from any of your outfalls?



Effluent Characteristics Continued



Yes



Table E. Certain Hazardous Substances and Asbestos
7.13 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed in Table E
for all outfalls?


7.14

Yes



Have you completed Table E by reporting the reason the pollutants are expected to be present and available
quantitative data for pollutants you indicated are “Believed Present” for each applicable outfall?



Yes



Engineering Report

Intake Credits, Tables A through E
7.15 Are you applying for net credits for the presence of any of the pollutants on Tables A through E for any of your
outfalls?
Yes  Consult with your NPDES permitting

 No
authority.
SECTION 8. ENGINEERING REPORT (40 CFR 122.21(k)(6))
8.1
Do you have any technical evaluations of your wastewater treatment, including engineering reports or pilot plant
studies?



8.2



No  SKIP to Item 8.3.

Have you provided the technical evaluation and all related documents to this application package?



8.3

Yes
Yes



Are you aware of any existing plant(s) that resemble production processes, wastewater constituents, or wastewater
treatment at your facility?



Yes

EPA Form 3510-2D (Revised )



No  SKIP to Section 9.

Page 5

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Engineering Report
Continued

8.4

Provide the name and location of the similar plants.
Name of Similar Plants

Location of Similar Plants

SECTION 9. OTHER INFORMATION (40 CFR 122.21(k)(7))
9.1
Have you attached any optional information that you would like considered as part of the application review process
(i.e., material beyond that which you have already noted in the application as being attached)?
9.2



Yes

No  SKIP to Section 10.

List the additional items and briefly note why you have included them.
1.
2.

Other Information



R


Section 4: Line Drawing



w/ line drawing



Section 5: Intermittent or
Seasonal Flows



w/ attachments



Section 6: Production



w/ attachments



Checklist and Certification Statement

SECTION 10. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
10.1 In Column 1 below, mark the sections of Form 2D that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to complete all sections or tables, or provide attachments.
Column 1
Column 2
Section 1: Expected Outfall
 w/ attachments (e.g., responses for additional outfalls)

Location
Section 2: Expected
 w/ attachments

Discharge Date
Section 3: Average Flows
 w/ attachments

and Treatment



Section 7: Effluent
Characteristics



Section 8: Engineering
Report



Section 9: Other Information



Section 10: Checklist and
Certification Statement

EPA Form 3510-2D (Revised )



w/ additional attachments

w/ Table A waiver
request or
approval



Table A



Table B



Table C



Table D



Table E



w/ other
attachments




w/ technical evaluations and related attachments
w/ optional information



w/ attachments

Page 6

Contains Nonbinding Recommendations
NPDES
NumberForms - Not for Implementation
Facility Name
Draft Permit
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

10.2

Certification Statement
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.
Name (print or type first and last name)
Official title
Signature

Date signed

Checklist and Certification Statement
Continued

EPA Form 3510-2D (Revised )

Page 7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
FacilityDraft
NameApplication Forms - Not for Implementation
Outfall Number

EPA Identification Number

TABLE A. CONVENTIONAL AND NON-CONVENTIONAL PARAMETER ESTIMATES (40 CFR 122.21(k)(5)(i))1
Effluent Data
Waiver
Units
Maximum Daily Average Daily
Pollutant
Requested
Source of Information
Discharge
Discharge
(if applicable)
(use codes in instructions)
(required)

(if available)



Check here if you have applied to your NPDES authority for a waiver for all of the pollutants listed on this table for the noted outfall.

Biochemical oxygen
demand (BOD5)



Chemical oxygen demand
(COD)



Total organic carbon
(TOC)



Total suspended solids
(TSS)



Ammonia (as N)



Flow

Temperature (summer)

Concentration

Mass
Concentration
Mass

Concentration
Mass

Temperature (winter)

Mass



Rate



°C



°C

Concentration

pH (minimum)



Standard units

s.u.

pH (maximum)



Standard units

s.u.

Form Approved
OMB No.
Form Expires

Intake Water
Believed Present?
(check only one response per
parameter)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



EPA Form 3510-2D (Revised )

Page 1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
Facility
Name
Outfall Number
Draft
Application Forms - Not for Implementation

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1
Presence or Absence
Estimated Data for Pollutants Expected to be Present or Limited by an ELG
(check one)

Pollutant

Believed
Present

(Provide both concentration and mass estimates for each pollutant.)

Believed
Absent

Units

Effluent
Maximum Daily Average Daily
Discharge
Discharge
(required)

(if available)

Source of Information

Intake Water
Believed Present?
(check only one
response per item)

(use codes in instructions)

Check () here if you believe all pollutants listed to be absent from the discharge. You need not complete Table B for the noted outfall unless you have quantitative data available.

Bromide
(24959-67-9)



Chlorine, total
residual



Color



Fecal coliform



Fluoride
(16984-48-8)



Nitrate-nitrite



Nitrogen, total
organic (as N)



Oil and grease



Phosphorus (as P),
total (7723-14-0)



Sulfate (as SO4)
(14808-79-8)



Sulfide (as S)



11.

Mass
Concentration
Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

10.

Concentration

EPA Form 3510-2D (Revised )



Concentration

Mass

Concentration
Mass

Concentration

Mass



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 3

Contains Nonbinding Recommendations
Facility
Name
Outfall Number
Draft
Application Forms - Not for Implementation

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1
Presence or Absence
Estimated Data for Pollutants Expected to be Present or Limited by an ELG
(check one)

Pollutant

Believed
Present

(Provide both concentration and mass estimates for each pollutant.)

Believed
Absent

Units

Effluent
Maximum Daily Average Daily
Discharge
Discharge
(required)



13.

Surfactants



14.

Aluminum, total
(7429-90-5)



15.

Barium, total
(7440-39-3)



16.

Boron, total
(7440-42-8)



17.

Cobalt, total
(7440-48-4)



18.

Iron, total
(7439-89-6)



19.

Magnesium, total
(7439-95-4)



20.

Molybdenum, total
(7439-98-7)



21.

Manganese, total
(7439-96-5)



22.

Tin, total
(7440-31-5)



Concentration
Mass
Concentration
Mass
Concentration
Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

Concentration

Mass

EPA Form 3510-2D (Revised )

Concentration

Mass

Concentration

Mass

(check only one
response per item)

(use codes in instructions)



Sulfite (as SO3)
(14265-45-3)

12.

(if available)

Source of Information

Intake Water
Believed Present?



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 4

Contains Nonbinding Recommendations
Facility
Name
Outfall Number
Draft
Application Forms - Not for Implementation

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1
Presence or Absence
Estimated Data for Pollutants Expected to be Present or Limited by an ELG
(check one)

Pollutant

Believed
Present

(Provide both concentration and mass estimates for each pollutant.)

Believed
Absent

Units

Effluent
Maximum Daily Average Daily
Discharge
Discharge
(required)

Titanium, total
(7440-32-6)

24.

Radioactivity

24.1 Alpha, total



Concentration
Mass
Concentration
Mass

(check only one
response per item)

(use codes in instructions)

23.

(if available)

Source of Information

Intake Water
Believed Present?



Yes



Yes





Concentration
 Yes  No
Mass
Concentration
24.3. Radium, total

 Mass
 Yes  No
Concentration
24.4 Radium 226, total

 Mass
 Yes  No
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
24.2 Beta, total

EPA Form 3510-2D (Revised )

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
Facility
DraftName
Application Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE C. TOXIC METALS, TOTAL CYANIDE, AND TOTAL PHENOLS (40 CFR 122.21(k)(5)(iii)(A))1
Presence or Absence
Estimated Data for Pollutants Expected to be Present in Discharge
(check one)

Pollutant
(CAS Number, if available)

Believed
Present

(Provide both concentration and mass estimates for each pollutant.)

Believed
Absent

Units

Effluent
Maximum
Average
Daily
Daily
Discharge Discharge
(required)

Intake Water
Source of Information
(Use codes in Instructions.)

(if available)

Believed Present?
(Check only one
response per pollutant.)

() here if you believe all pollutants listed to be absent from the discharge. You need not complete Table C for the noted outfall unless you have quantitative data
 Check
available.
1. Antimony, Total
Concentration


 Yes
 No
(7440-36-0)
Mass
2. Arsenic, Total
Concentration


 Yes
 No
(7440-38-2)
Mass
3. Beryllium, Total
Concentration


 Yes
 No
(7440-41-7)
Mass
4. Cadmium, Total
Concentration


 Yes
 No
(7440-43-9)
Mass
5. Chromium, Total
Concentration


 Yes
 No
(7440-47-3)
Mass
6. Copper, Total
Concentration


 Yes
 No
(7440-50-8)
Mass
7. Lead, Total
Concentration


 Yes
 No
(7439-92-1)
Mass
8. Mercury, Total
Concentration


 Yes
 No
(7439-97-6)
Mass
9. Nickel, Total
Concentration


 Yes
 No
(7440-02-0)
Mass
10. Selenium, Total
Concentration


 Yes
 No
(7782-49-2)
Mass
11. Silver, Total
Concentration


 Yes
 No
(7440-22-4)
Mass
12. Thallium, Total
Concentration


 Yes
 No
(7440-28-0)
Mass
13. Zinc, Total
Concentration


 Yes
 No
(7440-66-6)
Mass
14. Cyanide, Total
Concentration


 Yes
 No
(57-12-5)
Mass
15. Phenols, Total
Concentration


 Yes
 No
Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See Instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2D (Revised )

Page 7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1
Presence or Absence
Estimated Data for Pollutants Expected to Be Present in Discharge
(check one)

Pollutant

Believed
Present

(CAS Number, if available)

Believed
Absent

(provide both concentration and mass estimates for each pollutant)

Units

Maximum
Daily
Discharge

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

Intake Water
Believed Present?
(check only one response per
pollutant)

Check here if all pollutants listed in Table D are expected to be absent from your facility’s discharge.



Check here if the facility believes it is exempt from Table D reporting requirements because it is a qualified small business. See the instructions for exemption criteria and for a list
of materials you must attach to the application.



Note: If you check either of the above boxes, you do not need to complete Table D for the noted outfall unless you have quantitative data available.

1. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)
1.1
Acrolein
Concentration


(107-02-8)
Mass
1.2
Acrylonitrile
Concentration


(107-13-1)
Mass
1.3
Benzene
Concentration


(71-43-2)
Mass
1.4
Bromoform
Concentration


(75-25-2)
Mass
1.5
Carbon tetrachloride
Concentration


(56-23-5)
Mass
1.6
Chlorobenzene
Concentration


(108-90-7)
Mass
1.7
Chlorodibromomethane
Concentration


(124-48-1)
Mass
1.8
Chloroethane
Concentration


(75-00-3)
Mass
1.9
2-chloroethylvinyl ether
Concentration


(110-75-8)
Mass
1.10 Chloroform (67-66-3)
Concentration


Mass
1.11 Dichlorobromomethane
Concentration


(75-27-4)
Mass
EPA Form 3510-2D (Revised )



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



No
Page 9

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Absent

1,1-dichloroethane
(75-34-3)



1,2-dichloroethane
(107-06-2)



1,1-dichloroethylene
(75-35-4)



1.15

1,2-dichloropropane
(78-87-5)



1.16

1,3-dichloropropylene
(542-75-6)



1.17

Ethylbenzene
(100-41-4)



1.18

Methyl bromide
(74-83-9)



1.19

Methyl chloride
(74-87-3)

1.20

Methylene chloride
(75-09-2)

1.21

1,1,2,2-tetrachloroethane
(79-34-5)

1.22

1.13
1.14









Tetrachloroethylene
(127-18-4)



1.23

Toluene
(108-88-3)



1.24

1,2-trans-dichloroethylene
(156-60-5)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

Concentration
Mass
Concentration
Mass
Concentration
Mass

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

1.12

Units

Maximum
Daily
Discharge

Believed
Present

(CAS Number, if available)

Pollutant

(provide both concentration and mass estimates for each pollutant)

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 10

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

Believed
Absent

1,1,1-trichloroethane
(71-55-6)



1.26

1,1,2-trichloroethane
(79-00-5)



1.27

Trichloroethylene
(79-01-6)



1.28

Vinyl chloride
(75-01-4)



2. Organic Toxic Pollutants (GC/MS Fraction—Acid Compounds)
2.1
2-chlorophenol


(95-57-8)
2,4-dichlorophenol
(120-83-2)



2.3

2,4-dimethylphenol
(105-67-9)



2.4

4,6-dinitro-o-cresol
(534-52-1)

2.5

2,4-dinitrophenol
(51-28-5)

2.6

2-nitrophenol
(88-75-5)

2.7




Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

2.2

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass



4-nitrophenol
(100-02-7)



2.8

p-chloro-m-cresol
(59-50-7)



2.9

Pentachlorophenol
(87-86-5)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

1.25

Units

Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 11

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

2.10

Phenol
(108-95-2)

Believed
Absent

Units

Concentration
Mass
2.11 2,4,6-trichlorophenol
Concentration


(88-05-2)
Mass
3. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds)
3.1
Acenaphthene
Concentration


(83-32-9)
Mass
Acenaphthylene
(208-96-8)



3.3

Anthracene
(120-12-7)



3.4

Benzidine
(92-87-5)



3.5

Benzo (a) anthracene
(56-55-3)



3.6

Benzo (a) pyrene
(50-32-8)

3.7

3,4-benzofluoranthene
(205-99-2)

3.8

Benzo (ghi) perylene
(191-24-2)

3.9








Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

3.2



Benzo (k) fluoranthene
(207-08-9)



3.10

Bis (2-chloroethoxy) methane
(111-91-1)



3.11

Bis (2-chloroethyl) ether
(111-44-4)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)



Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 12

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

Believed
Absent

Bis (2-chloroisopropyl) ether
(102-80-1)



3.13

Bis (2-ethylhexyl) phthalate
(117-81-7)



3.14

4-bromophenyl phenyl ether
(101-55-3)



3.15

Butyl benzyl phthalate
(85-68-7)



3.16

2-chloronaphthalene
(91-58-7)



3.17

4-chlorophenyl phenyl ether
(7005-72-3)



3.18

Chrysene
(218-01-9)



3.19

Dibenzo (a,h) anthracene
(53-70-3)



3.20

1,2-dichlorobenzene
(95-50-1)

3.21

1,3-dichlorobenzene
(541-73-1)

3.22

1,4-dichlorobenzene
(106-46-7)

3.23











3,3-dichlorobenzidine
(91-94-1)



3.24

Diethyl phthalate
(84-66-2)



3.25

Dimethyl phthalate
(131-11-3)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

3.12

Units

Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 13

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

Believed
Absent

Di-n-butyl phthalate
(84-74-2)



3.27

2,4-dinitrotoluene
(121-14-2)



3.28

2,6-dinitrotoluene
(606-20-2)



3.29

Di-n-octyl phthalate
(117-84-0)



3.30

1,2-diphenylhydrazine
(as azobenzene) (122-66-7)



3.31

Fluoranthene
(206-44-0)



3.32

Fluorene
(86-73-7)



3.33

Hexachlorobenzene
(118-74-1)



3.34

Hexachlorobutadiene
(87-68-3)

3.35









Hexachlorocyclopentadiene
(77-47-4)



3.36

Hexachloroethane
(67-72-1)



3.37.

Indeno (1,2,3-cd) pyrene
(193-39-5)



3.38

Isophorone
(78-59-1)



3.39

Naphthalene
(91-20-3)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

3.26

Units

Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 14

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

Believed
Absent

Nitrobenzene
(98-95-3)



3.41

N-nitrosodimethylamine
(62-75-9)



3.42

N-nitrosodi-n-propylamine
(621-64-7)



3.43

N-nitrosodiphenylamine
(86-30-6)



3.44

Phenanthrene
(85-01-8)



3.45

Pyrene
(129-00-0)



3.46

1,2,4-trichlorobenzene
(120-82-1)



α-BHC
(319-84-6)

4.3

β-BHC
(319-85-7)

4.4






4. Organic Toxic Pollutants (GC/MS Fraction—Pesticides)
4.1. Aldrin

(309-00-2)
4.2

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass






γ-BHC
(58-89-9)



4.5

δ-BHC
(319-86-8)



4.6

Chlordane
(57-74-9)



EPA Form 3510-2D (Revised )

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

3.40

Units

Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Page 15

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Believed
Present

Believed
Absent

4,4’-DDT
(50-29-3)



4.8

4,4’-DDE
(72-55-9)



4.9

4,4’-DDD
(72-54-8)



4.10

Dieldrin
(60-57-1)



4.11

α-endosulfan
(115-29-7)



β-endosulfan
(115-29-7)



Endosulfan sulfate
(1031-07-8)



4.13
4.14

Endrin aldehyde
(7421-93-4)





Concentration
Mass



Concentration
Mass

Intake Water
Believed Present?
(check only one response per
pollutant)



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



Yes



4.15

Endrin
(72-20-8)



4.12

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

4.7

Units

Maximum
Daily
Discharge

Pollutant
(CAS Number, if available)

(provide both concentration and mass estimates for each pollutant)

EPA Form 3510-2D (Revised )

Page 16

Contains Nonbinding Recommendations
Facility
Name
Draft Application
Forms - Not for Implementation Outfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

Pollutant

Believed
Present

(CAS Number, if available)

4.16

Heptachlor
(76-44-8)

(provide both concentration and mass estimates for each pollutant)

Believed
Absent

Units

Maximum
Daily
Discharge

Effluent
Average
Source of
Daily
Information
Discharge (use codes in instructions)

Intake Water
Believed Present?
(check only one response per
pollutant)

Concentration
 Yes 
Mass
4.17 Heptachlor epoxide
Concentration


 Yes 
(1024-57-3)
Mass
4.18 PCB-1242
Concentration


 Yes 
(53469-21-9)
Mass
4.19 PCB-1254
Concentration


 Yes 
(11097-69-1)
Mass
4.20 PCB-1221
Concentration


 Yes 
(11104-28-2)
Mass
4.21 PCB-1232
Concentration


 Yes 
(11141-16-5)
Mass
4.22 PCB-1248
Concentration


 Yes 
(12672-29-6)
Mass
4.23 PCB-1260
Concentration


 Yes 
(11096-82-5)
Mass
4.24 PCB-1016
Concentration


 Yes 
(12674-11-2)
Mass
4.25 Toxaphene
Concentration


 Yes 
(8001-35-2)
Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).



No
No
No
No
No
No
No
No
No
No



EPA Form 3510-2D (Revised )

Page 17

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

Contains Nonbinding Recommendations
Facility
Name
Draft
Application Forms - Not for ImplementationOutfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Believed
Absent

Reason Pollutant Believed Present in Discharge

Available Quantitative Data
(specify units)

Check () here if you believe all pollutants listed to be absent from the discharge. You need not complete Table E for the noted outfall unless you have quantitative data available.

Asbestos



Acetaldehyde



Allyl alcohol



Allyl chloride



Amyl acetate



Aniline



Benzonitrile



Benzyl chloride



Butyl acetate



15. Chlorpyrifos



16. Coumaphos



17. Cresol



12. Carbaryl
13. Carbofuran

14. Carbon disulfide

10. Butylamine
11. Captan



18. Crotonaldehyde

EPA Form 3510-2D (Revised )

Page 19

Contains Nonbinding Recommendations
Facility
Name
Draft
Application Forms - Not for ImplementationOutfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1
Presence or Absence
Believed
Absent

19. Cyclohexane



20. 2,4-D (2,4-dichlorophenoxyacetic acid)



21. Diazinon



22. Dicamba



23. Dichlobenil



24. Dichlone



35. Ethylene diamine



36. Ethylene dibromide



37. Formaldehyde



25. 2,2-dichloropropionic acid
26. Dichlorvos
27. Diethyl amine
28. Dimethyl amine

31. Disulfoton
32. Diuron

34. Ethion

33. Epichlorohydrin

Available Quantitative Data
(specify units)

29. Dintrobenzene
30. Diquat

Reason Pollutant Believed Present in Discharge

Believed
Present

(check one)

Pollutant

EPA Form 3510-2D (Revised )

Page 20

Contains Nonbinding Recommendations
Facility
Name
Draft
Application Forms - Not for ImplementationOutfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1
Presence or Absence
Believed
Absent

38. Furfural



39. Guthion



40. Isoprene



41. Isopropanolamine



42. Kelthane



43. Kepone



53. Monomethyl amine



54. Naled



55. Naphthenic acid



56. Nitrotoluene



44. Malathion
45. Mercaptodimethur
46. Methoxychlor
47. Methyl mercaptan

50. Mevinphos
51. Mexacarbate

52. Monoethyl amine

Available Quantitative Data
(specify units)

48. Methyl methacrylate
49. Methyl parathion

Reason Pollutant Believed Present in Discharge

Believed
Present

(check one)

Pollutant

EPA Form 3510-2D (Revised )

Page 21

Contains Nonbinding Recommendations
Facility
Name
Draft
Application Forms - Not for ImplementationOutfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1
Presence or Absence
Believed
Absent

57. Parathion



58. Phenolsulfonate



59. Phosgene



60. Propargite



61. Propylene oxide



62. Pyrethrins



72. Triethanolamine



73. Triethylamine



74. Trimethylamine



75. Uranium



63. Quinoline
64. Resorcinol
65. Strontium
66. Strychnine
67. Styrene
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid)

69. TDE (tetrachlorodiphenyl ethane)
70.

2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]

71. Trichlorofon

Available Quantitative Data
(specify units)

68.

Reason Pollutant Believed Present in Discharge

Believed
Present

(check one)

Pollutant

EPA Form 3510-2D (Revised )

Page 22

Contains Nonbinding Recommendations
Facility
Name
Draft
Application Forms - Not for ImplementationOutfall Number

EPA Identification Number

Form Approved
OMB No.
Form Expires

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1
Presence or Absence
Believed
Present

Believed
Absent

76. Vanadium



77. Vinyl acetate



78. Xylene



79. Xylenol



80. Zirconium



Reason Pollutant Believed Present in Discharge

Available Quantitative Data
(specify units)

(check one)

Pollutant

EPA Form 3510-2D (Revised )

Page 23

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2E
Revised

Water Permits Division

Application Form 2E

Manufacturing, Commercial,
Mining, and Silvicultural
Facilities Which Discharge
Only Nonprocess Wastewater

NPDES Permitting Program

Note: Complete this form and Form 1 if your facility is a new or existing manufacturing, commercial,
mining, and silvicultural facility that discharges only nonprocess wastewater.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect and complete
Form 2E to be 14 hours. 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 about the burden estimate or any other aspect of this collection of
information to the Chief, Information Policy Branch (PM-223), U.S. Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17th Street, Washington, DC 20503, marked
“Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2E—INSTRUCTIONS
Follow-up Requirements for New Dischargers
Note that no later than 24 months after commencement of
discharge from the proposed facility, you must complete and
submit Section 4 of this form. At that time you must test and report
actual rather than estimated data for the pollutants or parameters
listed, unless waived by the NPDES permitting authority.

Line-by-Line Instructions
If you have multiple outfalls, you must submit a separate Form 2E
for each (Sections 1, 3, and 4 only).

Section 1. Outfall Location
Item 1.1. Complete sections 1 through 6 for each outfall. Provide
the latitude and longitude to the nearest 15 seconds for the outfall.
Latitude and longitude coordinates may be obtained in a variety of
ways, including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS). The
location of each outfall (i.e., where the coordinates are collected)
shall be the point where the discharge is released into a water of
the United States. If you need further guidance in responding to
Item 1.1, refer to http://www.epa.gov/geospatial/latitudelongitudedata-standard.

General Instructions
Who Must Complete Form 2E?
You must complete Form 2E if you answered “Yes” to Item 1.2.4 on
Form 1—that is, if you are a new or existing facility (including
manufacturing, commercial, mining, and silvicultural facilities) that
discharges only nonprocess wastewater.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2E) to
your National Pollutant Discharge Elimination System (NPDES)
permitting authority. Consult Exhibit 1–1 of Form 1’s “General
Instructions” to identify your NPDES permitting authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2E (or related attachments) as
confidential.
You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2E. Note that NPDES permitting authorities will deny claims for
treating any effluent data as confidential. If you do not assert a
claim of confidentiality at the time you submit your information to
the NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will handle
claims of confidentiality in accordance with the Agency’s business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).
Completion of Forms
Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.
Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of
each page of Form 2E and any attachments. If you do not know
your EPA Identification Number, contact your NPDES permitting
authority. See Exhibit 1–1 of Form 1’s “General Instructions” for
contact information.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter “NA” for “not applicable” to
demonstrate that you considered the item and determined a
response was not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
Definitions
The legal definitions of all key terms used in these instructions and
Form 2E are in the “Glossary” at the end of the “General
Instructions” in Form 1.

Section 2. Discharge Date
Item 2.1. Indicate whether you are a new or an existing discharger.
If you are an existing discharger, skip to Section 3 after completing
this item.
Item 2.2. Indicate the date on which the facility will or is estimated
to commence discharge.
Section 3. Waste Types
Item 3.1. Indicate the general type(s) of wastes being discharged or
to be discharged, depending on whether you are an existing or new
discharger. If you mark the response “Other Nonprocess
Wastewater,” specify the nature of your discharge.
Item 3.2. Indicate if the facility uses cooling water additives. If yes,
continue. If no, skip to Section 4.
Item 3.3. List the cooling water additives being used (or to be used)
and specify the composition of the additives, if such information is
available to you. You can generally find composition information on
product labels or from manufacturers’ data sheets.
Section 4. Effluent Characteristics
Items 4.1 to 4.8. These items require you to collect and report data
for the parameters and pollutants listed in Section 4. The
instructions are distinct for applicants with existing discharges
versus applicants that are new.
Important note: Read the “General Instructions for Reporting,
Sampling, and Analysis” on pages 2E-3 and 2E-4 before
completing Section 4.

2E-1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2E—INSTRUCTIONS CONTINUED

limitations. 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) add a short
statement as to why you believe you are eligible. See also 40 CFR
122.45(g). You will be contacted by the NPDES permitting authority
with further instructions.
Section 8. Checklist and Certification Statement
Item 8.1. Review the checklist provided on the application. In
Column 1, mark the sections of Form 2E that you have completed
and are submitting with your application. For each section in
Column 2, indicate whether you are submitting attachments.
Item 8.2. The Clean Water Act (CWA) provides for severe penalties
for submitting false information on this application form. CWA
Section 309(c)(2) 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 AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A. For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) 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 (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END

Item 4.1. Indicate whether you have completed monitoring for all
parameters in the table under Item 4.2 and attached it to the
application package. If you answer “No” because you have
requested a waiver from your NPDES authority, skip to Section 5. If
“Yes,” continue to Item 4.2.
Item 4.2. Provide the sampling data requested in the table per the
“General Instructions for Reporting, Sampling, and Analysis” for
biochemical oxygen demand (BOD), total suspended solids (TSS),
oil and grease, ammonia (as N), flow, pH, and temperature (winter
and summer).
Item 4.3. Answer whether you believe fecal coliform to be present
in your discharge or whether sanitary waste is discharged (or will be
discharged). If you answer “No,” skip to Item 4.5. Otherwise,
continue to Item 4.4.
Item 4.4. Provide the sampling data requested in the table per the
“General Instructions for Reporting, Sampling, and Analysis” for
fecal coliform, Escherichia coli (E. coli), and enterococci.
Item 4.5. Indicate whether chlorine is used (or will be used). If no,
skip to Item 4.7. Otherwise, continue to Item 4.6.
Item 4.6. Provide the sampling data requested in the table per the
“General Instructions for Reporting, Sampling, and Analysis” for
total residual chlorine.
Item 4.7. Answer whether non-contact cooling water is (or will be)
discharged from your facility. If no, skip to Section 5. If yes,
continue to Item 4.8.
Item 4.8. Provide the sampling data requested in the table per the
“General Instructions for Reporting, Sampling, and Analysis” for
chemical oxygen demand (COD), and total organic carbon (TOC).
Section 5. Flow
Item 5.1. Indicate whether any of the discharges that you described
in Sections 1 and 3 (except for stormwater runoff, leaks, or spills)
are intermittent or seasonal. If yes, continue to Item 5.2. If no, skip
to Section 6.
Item 5.2. Describe the average frequency of flow and duration of
any intermittent or seasonal discharge (except for stormwater
runoff, leaks, or spills) in gallons or million gallons per day (gpd or
mgd), whichever is appropriate. The frequency of flow is the
number of days or months per year there is an intermittent
discharge. Duration is the number of days or hours per discharge.
For new dischargers, report your best estimate.
Section 6. Treatment System
Item 6.1. Briefly describe 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 (or to be applied), such as grit
removal, ammonia stripping, dialysis, etc.
Section 7. Other Information
Item 7.1. OPTIONAL ITEM. Report any additional information or
data (such as sampling results) that you believe the NPDES
permitting authority should consider when establishing permit

2E-2

Submit your completed Form 1, Form 2E, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis
Important note: Read these instructions before completing Section
4 of Form 2E.
General Items
Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit number,
facility name, and applicable outfall number at the top of each page
of any associated attachments.
You may report some or all of the required data by attaching
separate sheets of paper instead of completing Section 4 for each
of your outfalls so long as the sheets contain all of the required
information and are similar in format to Section 4.

ppb = parts per billion
µg/L = micrograms per liter

Flow, temperature, pH, and fecal coliform organisms must be
reported as mgd, degrees Celsius (°C), standard units, and most
probable number per 100 milliliters (MPN/100 mL), respectively.
Use the following abbreviations in the columns requiring “units” in
Section 4.

mg/L = milligrams per liter

MPN = most probable number per
100 milliliters

Mass

lbs = pounds

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 in-house or contractor engineering reports or any other
studies performed on the proposed facility.

ton = tons (English tons)
mg = milligrams

g = grams
kg = kilograms
T = tonnes (metric tons)

Pollutants Solely in Intake Water
If you expect a pollutant to be present solely because of its
presence in your intake water, you must still provide an estimate or
analytical result in Section 4; however, you should indicate in
Section 7 in Item 7.1 that you believe the pollutant or parameter to
be present only due to its presence in your source water. See the
instructions under Item 7.1.

Existing Dischargers

You must provide maximum daily and average daily discharge
estimates for the parameters or pollutants listed in Section 4, unless
specifically indicated on the form. Note that if you have the results
of actual analyses for the listed parameters or pollutants, you are
required to report those results rather than submit estimates.

Report pollutant levels for all pollutants in Section 4 as
concentration and total mass, with the exception of flow, pH, and
temperature. Total mass is the total weight of pollutants
discharged over a day.

ppm = parts per million

New Dischargers

Report or estimate all parameter or pollutant levels as concentration
and as total mass, except for flow, pH, and temperature. Indicate
the source of all estimates in the appropriate column in the
Section 4 tables using the engineering study codes below. Note
that you are required to conduct follow-up testing and reporting no
later than two years once your facility commences discharge.
Engineering Report Codes
Actual data from pilot plants ................................... 1
Estimates from other engineering reports ............. 2
Data from other similar plants ................................ 3
Best professional estimates ................................... 4
Others ..........................................specify on the form

Reporting of Effluent Data

Concentration

If you have sampling and analysis questions, direct them to your
NPDES permitting authority. The authority may request that you do
additional testing, if appropriate, on a case-by-case basis under
CWA Section 308.

You must provide at least one analysis for each parameter or
pollutant, including the following: BOD, TSS, oil and grease,
ammonia (as N), fecal coliform including E. coli and enterococci (if
believed present or if sanitary waste is or will be discharged), total
residual chlorine (if chlorine is or will be used), COD, and TOC (if
non-contact cooling water is or will be discharged), discharge flow,
pH, and temperature (winter and summer).

Testing Waivers
The NPDES permitting authority may waive the testing and
reporting requirements for flow or any of the pollutants listed in
Section 4 if you submit a written request for such a waiver before
or with your application. Contact your NPDES permitting authority
for more information.

You may report quantitative data that you have collected over the
past 365 days if they are representative of your current operations.
The data reported must include maximum daily discharge, average
daily discharge, and number of analyses. Most existing facilities
routinely monitor the pollutants and parameters listed in Section 4
as part of their existing NPDES permit requirements.

Sampling

You must collect and analyze samples in accordance with 40 CFR
136. Grab samples must be used for analyses of pH, temperature,
total residual chlorine, oil and grease, fecal coliform (including E.
coli), and enterococci (previously known as fecal streptococcus)
and volatile organic compounds. Twenty-four-hour composite
samples must be used for all other pollutants, using at least four
grab samples unless otherwise specified at 40 CFR 136. For a
composite sample, only one analysis of the composite of aliquots is
required.

2E-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued

Analysis
Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical
methods approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O. A method is “sufficiently sensitive”
when:
The method minimum level (ML) is at or below the level of the
applicable water quality criterion for the measured pollutant or
pollutant parameter.



The method has the lowest ML of the analytical methods
approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O for the measured pollutant or
pollutant parameter.



2E-4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

FORM
2E
NPDES

Outfall Location

MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURAL FACILITIES WHICH
DISCHARGE ONLY NONPROCESS WASTEWATER
SECTION 1. OUTFALL LOCATION (40 CFR 122.21(h)(1))
1.1
Provide information on each of the facility’s outfalls in the table below.
Outfall
Receiving Water Name
Latitude
Longitude
Number

Discharge
Date

SECTION 2. DISCHARGE DATE (40 CFR 122.21(h)(2))
2.1
Are you a new or existing discharger? (Check only one response.)
 New discharger
 Existing discharger  SKIP to Section 3.
2.2
Specify your anticipated discharge date:




3.2
3.3

Waste Types

SECTION 3. WASTE TYPES (40 CFR 122.21(h)(3))
3.1
What types of wastes are currently being discharged if you are an existing discharger or will be discharged if you are a
new discharger? (Check all that apply.)
 Sanitary wastes
 Other nonprocess wastewater (describe/explain
directly below)
Restaurant or cafeteria waste
________________________________________

Non-contact cooling water

Does the facility use cooling water additives?
 Yes
 No  SKIP to Section 4.
List the cooling water additives used and describe their composition.
Cooling Water Additives
Composition of Additives
(if available to you)

(list)

Effluent Characteristics

SECTION 4. EFFLUENT CHARACTERISTICS (40 CFR 122.21(h)(4))
4.1
Have you completed monitoring for all parameters in the table below at each of your outfalls and attached the results to
this application package?
a waiver has been requested from my NPDES permitting authority
 Yes
 No;
(attach waiver request and additional information)  SKIP to Section 5.
4.2
Provide data as requested in the table below.1 (See instructions for specifics.)
Maximum Daily
Average Daily
Number of
Source
Discharge
Discharge
(use codes
Analyses
Parameter or Pollutant
(if actual data
reported)

(specify units)

Mass

Conc.

(specify units)

Mass

Conc.

per
instructions)

Biochemical oxygen demand (BOD5)
Total suspended solids (TSS)
Oil and grease
Ammonia (as N)
Discharge flow
pH (report as range)
Temperature (winter)
Temperature (summer)

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant
parameters or required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2E (revised )

Page 1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

4.3
4.4

Is fecal coliform believed present, or is sanitary waste discharged (or will it be discharged)?
 Yes
 No  SKIP to Item 4.5.
Provide data as requested in the table below.1 (See instructions for specifics.)
Maximum Daily
Average Daily
Number of
Discharge
Discharge
Analyses
Parameter or Pollutant
(specify units)

4.6

Mass

Conc.

(specify units)

4.8

(specify units)

Mass

Fecal coliform
E. coli
Enterococci
Is chlorine used (or will it be used)?
 Yes
 No  SKIP to Item 4.7.
Provide data as requested in the table below.1 (See instructions for specifics.)
Maximum Daily
Average Daily
Number of
Discharge
Discharge
Analyses
Parameter or Pollutant
(if actual data
reported)

4.7

Conc.

Mass

Conc.

Mass

Conc.

Total Residual Chlorine
Is non-contact cooling water discharged (or will it be discharged)?
 Yes
 No  SKIP to Section 5.
Provide data as requested in the table below.1 (See instructions for specifics.)
Maximum Daily
Average Daily
Number of
Discharge
Discharge
Analyses
Parameter or Pollutant
(specify units)
(specify units)

Effluent Characteristics Continued

(if actual data
reported)

4.5

Form Approved
OMB No.
Form Expires

(if actual data
reported)

Mass

Conc.

Mass

Conc.

Source
(Use codes
per
Instructions.)

Source
(use codes
per
instructions)

Chemical oxygen demand (COD)
Total organic carbon (TOC)
SECTION 5. FLOW (40 CFR 122.21(h)(5))
5.1
Except for stormwater water runoff, leaks, or spills, are any of the discharges you described in Sections 1 and 3 of this
application intermittent or seasonal?

Yes  Complete this section.

5.2



No  SKIP to Section 6.

Briefly describe the frequency and duration of flow.

Flow



Treatment System

SECTION 6. TREATMENT SYSTEM (40 CFR 122.21(h)(6))
6.1
Briefly describe any treatment system(s) used (or to be used).

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant
parameters or required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2E (revised )

Page 2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

Other Information

SECTION 7. OTHER INFORMATION (40 CFR 122.21(h)(7))
7.1
Use the space below to expand upon any of the above items. Use this space to provide any information you believe the
reviewer should consider in establishing permit limitations. Attach additional sheets as needed.

T


w/ attachments (e.g., responses for additional outfalls)



Section 2: Discharge Date



w/ attachments



Section 3: Waste Types



w/ attachments



Section 4: Effluent Characteristics



w/ attachments



Section 5: Flow



w/ attachments



Section 6: Treatment System



w/ attachments



Section 7: Other Information



w/ attachments



Section 8: Checklist and Certification Statement



w/ attachments

Section 1: Outfall Location

8.2



Certification Statement

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.
Name (print or type first and last name)
Official title

Checklist and Certification Statement

SECTION 8. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
8.1
In Column 1 below, mark the sections of Form 2E that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that
not all applicants are required to provide attachments.
Column 1
Column 2

Signature

Date signed

EPA Form 3510-2E (revised )

Page 3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2F
Revised

Water Permits Division

Application Form 2F
Stormwater Discharges
Associated with Industrial
Activity

NPDES Permitting Program

Note: Complete this form and Form 1 if you are a new or existing facility whose discharge is composed
entirely of stormwater associated with industrial activity, excluding discharges from construction
activity under 40 CFR 122.26(b)(14)(x) or (b)(15). If your discharge is composed of stormwater and
non-stormwater, you must complete Forms 1 and 2F, and you must complete Form 2C, 2D, or 2E, as
appropriate. See the “Instructions” inside for further details.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect and complete
Form 2F to be 28.6 hours. The estimate includes time for reviewing instructions, searching existing data
sources, gathering and maintaining the needed data, and completing and reviewing the collection of
information. Send comments about the burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to the Chief, Information Policy Branch
(PM-223), U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC
20460, and to the Office of Information and Regulatory Affairs, Office of Management and Budget,
725 17th Street, NW, Washington, DC 20503, marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2F—INSTRUCTIONS
General Instructions

Where to File Your Completed Form

Who Must Complete Form 2F?

Submit your completed application package (Forms 1 and 2F plus
any other applicable forms) to your NPDES permitting authority.
Consult Exhibit 1–1 of Form 1’s “General Instructions” to identify
your NPDES permitting authority.

Notes
Form 2F must be completed by any operator of
a facility that discharges stormwater associated
with industrial activity or the operator of any
stormwater discharger 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.

•

For discharges composed entirely of
stormwater, the operator must complete
Form 2F in conjunction with Form 1.

•

For discharges of stormwater combined with
process wastewater, the operator must
complete and submit Form 2F, Form 1, and
Form 2C. 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.

R
For discharges of stormwater combined with
nonprocess wastewater, the operator must
complete Form 2F, Form 1, and Form 2E.
Nonprocess wastewater includes noncontact
cooling water and sanitary wastes that are not
regulated by effluent guidelines, except
discharges by educational, medical, or
commercial chemical laboratories.

•

The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to the
public for inspection and copying upon request. You may not claim
any information on Form 2F (or related attachments) as confidential.
You may make a claim of confidentiality for any information that you
submit to EPA that goes beyond the information required by Form
2F. Note that NPDES permitting authorities will deny claims for
treating any effluent data (estimated or actual) as confidential. If you
do not assert a claim of confidentiality at the time you submit your
information to the NPDES permitting authority, EPA may make the
information available to the public without further notice to you. EPA
will handle claims of confidentiality in accordance with the Agency’s
business confidentiality regulations in Part 2 of Title 40 of the Code
of Federal Regulations (CFR).

•

Public Availability of Submitted Information

You must complete Form 2F if you answered “Yes” to Item 1.2.5 on
Form 1—that is, you are a new or existing facility and your
discharge is composed entirely of stormwater associated with
industrial activity (excluding discharges from construction activity
under 40 CFR 122.26(b)(14)(x) or (b)(15)) or composed of
stormwater and non-stormwater and are seeking coverage under
an individual National Pollutant Discharge Elimination System
(NPDES) permit. Note that applicants in the latter category must
also complete Forms 2C, 2D, or 2E, as applicable. See inset
below.

For new discharges of stormwater associated
with industrial activity that will be combined with
other new non-stormwater discharges, the
operator must submit Form 2F, Form 1, and
Form 2D.

Completion of Forms

Print or type in the specified areas only. If you do not have enough
space on the form to answer a question, you may continue on
additional sheets, as necessary, using a format consistent with the
form.
Provide your EPA Identification Number from the Federal Registry
Service, NPDES permit number, and facility name at the top of each
page of Form 2F and any attachments. If your facility is new (i.e.,
not yet constructed), write or type “New Facility” in the space
provided for the EPA Identification Number an NPDES permit
number. If you do not know your EPA Identification Number, contact
your NPDES permitting authority. See Exhibit 1–1 of Form 1’s
“General Instructions” for contact information. Additionally, for
Tables A through D, provide the applicable outfall number at the top
of each page.
Do not leave any response areas blank unless the form directs you
to skip them. If the form directs you to respond to an item that does
not apply to your facility or activity, enter “NA” for “not applicable” to
show that you considered the item and determined a response was
not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received and
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
independently of the status of any other permit application or permit
for the same facility or activity.
Definitions
The legal definitions of all key terms used in these instructions and
Form 2F are in the “Glossary” at the end of the “General
Instructions” in Form 1.

2F-1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2F—INSTRUCTIONS CONTINUED

Note: In EPA’s stormwater permits, “outfalls” are referred to as
“discharge points.”

•

Each of its drainage and discharge structures.

•

The drainage area of each stormwater outfall.

•

Paved areas and buildings within the drainage area of each
stormwater outfall; each past or present area used for outdoor
storage or disposal of significant materials; each existing
structural control measure to reduce pollutants in stormwater
runoff; materials loading and access areas; and areas where
pesticides, herbicides, soil conditioners, and fertilizers are
applied.

•

Each hazardous waste treatment, storage, or disposal facility
(including each area not required to have a Resource
Conservation and Recovery Act permit and 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.

Note that space has been provided on the form for six outfalls. If
you have more than this number, type your information on a
separate sheet of paper in a format similar to that of the form.
Make sure you note the EPA Identification Number, NPDES permit
number, and facility name at the top of the page and indicate the
specific item of the form to which you are responding—Item 1.1 in
this case. In other sections of the form, you will be asked to provide
information by outfall number (Sections 2, 4, 5, and 7).

Section 3. Site Drainage Map
Item 3.1 Attach a site drainage map showing the topography of the
facility. If a topographic map is unavailable, you may provide an
outline of drainage areas served by the outfall(s) covered in the
application. The site map must include the following information:

Line-by-Line Instructions
Section 1. Outfall Location
Item 1.1. Identify each of the facility’s outfalls by number. For each
outfall, specify the latitude and longitude to the nearest 15 seconds
and name of the receiving water. Latitude and longitude
coordinates may be obtained in a variety of ways, including use of
hand held devices (e.g., a GPS enabled smartphone), internet
mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps
from trusted sources (e.g., U.S. Geological Survey or USGS). The
location of each outfall (i.e., where the coordinates are collected)
shall be the location where collected and concentrated stormwater
flows are discharged from the facility such that the first receiving
water body into which the discharge flows, either directly or
through a separate storm sewer system, is a water of the United
States. If you need further guidance in responding to Item 1.1, refer
to http://www.epa.gov/geospatial/latitudelongitude-data-standard.

Section 2. Improvements
Item 2.1. Indicate if you are required by any federal, state, or local
authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or
practices or any other environmental programs that could affect the
discharges described in this application. The requirements include,
but are not limited to, permit conditions, administrative enforcement
orders, enforcement compliance schedule letters, stipulations,
court orders, and grant or loan conditions. If yes, continue to Item
2.2. If no, skip to Section 3.
Item 2.2. Briefly identify and describe each applicable project (e.g.,
consent decree, enforcement order, or permit condition). For each
condition, specify the affected outfall number(s), the source(s) of
the discharge, the required final compliance date, and the
projected final compliance date.

•

Springs and other surface water bodies that receive stormwater
discharges from the facility.
When you have completed and attached your site map to Form 2F,
answer “Yes” to Item 3.1.
Section 4. Pollutant Sources
Item 4.1. List all outfalls discharging stormwater. Provide an
estimate of the impervious surface area drained by the outfall.
Specify units of measure. (Impervious surfaces are surfaces where
stormwater runs off at rates significantly higher than background
rates—e.g., predevelopment levels. They include paved areas,
building roofs, parking lots, and roadways.)
Provide an estimate of the total surface area (impervious and
pervious areas) drained by each outfall (within a mile radius of the
facility). You may use the site map developed under Item 3.1 to
estimate the total area drained by each outfall. For areas under
5 acres, consult your NPDES permitting authority to determine
whether the area should be reported to the nearest tenth of an acre
or nearest quarter of an acre.
Item 4.2. Provide a narrative description of the following:

Item 2.3. OPTIONAL ITEM. Indicate if you have attached any
sheets describing any additional water pollution control programs
(or other environmental projects that could affect your discharges)
that you may now have underway or planned. If you attach
additional sheets, indicate in the attachment whether each program
is actually underway or is planned, and indicate your actual or
planned schedule for construction. Be sure to note your EPA
Identification Number, NPDES permit number, and facility name at
the top of any attached pages.

•

Significant materials that in three years prior to the submittal of
this application have been treated, stored, or disposed of in a
manner to allow exposure to stormwater.

•

Method of treatment, storage, or disposal of such materials.

•

Materials management practices employed, in the three years
prior to the submittal of this application, to minimize contact by
these materials with stormwater runoff.

•

Materials loading and access areas.

•

The location, manner, and frequency in which pesticides,
herbicides, soil conditioners, and fertilizers are applied.

You should identify your significant materials by chemical name,
2F-2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2F—INSTRUCTIONS CONTINUED

Important note: Read the “General Instructions for Reporting,
Sampling, and Analysis” below before completing Items 7.2 to 7.17.
Item 7.2 and Table A. All applicants must complete Table A. If the
discharge is an existing discharge and your discharge is composed
exclusively of stormwater (i.e., no process or nonprocess
wastewater) then you only need to provide monitoring data for oil and
grease, total phosphorus, total Kjeldahl nitrogen, and total nitrogen.
Indicate “NA” for “not applicable” in the columns for all other
parameters. Answer “Yes” to Item 7.2 once you have completed this
task.
Item 7.3 and Table B. Indicate whether the facility is subject to an
effluent limitations guideline (ELG) (see 40 CFR Subchapter N to
determine which pollutants are limited in ELGs) or if the facility is
subject to effluent limitations in an NPDES permit for its process
wastewater or stormwater (if the facility is operating under an existing
NPDES permit). If yes, continue to Item 7.4. If no, skip to Item 7.5.

Item 4.3. For each outfall, list the location and type of existing
structural and non-structural control measure(s) to reduce
pollutants in stormwater runoff. Structural controls include
structures that enclose materials handling or storage areas;
structures that cover materials; and berms, dikes, or diversion
ditches around manufacturing, production, storage, or treatment
units and retention ponds. Spill prevention plans, employee
training, visual inspections, preventive maintenance, and
housekeeping measures are examples of non-structural controls.

Tables A, B, C, and D
Items 7.2 to 7.17. These items require you to collect and report data
in Tables A through D, at the end of Form 2F, for the parameters and
pollutants listed in Exhibits 2F–2, 2F–3, and 2F–4 (at the end of the
instructions). The instructions for completing Tables A through D are
table-specific, as are the criteria for determining who should
complete them.

form (e.g., powder, liquid, etc.), and type of container or treatment
unit. Indicate any materials treated, stored, or disposed of
together. The term “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 the
Comprehensive Environmental Response, Compensation, and
Liability Act; any chemical the facility is required to report pursuant
to Section 313 of Title III of the Superfund Amendments and
Reauthorization Act; and fertilizers; pesticides; and waste products
such as ashes, slag, and sludge that have the potential to be
released with stormwater discharges.

Describe the treatment, including the schedule and type of
maintenance activities performed, and the ultimate disposal of any
solid or fluid wastes other than by discharge. For each structural
control identified, indicate the type of treatment the stormwater
receives using the codes in Exhibit 2F–1, at the end of the
instructions. For each non-structural control identified, indicate
“Not Applicable” in the “Codes from Exhibit 2F–1” column.

Section 5. Non-Stormwater Discharges
Item 5.1. Provide a certification that all outfalls that should contain
stormwater discharges associated with industrial activity have
been tested or evaluated for the presence of non-stormwater
discharges. Tests for such non-stormwater discharges can include
smoke tests, fluorometric dye tests, analysis of accurate
schematics, and others.

Item 5.2. Include a description of the method used, the date of any
testing, and the onsite drainage points that were directly observed
during a test used to support the certification in Item 5.1. All nonstormwater discharges must be identified in a Form 2C, 2D, or 2E.
See “Who Must Complete Form 2F?” above for more information.
Section 6. Significant Leaks or Spills
Item 6.1. Describe any significant leaks or spills of toxic or
hazardous pollutants at the facility within the three years prior to
the submittal of this application. Include the approximate date and
location of the spill or leak and the type and amount of material
released.
Section 7. Discharge Information
Item 7.1. Answer whether you are a new source or new discharge.
Contact your NPDES permitting authority to determine if you are a
new source or new discharge.

Note: Stormwater discharges from certain industrial sources or
activities have specific ELGs for which they must comply. These
stormwater-specific ELGs include:
Regulated Discharge

40 CFR Section

Discharges resulting from spraydown or intentional
wetting of logs at wet deck storage areas

Part 429, Subpart I

Runoff from phosphate fertilizer manufacturing facilities
that comes into contact with any raw materials, finished
product, byproducts or waste products (SIC 2874)

Part 418, Subpart A

Runoff from asphalt emulsion facilities

Part 443, Subpart A

Runoff from material storage piles at cement
manufacturing facilities

Part 411, Subpart C

Mine dewatering discharges at crushed stone,
construction sand and gravel, or industrial sand mining
facilities

Part 436, Subparts B,
C, and D

Runoff from hazardous waste and non-hazardous waste
landfills

Part 445, Subparts A
and B

Runoff from coal storage piles at steam electric
generating facilities

Part 423

Runoff containing urea from airfield pavement deicing at
existing and new primary airports with 1,000 or more
annual non-propeller aircraft departures

Part 449

Item 7.4. In Table B, list all pollutants that are limited in an ELG to
which the facility is subject and all pollutants listed in the facility's
NPDES permit for its process wastewater (if the facility is operating
under an existing NPDES permit) and provide quantitative data for
each pollutant (provide actual data for existing dischargers and
estimated data for new sources and new dischargers). If a pollutant
in Exhibits 2F–2 or 2F–3 is indirectly limited by an ELG through an
indicator (e.g., use of total suspended solids as an indicator to
control the discharge of iron and aluminum), you must provide data
for the pollutant in Table B. Complete one table for each outfall.
Answer “Yes” to Item 7.4 once you have completed this task.
2F-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2F—INSTRUCTIONS CONTINUED

Indicate whether you know or have reason to believe any pollutants
in Exhibit 2F–2 are present in the discharge. If yes, continue to Item
7.6. If no, skip to Item 7.7.
Item 7.6. For each outfall, list all pollutants in Exhibit 2F–2 that you
know or have reason to believe are present in the discharge in
Table C (except pollutants previously listed in Table B that are
limited directly or indirectly by an ELG) and either report quantitative
data or briefly describe the reasons the pollutant is expected to be
discharged. Answer “Yes” to Item 7.6 once you have completed this
task.
Item 7.7. This item asks if you qualify as a “small business.” If so,
you are exempt from the reporting requirements for the organic toxic
pollutants listed in Exhibit 2F–3.

Item 7.12. Indicate whether you expect acrolein, acrylonitrile, 2,4dinitrophenol, or 2-methyl-4,6-dinitrophenol to be discharged in
concentrations of 100 ppb or greater. If yes, continue to Item 7.13.
If no, skip to Item 7.14.
Item 7.13. Provide quantitative data in Table C for the pollutants
identified in Item 7.12 that you expect to be discharged in
concentrations of 100 ppb or greater (provide actual data for
existing dischargers and estimated data for new sources and new
dischargers). Answer “Yes” to Item 7.13 once you have completed
this task.
Item 7.14. For any pollutants you expect to be present in the
discharge at concentrations less than 10 ppb (or less than 100 ppb
for the above four pollutants), either submit quantitative data or
briefly describe the reasons the pollutant is expected to be
discharged in Table C. Answer “Yes” to Item 7.14 once you have
completed this task.

You can qualify as a small business in two ways: (1) 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; (2) 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 that is the source of the
discharge. The data should not be limited to production or sales for
the process or processes that contribute to the discharge, unless
those are the only processes at your facility. For sales data, in
situations involving intra-corporate 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 online from the U.S. Department
of Commerce, Bureau of Economic Analysis at
http://www.bea.gov/national/pdf/SNTables.pdf.

Item 7.11. Provide quantitative data in Table C for those pollutants
in Exhibit 2F–3 that you expect to be discharged in concentrations
of 10 ppb or greater (provide actual data for existing dischargers
and estimated data for new sources and new dischargers). Answer
“Yes” to Item 7.11 once you have completed this task.

Item 7.5 and Table C. Table C requires you to address the
pollutants in Exhibits 2F–2, 2F–3, and 2F–4 for each outfall.
Pollutants in each of these exhibits are addressed differently.

Item 7.15. Indicate whether you know or have reason to believe
any pollutants in Exhibit 2F–4 are present in the discharge. If yes,
continue to Item 7.16. If no, skip to Item 7.17.
Item 7.16. For each outfall, list any pollutant in Exhibit 2F–4 that
you know or believe to be present in the discharge in Table C and
explain why you believe it to be present. No analysis is required,
but if you have analytical data, you must report it. Answer “Yes” to
Item 7.16 once you have completed this task.

Note: Under 40 CFR 117.12(a)(2), certain discharges of hazardous
substances (listed in Exhibit 2F-5) may be exempted from the requirements of
CWA Section 311, which establishes reporting requirements, civil penalties,
and liability for cleanup costs for spills of oil and hazardous substances. A
discharge of a particular substance can 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. If you would like to apply for
an exemption from the requirements of CWA Section 311, attach additional
sheets of paper to your application, setting forth the following information:

If you qualify as a small business according to the criteria above,
answer “Yes” to Item 7.7 and skip to Item 7.18. Otherwise, answer
“No” and continue to Item 7.8.

1. The substance and the amount of each substance that might be
discharged.
2. The origin and source of the discharge of the substance.
3. The treatment 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 that
is additionally capable of treating the amount of the substance
identified under paragraph 1 above; or
c. Any combination of the above.

Item 7.8. Indicate whether you know or have reason to believe any
pollutants in Exhibit 2F–3 are present in the discharge. If yes,
continue to Item 7.9. If no, skip to Item 7.10.
Item 7.9. For each outfall, list all pollutants in Exhibit 2F–3 that you
know or have reason to believe are present in the discharge in
Table C (except pollutants previously listed in Table B). Answer
“Yes” to Item 7.9 once you have completed this task.
Item 7.10. Indicate whether you expect any of the pollutants from
Exhibit 2F–3 to be discharged in concentrations of 10 parts per
billion (ppb) or greater. If yes, continue to Item 7.11. If no, skip to
Item 7.12.

See 40 CFR 117.12(a)(2) and (c) or contact your NPDES permitting authority
for further information on exclusions from CWA Section 311.

Item 7.17 and Table D. Provide data for the storm event(s) that
resulted in the maximum daily discharges for the flow weighted
composite sample in Table D. If sampling is conducted during more
than one storm event, you only need to report the information
2F-4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2F—INSTRUCTIONS CONTINUED

Item 10.2. The Clean Water Act (CWA) provides for severe
penalties for submitting false information on this application form.
Section 309(c)(2) of the CWA 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 six months or both.”
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:
A.

For a corporation, by a responsible corporate officer. For the
purpose of this section, a responsible corporate officer means:
(1) 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 (2) 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.
B. For a partnership or sole proprietorship, by a general partner
or the proprietor, respectively.
C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END

Provide flow measurements or estimates of the flow rate, as well as
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 that 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.
Answer “Yes” to Item 7.17 once you have completed this task.
Used or Manufactured Toxics
Item 7.18. Review Exhibits 2F–2 through 2F–4 and determine if you
currently use or manufacture any of the pollutants listed as
intermediate or final products or byproducts. If so, answer “Yes.”
You should also answer “Yes” if you know or have reason to
believe that 2,3,7,8-tetrachloro-dibenzo-p-dioxin (TCDD) is
discharged or if you use or manufacture 2,4,5-trichlorphenoxy
acetic acid (2,4,5-T); 2-(2,4,5-trichlorophenoxy) propanoic acid
(Silvex, 2,4,5-TP); 2-(2,4,5-trichlorophenoxy) ethyl, 2,2dichloropropionate (Erbon); 0,0-dimethyl 0-(2,4,5-trichlorphenyl)
phosphorothioate (Ronnel); 2,4,5-trichlorophenol (TCP); or
hexachlorophene (HCP). If your answer to Item 7.18 is “No,” skip to
Section 8.

Section 10. Checklist and Certification Statement
Item 10.1. Review the checklist provided on the application. In
Column 1, mark the sections of Form 2F that you have completed
and are submitting with your application. For each section in
Column 2, indicate whether you are submitting attachments.

requested on Table D for the storm event(s) that resulted in any
maximum pollutant concentration reported on Tables A through C.

Item 7.19. List all of the toxic pollutants identified under Item 7.18,
including TCDD. Note that the NPDES permitting authority may
waive or modify the requirement if you demonstrate that it would be
unduly burdensome to identify each toxic pollutant and the NPDES
permitting authority has adequate information to issue your permit.
You may not claim any information submitted in response to Item
7.18 as confidential; however, you do not have to distinguish
between use or production of the pollutants or list the amounts.

Section 8. Biological Toxicity Testing Data
Item 8.1. Answer whether you know of or have reason to believe
that biological toxicity testing has been conducted of your
wastewater treatment, including engineering reports or pilot plant
studies. If no, skip to Section 9. Otherwise, continue.

Item 8.2. List any tests of which you are aware and their purposes.
Section 9. Contract Analysis Information
Item 9.1. Indicate if any of the analyses performed in Section 7
were performed by a contract laboratory or consulting firm. If no,
skip to Section 10. If yes, continue to Item 9.2.
Item 9.2. Provide the name, address, phone number, and pollutants
analyzed by the laboratory or consulting firm(s) in the spaces
provided.

2F-5

Submit your completed Form 1, Form 2F, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis
Important note: Read these instructions before completing Tables
A through C and Section 7 of Form 2F.

byproducts, and any previous analyses known to you of your
effluent or similar effluent.

General Items

Sampling

Complete the applicable tables for each outfall at your facility. Be
sure to note the EPA Identification Number, NPDES permit
number, facility name, and applicable outfall number at the top of
each table page and any associated attachments.

The collection of the samples for the reported analyses should be
supervised by a person experienced in performing sampling of
industrial wastewater or stormwater discharges. You may contact
your NPDES permitting authority for detailed guidance on sampling
techniques and for answers to specific questions. See Exhibit 1–1 of
Form 1 for contact information. Any specific requirements in the
analytical methods—for example, sample containers, sample
preservation, holding times, and the collection of duplicate
samples—must be followed.

You may report some or all of the required data by attaching
separate sheets of paper instead of completing Tables A through C
for each of your outfalls so long as the sheets contain all of the
required information and are similar in format to Tables A through
C. For example, you may be able to print a report in a compatible
format from the data system used in your gas chromatography/
mass spectrometry (GC/MS) analysis completed under Table B.

The time when you sample should be representative of your normal
operation, to the extent feasible, with all processes that contribute
wastewater in normal operation, and with your treatment system
operating properly with no system upsets. Collect samples from the
center of the flow channel, where turbulence is at a maximum, at a
site specified in your present NPDES permit, or at any site adequate
for the collection of a representative sample.
Grab samples must be taken in the first 30 minutes of discharge (or
as soon thereafter as practicable) for pH, temperature, cyanide, total
phenols, residual chlorine, oil and grease, fecal coliform (including
E. coli) and enterococci (previously known as fecal streptococcus at
40 CFR 122.26(d)(2)(iii)(A)(3)), and volatile organic compounds.
You are not required to analyze a flow-weighted composite for these
parameters.

Data Source
Engineering reports
Actual data from pilot plants
Estimates from other engineering
reports
Data from other similar plants
Best professional estimates

Code
1
1

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.

3
4
5 and specify on
the table

Others

If you are an existing discharger, you are required to report actual
quantitative data. See “Use of Historic Data” below for use of
historic data. If you are a new source or discharge, you may supply
estimated data along with the source of each estimate. If you have
quantitative data available, however, you must provide it. Base
estimates on available, in-house or contractor engineering reports,
or any other studies performed on the proposed facility. Use the
following codes to report your source information in the “Source of
Information” column:

No later than 24 months after your facility commences to
discharge, you must complete and submit sampling and analysis
data for the pollutants and parameters in Tables A through C.
However, you need not report results for tests you have already
performed and reported under the discharge monitoring
requirements of your NPDES permit.

Table A requires you to report at least one analysis for each
pollutant listed. Tables B and C require you to report analytical data
in two ways. For some pollutants addressed in Tables 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 Tables 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 Items 7.2 through
7.17 of the instructions for completing Tables A through C.). Base
your determination that a pollutant is/will be present in your
discharge on your knowledge of the facility’s raw materials,
material management practices, maintenance chemicals, history of
spills and releases, intermediate and final products and

All samples must 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 must be taken during the first 30 minutes of the
discharge (or as soon thereafter as practicable), and a flowweighted composite must be taken for the entire event or for the first
three hours of the event.
Grab and composite samples are defined as follows:
Grab sample: An individual sample of at least 100 milliliters
collected during the first 30 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

2F-6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued
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 15 minutes between aliquot collections. The
composite must be flow proportional; the time interval between
either each aliquot or the volume of each aliquot must be
proportional to either the stream (effluent) flow at the time of
sampling or the total stream (effluent) flow since the collection of
the previous aliquot. Aliquots may be collected manually or
automatically. Where GC/MS volatile organic analysis is required,
aliquots must be combined in the laboratory immediately before
analysis. Only one analysis for the composite sample is required.

All reporting of values for metals must be in terms of “total
recoverable metal” unless:

Use of Historical Data
Existing data may be used, if available, in lieu of sampling
conducted solely for the purposes of this application, provided it is
representative of the present discharge and was collected within
3 years of the application due date. If you sample for a listed
pollutant on a monthly or more frequent basis, summarize the data
collected within one year of the application for the pollutant(s) at
issue.

•

An applicable, promulgated ELG specifies the limitation for the
metal in dissolved, valent, or total form;

•

All approved analytical methods for the metal inherently
measure only its dissolved form (e.g., hexavalent chromium);
or

•

The NPDES permitting authority has determined that in
establishing case-by-case limitations it is necessary to express
the limitations of the metal in dissolved, valent, or total form to
carry out the provisions of the CWA.

If you measure more than one value for a grab sample or a flowweighted 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 analysis.

Among the factors that would cause the data to be
unrepresentative are significant changes in production level;
changes in raw materials, processes, or final products; and
changes in stormwater treatment. The NPDES permitting authority
may request additional information, including current quantitative
data, if they determine it to be necessary to assess your
discharges. The NPDES permitting authority 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 136,
and additional time for submitting data on a case-by-case basis.

If you measure only one grab sample and one flow-weighted
composite sample for a given outfall, complete only the “Maximum
Daily Discharge” columns in the tables and enter “1” in the “Number
of Storm Events Sampled” column. The NPDES permitting authority
may require you to conduct additional analyses to further
characterize your discharges.

Reporting
Report sampling results for all pollutants in Tables A through C as
concentration and mass, with the exception of flow, temperature,
pH, color, and fecal coliform organisms.
Flow, temperature, pH, color, and fecal coliform organisms must
be reported as million gallons per day (mgd), degrees Celsius
(°C), standard units, color units, and most probable number per
100 milliliters (MPN/100 mL), respectively. Use the following
abbreviations in the columns requiring “units” in Tables A through
C.
Concentration
ppm = parts per million
mg/L = milligrams per liter
ppb = parts per billion
µg/L = micrograms per liter
MPN = most probable number per
100 milliliters

Mass
lbs = pounds
ton = tons (English tons)
mg = milligrams
g = grams
kg = kilograms
T = tonnes (metric tons)

The “Average Daily Discharge” column on Tables A to C is not
compulsory but should be filled out if data are available. To
complete the “Average Daily Discharge” column, determine the
average of all values within the last year and report the
concentration and mass. Report the total number of storm events
sampled under the “Number of Storm Events Sampled” column.
Substantially Identical Outfalls

If you have two or more substantially identical outfalls, you may
request permission from your NPDES permitting authority to sample
and analyze only one outfall and submit the results of the analysis
for all substantially identical outfalls. If your request is granted,
submit the following information on a separate sheet attached to the
application form: the identity of the outfall you did test and an
explanation of how it is substantially identical to the outfall(s) that
you did not test.
Analysis
Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical methods
approved under 40 CFR 136 or required under 40 CFR chapter I,
subchapter N or O. A method is “sufficiently sensitive” when:
•

The method minimum level (ML) is at or below the level of the
applicable water quality criterion for the measured pollutant or
pollutant parameter.

•

2F-7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued
•

select a different method from the remaining EPA-approved
methods that is sufficiently sensitive consistent with 40 CFR
122.21(e)(3)(i). Where no other EPA-approved methods exist, you
must select a method consistent with 40 CFR 122.21(e)(3)(ii).
When there is no analytical method that has been approved under
40 CFR 136; required under 40 CFR chapter I, subchapter N or O,
and is not otherwise required by the NPDES permitting authority,
you may use any suitable method but shall provide a description of
the method. When selecting a suitable method, other factors such
as a method’s precision, accuracy, or resolution, may be considered
when assessing the performance of the method.

The method has the lowest ML of the analytical methods
approved under 40 CFR 136 or required under 40 CFR
chapter I, subchapter N or O, for the measured pollutant or
pollutant parameter.
Consistent with 40 CFR 136, you may provide matrix- or samplespecific MLs rather than the published levels. Further, where you
can demonstrate that, despite a good faith effort to use a method
that would otherwise meet the definition of “sufficiently sensitive,”
the analytical results are not consistent with the quality assurance
(QA)/quality control (QC) specifications for that method, then the
NPDES permitting authority may determine that the method is not
performing adequately and the NPDES permitting authority should

2F-8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–1. Codes for Treatment Units and Disposal of Wastes Not Discharged

1–A................. Ammonia stripping
1–B................. Dialysis
1–C ................ Diatomaceous earth filtration
1–D ................ Distillation
1–E................. Electrodialysis
1–F ................. Evaporation
1–G ................ Flocculation
1–H ................ Flotation
1–I .................. Foam fractionation
1–J ................. Freezing
1–K................. Gas-phase separation
1–L ................. Grinding (comminutors)
2.

CHEMICAL TREATMENT PROCESSES
2–G ................ Disinfection (ozone)
2–H ................ Disinfection (other)
2–I .................. Electrochemical treatment
2–J ................. Ion exchange
2–K ................ Neutralization
2–L ................. Reduction

PHYSICAL TREATMENT PROCESSES
1–M ................ Grit removal
1–N ................ Microstraining
1–O ................ Mixing
1–P ................ Moving bed filters
1–Q ................ Multimedia filtration
1–R ................ Rapid sand filtration
1–S ................ Reverse osmosis (hyperfiltration)
1–T ................ Screening
1–U ................ Sedimentation (settling)
1–V ................ Slow sand filtration
1–W ............... Solvent extraction
1–X ................ Sorption

3.
3–A................. Activated sludge
3–B................. Aerated lagoons
3–C ................ Anaerobic treatment
3–D ................ Nitrification–denitrification

4. WASTEWATER DISPOSAL PROCESSES
4–A................. Discharge to surface Water
4–C ................ Reuse/recycle of treated effluent
4–B................. Ocean discharge through outfall
4–D ................ Underground injection
SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–A................. Aerobic digestion
5–M ................ Heat drying
5–B................. Anaerobic digestion
5–N ................ Heat treatment
5–C ................ Belt filtration
5–O ................ Incineration
5–D ................ Centrifugation
5–P ................ Land application
5–E................. Chemical conditioning
5–Q ................ Landfill
5–F ................. Chlorine treatment
5–R ................ Pressure filtration
5–G ................ Composting
5–S ................ Pyrolysis
5–H ................ Drying beds
5–T ................ Sludge lagoons
5–I .................. Elutriation
5–U ................ Vacuum filtration
5–J ................. Flotation thickening
5–V ................ Vibration
5–K................. Freezing
5–W ............... Wet oxidation
5–L ................. Gravity thickening

2F-9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–2. Conventional and Nonconventional Pollutants (40 CFR 122.21, Appendix D, Table IV)

Bromide
Chlorine, total residual
Color
Fecal coliform
Fluoride
Nitrate-nitrite
Nitrogen, total organic (as N)
Oil and grease
Phosphorus (as P), total
Radioactivity (as alpha, total; beta, total; radium, total; and radium 226, total)
Sulfate (as SO4)
Sulfide (as S)
Sulfite (as SO3)
Surfactants
Aluminum, total
Barium, total
Boron, total
Cobalt, total
Iron, total
Magnesium, total
Molybdenum, total
Manganese, total
Tin, total
Titanium, total

2F-10

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–3. Toxic Pollutants (40 CFR 122.21, Appendix D, Tables II and III)
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—Volatile Compounds
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

Acrolein
Acrylonitrile
Benzene
Bromoform
Carbon tetrachloride
Chlorobenzene
Chlorodibromomethane
Chloroethane
2-Chloroethylvinyl ether
Chloroform

GC/MS Fraction—Acid Compounds
2,4-dinitrophenol
2-nitrophenol
4-nitrophenol
P-chloro-m-cresol

Pentachlorophenol
Phenol
2,4,6-trichlorophenol

2-chlorophenol
2,4-dichlorophenol
2,4-dimethylphenol
4,6-dinitro-o-cresol

GC/MS Fraction—Base/Neutral Compounds
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-octyl phthalate
1,2-diphenylhydrazine (as azobenzene)
Fluoranthene
Fluorene

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-ethylhexyl) phthalate
4-bromophenyl phenyl ether
Butyl benzyl phthalate
2-chloronaphthalene
Aldrin
α-BHC
β-BHC
γ-BHC
δ-BHC
Chlordane
4,4’-DDT
4,4’-DDE
4,4’-DDD

Hexachlorobenzene
Hexachlorobutadiene
Hexachlorocyclopentadiene
Hexachloroethane
Indeno (1,2,3-cd) pyrene
Isophorone
Naphthalene
Nitrobenzene
N-nitrosodimethylamine
N-nitrosodi-n-propylamine
N-nitrosodiphenylamine
Phenanthrene
Pyrene
1,2,4-trichlorobenzene

GC/MS Fraction—Pesticides

Dieldrin
α-endosulfan
β-endosulfan
Endosulfan sulfate
Endrin
Endrin aldehyde
Heptachlor
Heptachlor epoxide
PCB-1242

PCB-1254
PCB-1221
PCB-1232
PCB-1248
PCB-1260
PCB-1016
Toxaphene

2F-11

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–4. Certain Hazardous Substances and Asbestos (40 CFR 122.21, Appendix D, Table V)
Toxic Pollutant
Asbestos
Hazardous Substances

Chlorpyrifos

Kelthane

Coumaphos

Kepone

Cresol

Naphthenic 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

Dintrobenzene
Diquat
Disulfoton
Diuron
Epichlorohydrin
Ethion
Ethylene diamine
Ethylene dibromide
Formaldehyde
Furfural
Guthion
Isoprene
Isopropanolamine

Acetaldehyde
Allyl alcohol
Allyl chloride
Amyl acetate
Aniline
Benzonitrile
Benzyl chloride
Butyl acetate
Butylamine
Captan
Carbaryl
Carbofuran
Carbon disulfide

Malathion

Mercaptodimethur
Methoxychlor
Methyl mercaptan
Methyl methacrylate
Methyl parathion
Mevinphos
Mexacarbate
Monoethyl amine
Monomethyl amine
Naled

Crotonaldehyde
Cyclohexane
2,4-D (2,4-dichlorophenoxyacetic acid)
Diazinon
Dicamba
Dichlobenil
Dichlone
2,2-dichloropropionic acid
Dichlorvos
Diethyl amine
Dimethyl amine

2F-12

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–5. Hazardous Substances
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 fluorite
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

2F-13

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Exhibit 2F–5. Hazardous Substances
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 fluoride
296. Zirconium sulfate
297. Zirconium tetrachloride

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 (2,4,5-trichlorophenoxyacetic 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 (2,4,5-trichlorophenoxy
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

2F-14

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2F
NPDES

STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY

SECTION 1. OUTFALL LOCATION (40 CFR 122.21(g)(1))
1.1
Provide information on each of the facility’s outfalls in the table below
Outfall
Receiving Water Name
Latitude
Number

Outfall Location

Longitude


2.2

Yes

SECTION 2. IMPROVEMENTS (40 CFR 122.21(g)(6))
Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
2.1
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
No  SKIP to Section 3.

Briefly identify each applicable project in the table below.
Affected Outfalls

(list outfall numbers)

Final Compliance Dates

Source(s) of Discharge
Required

Projected

Brief Identification and
Description of Project

Improvements



2.3



Yes

EPA Form 3510-2F (Revised



No
Page 1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

Site
Drainage
Map

SECTION 3. SITE DRAINAGE MAP (40 CFR 122.26(c)(1)(i)(A))
3.1
Have you attached a site drainage map containing all required information to this application? (See instructions for
specific guidance.)



Yes

SECTION 4. POLLUTANT SOURCES (40 CFR 122.26(c)(1)(i)(B))
4.1
Provide information on the facility’s pollutant sources in the table below.
Outfall
Number

Impervious Surface Area
(within a mile radius of the facility)
specify units

Total Surface Area Drained
(within a mile radius of the facility)

specify units

Provide the location and a description of existing structural and non-structural control measures to reduce pollutants in
stormwater runoff. (See instructions for specific guidance.)

4.3

specify units

Provide a narrative description of the facility’s significant material in the space below. (See instructions for content
requirements.)

Pollutant Sources

4.2

specify units

Outfall
Number

EPA Form 3510-2F (Revised

Stormwater Treatment

Control Measures and Treatment

Codes
from
Exhibit
2F–1
(list)

Page 2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 5. NON-STORMWATER DISCHARGES (40 CFR 122.26(c)(1)(i)(C))
5.1
I certify under penalty of law that the outfall(s) covered by this application have been tested or evaluated for the
presence of non-stormwater discharges. Moreover, I certify that the outfalls identified as having non-stormwater
discharges are described in either an accompanying NPDES Form 2C, 2D, or 2E application.
Name (print or type first and last name)
Official title

5.2

Date signed

Provide the testing information requested in the table below.
Outfall
Number

Date(s) of Testing

Onsite Drainage Points
Directly Observed
During Test

Description of Testing Method Used

Non-Stormwater Discharges

Signature

Significant Leaks or Spills

SECTION 6. SIGNIFICANT LEAKS OR SPILLS (40 CFR 122.26(c)(1)(i)(D))
6.1
Describe any significant leaks or spills of toxic or hazardous pollutants in the last three years.

Discharge Information

SECTION 7. DISCHARGE INFORMATION (40 CFR 122.26(c)(1)(i)(E))
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
7.1
Is this a new source or new discharge?
 See instructions regarding submission of
 See instructions regarding submission of
 Yes
 No
estimated data.
actual data.
Tables A, B, C, and D
7.2
Have you completed Table A for each outfall?



Yes

EPA Form 3510-2F (Revised



Page 3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Is the facility subject to an effluent limitation guideline (ELG) or effluent limitations in an NPDES permit for its process
wastewater?



Have you completed Table B by providing quantitative data for those pollutants that are (1) limited either directly or
indirectly in an ELG and/or (2) subject to effluent limitations in an NPDES permit for the facility’s process wastewater?


7.5

Yes
Yes



No  SKIP to Item 7.12.

Yes



Yes



No  SKIP to Item 7.14.

Yes



D
Yes



Yes



No  SKIP to Item 7.17.

Have you listed pollutants in Exhibit 2F–4 that you know or believe to be present in the discharge and provided an
explanation in Table C?


7.17

Do you know or have reason to believe any pollutants in Exhibit 2F–4 are present in the discharge?



7.16



Have you provided quantitative data or an explanation in Table C for pollutants you expect to be present in the
discharge at concentrations less than 10 ppb (or less than 100 ppb for the pollutants identified in Item 7.12)?



7.15

No  SKIP to Item 7.10.

Have you provided quantitative data in Table C for the pollutants identified in Item 7.12 that you expect to be
discharged in concentrations of 100 ppb or greater?



7.14

Do you expect acrolein, acrylonitrile, 2,4-dinitrophenol, or 2-methyl-4,6-dinitrophenol to be discharged in concentrations
of 100 ppb or greater?



7.13




Yes

Discharge Information Continued

Yes SKIP to Item 7.18.

Have you provided quantitative data in Table C for those pollutants in Exhibit 2F–3 that you expect to be discharged in
concentrations of 10 ppb or greater?


7.12

Do you expect any of the pollutants in Exhibit 2F–3 to be discharged in concentrations of 10 ppb or greater?


7.11



Yes

Have you listed all pollutants in Exhibit 2F–3 that you know or have reason to believe are present in the discharge in
Table C?


7.10

No  SKIP to Item 7.7.

Do you know or have reason to believe any pollutants in Exhibit 2F–3 are present in the discharge?


7.9



Yes

Do you qualify for a small business exemption under the criteria specified in the Instructions?


7.8

Have you listed all pollutants in Exhibit 2F–2 that you know or have reason to believe are present in the discharge and
provided quantitative data or an explanation for those pollutants in Table C?


7.7



Yes

Do you know or have reason to believe any pollutants in Exhibit 2F–2 are present in the discharge?


7.6

No  SKIP to Item 7.5.

7.4



Yes

7.3

Form Approved
OMB No.
Form Expires

Yes



Have you provided information for the storm event(s) sampled in Table D?



Yes

EPA Form 3510-2F (Revised



Page 4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

Discharge Information Continued

EPA Identification Number

Form Approved
OMB No.
Form Expires

Used or Manufactured Toxics
7.18 Is any pollutant listed on Exhibits 2F–2 through 2F–4 a substance or a component of a substance used or
manufactured as an intermediate or final product or byproduct?


7.19



Yes

No  SKIP to Section 8.

List the pollutants below, including TCDD if applicable.
1.

8.2



Yes

Identify the tests and their purposes below.
Test(s)

Purpose of Test(s)

No  SKIP to Section 9.

Submitted to NPDES
Permitting Authority?



Yes



Yes



Yes



Biological Toxicity Testing Data

SECTION 8. BIOLOGICAL TOXICITY TESTING DATA (40 CFR 122.21(g)(11))
8.1
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 three years?

Date Submitted

SECTION 9. CONTRACT ANALYSIS INFORMATION (40 CFR 122.21(g)(12))
9.1
Were any of the analyses reported in Section 7 (on Tables A through C) performed by a contract laboratory or
consulting firm?



No  SKIP to Section 10.

Provide information for each contract laboratory or consulting firm below.

9.2

Yes

Laboratory Number 1

Laboratory Number 2

Laboratory Number 3

Contract Analysis Information

Name of laboratory/firm

Laboratory address

Phone number

Pollutant(s) analyzed

EPA Form 3510-2F (Revised

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation
NPDES Permit Number
Facility Name

EPA Identification Number

Form Approved
OMB No.
Form Expires

SECTION 10. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
10.1 In Column 1 below, mark the sections of Form 2F that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to complete all sections or provide attachments.

10.2

Column 2

Section 1



w/ attachments (e.g., responses for additional outfalls)



Section 2



w/ attachments



Section 3



w/ site drainage map



Section 4



w/ attachments



Section 5



w/ attachments




Section 6



w/ attachments

Section 7



Table A



Table B



Table C





w/ small business exemption request



w/ analytical results as an attachment



Table D

Checklist and Certification Statement

Column 1



Section 8



w/attachments



Section 9



w/attachments (e.g., responses for additional contact laboratories or firms)



Section 10



Certification Statement

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.

Name (print or type first and last name)

Signature

EPA Form 3510-2F (Revised

Official title

Date signed

Page 6

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE A. CONVENTIONAL AND NON-CONVENTIONAL PARAMETERS (40 CFR 122.26(c)(1)(i)(E)(3))1
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 and requirements.
Maximum Daily Discharge
Average Daily Discharge
Source of
(specify units)
(specify units)
Information
Number of Storm
Pollutant or Parameter
Grab Sample Taken
Grab Sample Taken
(new source/new
Events Sampled
Flow-Weighted
Flow-Weighted
1.

Oil and grease

Biochemical oxygen demand (BOD5)

Chemical oxygen demand (COD)

Total suspended solids (TSS)

Total phosphorus

Total Kjeldahl nitrogen (TKN)

Total nitrogen (as N)

pH (minimum)
pH (maximum)

Composite

During First
30 Minutes

Composite

dischargers only; use
codes in instructions)

AF
T

During First
30 Minutes

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

D
R

EPA Form 3510-2F (Revised

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Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

D
R

AF
T

This page intentionally left blank.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.26(c)(1)(i)(E)(4) and 40 CFR 122.21(g)(7)(vi)(A)) 1
List each pollutant that is limited in an effluent limitation guideline (ELG) that 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.
Maximum Daily Discharge
Grab Sample Taken
During First
30 Minutes

Flow-Weighted
Composite

Average Daily Discharge
(specify units)

Grab Sample Taken
During First
30 Minutes

Flow-Weighted
Composite

Number of Storm
Events Sampled

Source of
Information

(new source/new
dischargers only; use
codes in instructions)

D
R

AF
T

Pollutant and CAS Number (if available)

(specify units)

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
1

EPA Form 3510-2F (Revised )

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Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

D
R

AF
T

This page intentionally left blank.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE C. TOXIC POLLUTANTS, CERTAIN HAZARDOUS SUBSTANCES, AND ASBESTOS (40 CFR 122.26(c)(1)(i)(E)(4) and 40 CFR 122.21(g)(7)(vi)(B) and (vii)) 1
List each pollutant shown in Exhibits 2F–2, 2F–3, and 2F–4 that you know or have reason to believe is present. Complete one table for each outfall. See the instructions for additional
details and requirements.
Maximum Daily Discharge
Average Daily Discharge
Source of
(specify units)
(specify units)
Information
Number of Storm
Grab Sample Taken
Grab Sample Taken
Pollutant and CAS Number (if available)
(new source/new
Flow-Weighted
Flow-Weighted
Events Sampled
During First
During First
dischargers only; use
Composite

30 Minutes

Composite

codes in instructions)

D
R

AF
T

30 Minutes

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or O. See instructions and 40 CFR 122.21(e)(3).
1

EPA Form 3510-2F (Revised )

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Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

D
R

AF
T

This page intentionally left blank.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

EPA Identification Number

NPDES Permit Number

Facility name

Outfall Number

Form Approved
OMB No.
Form Expires

TABLE D. STORM EVENT INFORMATION (40 CFR 122.26(c)(1)(i)(E)(6))
Provide data for the storm event(s) that resulted in the maximum daily discharges for the flow-weighted composite sample.

(in hours)

Total Rainfall During
Storm Event
(in inches)

Number of Hours Between
Beginning of Storm Measured and
End of Previous Measurable Rain
Event

Maximum Flow Rate
During Rain Event
(in gpm or specify units)

Total Flow from Rain Event
(in gallons or specify units)

AF
T

Date of Storm Event

Duration of Storm Event

D
R

Provide a description of the method of flow measurement or estimate.

EPA Form 3510-2F (Revised )

Page 13

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

United States
Environmental Protection Agency

Office of Water
Washington, D.C.

EPA Form 3510-2S
Revised

Water Permits Division

Application Form 2S
New and Existing Treatment
Works Treating Domestic
Sewage

NPDES Permitting Program

Note: Complete Form 2S if you are a new or existing treatment works treating domestic sewage.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimates the average burden to collect and complete
Form 2S to be 8.7 hours. 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 about the burden estimate or any other aspect of this collection of
information to the Chief, Information Policy Branch (PM-223), U.S. Environmental Protection Agency,
1200 Pennsylvania Avenue, NW, Washington, DC 20460, and to the Office of Information and
Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503,
marked “Attention: Desk Officer for EPA.”

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GENERAL INSTRUCTIONS
Who Must Complete Form 2S?
If you are a TWTDS and discharge wastewater to surface water,
A person must complete Form 2S to apply for a National Pollutant you must also complete NPDES application Form 2A.
Discharge Elimination System (NPDES) permit covering sewage
40 CFR 503 defines “sewage sludge” as a solid, semi-solid, or
sludge (biosolids) use or disposal standards if they own or
liquid residue generated during the treatment of domestic sewage
operate a treatment works treating domestic sewage (TWTDS). A in a treatment works. Sewage sludge includes scum or solids
person is an owner or operator of a TWTDS if the facility
removed in primary, secondary, or advanced wastewater
generates, changes the quality of, or provides final disposition of
treatment processes and any material derived from sewage sludge
solids, practices for which are ultimately subject to Part 503 of
(e.g., a blended sewage sludge/fertilizer product) but does not
Title 40 of the Code of Federal Regulations (CFR).1
include grit and screenings or ash generated by the firing of
The TWTDS that are required to apply for NPDES permits include sewage sludge in an incinerator.
the following:
40 CFR 503 considers domestic septage as sewage sludge and
sets separate requirements for domestic septage applied to
 All generators of sewage sludge that are regulated by
agricultural land, forests, or reclamation sites. “Domestic septage”
40 CFR 503 (i.e., it is applied to the land, placed on a
surface disposal site, fired in a sewage sludge incinerator, or is defined as a liquid or solid material removed from a septic tank,
cesspool, portable toilet, Type III marine sanitation device, or
placed in a municipal solid waste landfill unit).
similar system that receives only domestic sewage. The 40 CFR
 Industrial facilities that separately treat domestic sewage and 503 definition of domestic septage excludes grease-trap pumpings
generate sewage sludge that are regulated by 40 CFR 503.
and commercial or industrial waste.
 All surface disposal site owners/operators.
At the state level, either EPA or an approved state agency
 All sewage sludge incinerator owners/operators.
administers the NPDES permit program. If you are located in a
jurisdiction in which an EPA regional office administers the
 Any person (e.g., individual, corporation, or government
NPDES permit program, you should use Form 2S. If you are
entity) who changes the quality of sewage sludge regulated
located in a jurisdiction where a state administers the NPDES
by 40 CFR 503 (e.g., sewage sludge blenders or
permit program, contact the state to determine the forms you
processors).2
should complete. States often develop their own application
 Any other person or facility designated by the NPDES
forms rather than use the federal forms. See
permitting authority as a TWTDS.
http://www.epa.gov/npdes/npdes-state-program-information for a
TWTDSs and other persons that may be required to apply for an
list of states that have approved NPDES permit programs and
NPDES permit3 include the following:
those that do not.
Sewage sludge land appliers, haulers, persons who store, or
transporters who do not generate or do not change the
quality of the sewage sludge.



Landowners of property on which sewage sludge are
applied.



Domestic septage pumpers/haulers/treaters/appliers.



Sewage sludge packagers/baggers that do not change the
quality of the sewage sludge.

Exhibit 2S–1 (see end of this section) provides contact
information for each of EPA’s 10 regional offices. Since the
exhibit’s content is subject to change, consult EPA’s website for
the latest information: http://www.epa.gov/aboutepa#regional.



Where to File Your Completed Form

If any of the above TWTDS categories are owned and operated
by different persons/entities, it is the operator’s duty to obtain the
NPDES permit.



If you are in a jurisdiction with an approved state sewage
sludge NPDES permit program, file according to the
instructions on the state forms.



If you are in a jurisdiction where EPA is the sewage sludge
NPDES permitting authority (i.e., the state is not a sewagesludge-authorized state), mail the completed application
forms to the EPA regional office that covers the state in which
your facility is located (see Exhibit 2S–1).



To determine where to send your completed Form 2S, visit
http://www.epa.gov/biosolids/forms/contact-us-aboutbiosolids.

Notes

1The U.S. Environmental Protection Agency (EPA) developed regulations in 1993

as required by the Clean Water Act (CWA) Amendments of 1987 to protect public
health and the environment from any reasonably anticipated adverse effects of
pollutants that might be present in sewage sludge biosolids. The regulation, The
Standards for the Use or Disposal of Sewage Sludge (40 CFR 503) was published
in the Federal Register on February 19, 1993 (58 CFR 9248 to 9404) and became
effective March 22, 1993. The regulations are often referred to as “the Part 503
rule” or “Part 503.”

2If all the sewage sludge received by a sewage sludge blender or composter are

of exceptional quality (EQ) per 40 CFR 503, then no permit will be required for the
person who receives or processes the EQ sludge.
3The NPDES permitting authority may request permit applications from these

facilities when necessary to protect public health and the environment from
reasonably anticipated effects of pollutants that may be present in sewage sludge.

When to File Your Completed Form
A TWTDS with a currently effective NPDES permit must submit a
permit application at the time of its next NPDES permit renewal
application (i.e., at least 180 days before your present NPDES
permit expires). Any other TWTDS must submit the information in
Part 1 of Form 2S within one year after publication of a standard
applicable to its sewage sludge or disposal practice(s). The

2S-1

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GENERAL INSTRUCTIONS CONTINUED
NPDES permitting authority will determine when such TWTDS
If you have previously submitted information that answers a specific
must submit a full permit application. The NPDES permitting
question to EPA or an approved state NPDES agency, you may
authority may require permit applications from a TWTDS at any
either repeat the information in the space provided or attach a copy
time if it determines that a permit is necessary to protect public
of the previous submission. Some items in the form require narrative
health and the environment from any potential adverse effects
explanations. If more space is necessary to answer a question,
that may occur from toxic pollutants in sewage sludge. Any
attach a separate sheet titled “Additional Information.” Provide your
TWTDS that commences operations after promulgation of an
information on this attachment in a format that is consistent with the
applicable “standard for sewage sludge use or disposal” must
form.
submit an application to the NPDES permitting authority at least
Upon request of the NPDES permitting authority, you must submit
180 days prior to the date proposed for commencing operations.
any other information necessary to assess sewage sludge use or
Fees
disposal practices at your facility or identify appropriate permitting
requirements.
EPA does not require applicants to pay a fee for applying for
NPDES permits. However, states that administer the NPDES
The NPDES permitting authority will consider your application
programs may charge fees. Consult with state officials for
complete when it and any supplementary material are received and
further information.
completed according to the authority’s satisfaction. The NPDES
permitting authority will judge the completeness of any application
Public Availability of Submitted Information
independently of the status of any other permit application or permit
EPA will make information from NPDES permit application forms for the same facility or activity.
available to the public for inspection and copying upon request.
Which Parts of the Form Apply?
You may not claim any information on Form 2S (or related
attachments) as confidential.
Form 2S is presented in a modular format, enabling information
collection to be tailored to your facility’s sewage sludge generation,
You may make a claim of confidentiality for any information that
treatment, use, or disposal practices. The form specifies which parts
you submit to EPA that goes beyond the information required by
must be filled out for each type of applicant.
Form 2S. Note that NPDES authorities will deny claims for
treating any biosolids data as confidential. If you do not assert a Part 1 requests a limited amount of information from ‘‘sludge-only’’
claim of confidentiality at the time you submit your information to facilities (facilities without a currently effective NPDES permit) that
the NPDES permitting authority, EPA may make the information are not directed by the permitting authority to submit a full permit
available to the public without further notice to you. EPA will
application at this time. It is intended to allow the permitting authority
handle claims of confidentiality in accordance with the Agency’s to identify these facilities, track sewage sludge use and disposal,
business confidentiality regulations at Part 2 of Title 40 of the
and establish priorities for permitting.
CFR.
Part 2 is for any facility that is submitting a full NPDES permit
Completion of Forms
application. See Exhibit 2S–2, at the end of these general
instructions, to determine which sections of Part 2 cover your
Print or type in the specified areas only. If you do not have
facility’s sewage sludge use or disposal practices.
enough space on the form to answer a question, you may
continue on additional sheets, as necessary, using a format
Complete the “Preliminary Information” section on page 1 by
consistent with the form.
indicating whether your facility has an effective NPDES permit or
you have been directed by your NPDES permitting authority to
Provide your EPA Identification Number from the Federal
submit a full Form 2S permit application. If yes, skip Part 1 and
Registry Service, NPDES permit number, and facility name at
complete Part 2 of the application package (see the line-by-line
the top of each page of Form 2S and any attachments. If your
instructions for Part 2). If no, complete only Part 1 of the application
facility is new (i.e., not yet constructed), write or type “New
package.
Facility” in the space provided for the EPA Identification Number
and NPDES permit number. If you do not know your EPA
Definitions
Identification Number, contact your NPDES permitting authority.
The legal definitions of all key terms used in the various NPDES
See Exhibit 2S–1 for contact information.
application forms are included in the “Glossary” at the end of these
instructions.
Do not leave any response areas blank unless the form directs
you to skip them. If the form directs you to respond to an item
that does not apply to your facility or activity, enter “NA” for “not
applicable” to show that you considered the item and
determined a response was not necessary for your facility.

2S-2

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GENERAL INSTRUCTIONS CONTINUED
Exhibit 2S–1. Addresses of EPA Regional Contacts and Covered States
REGION 6
U.S. Environmental Protection Agency, Region 6
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733
Phone: (214) 665-2200; toll free: (800) 887-6063
Fax: (214) 665-7113
Website: http://www.epa.gov/aboutepa/epa-region-6-south-central
Covered states: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas

2S-3

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GENERAL INSTRUCTIONS CONTINUED
Exhibit 2S–2. Part 2 Sections to Complete

Generates sewage sludge or derives material from
sewage sludge that is applied to the land in bulk form



Applies bulk sewage sludge to land or generates
sewage sludge that is applied to the land by others



Owns or operates a surface disposal site



Owns or operates a sewage sludge incinerator



INCINERATION

SURFACE DISPOSAL

GENERATION OF
SEWAGE SLUDGE OR
PREPARATION OF A
MATERIAL DERIVED
FROM SEWAGE SLUDGE



Generates sewage sludge or derives material from
sewage sludge that:
 Meets ceiling concentrations in Table 1 of 40
CFR 503.13, pollutant concentrations in Table 3
of Section 503.13, Class A pathogen
requirements in Section 503.32, and one of the
eight vector attraction reduction options in 40
CFR 503.33(b)(1)–(8)
 Is sold or given away in bags or other containers
for application to the land (and not already
addressed in Item 2.4)
 Is shipped off site for treatment or blending
 Is placed on a surface disposal site
 Is fired in an incinerator
 Is sent to a municipal solid waste landfill

LAND APPLICATION OF
BULK SEWAGE SLUDGE

GENERAL INFORMATION

Activity(ies) Performed

Part 2 Sections to Complete
3
4



2S-4

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—PART 1 LINE-BY-LINE INSTRUCTIONS
Part 1—Limited Background Information
disposal practices. Provide the average monthly concentration in
milligrams per kilogram (mg/kg) dry weight, analytical method, and
Complete Part 1 if your facility is a “sludge-only” facility (i.e., a
detection level. If available, base data on three or more samples
facility that does not currently have, and is not applying for, an
NPDES permit for a direct discharge to a surface body of water). taken at least one month apart, no more than 4.5 years old. If
providing the monitoring data in a separate attachment, check the
Section 1. Facility Information
box to indicate that this information has been attached to the
application package.
Item 1.1. Enter the facility’s official or legal name. Do not use a
colloquial name. Provide the mailing address of the facility.
Section 5. Treatment Provided at Your Facility
Next, give the name (first and last), title, work telephone
Item 5.1. In the “Use or Disposal Practice” column, check the
number, and email address of the person who is thoroughly
sewage sludge use or disposal practice used at your facility. In the
familiar with the operation of the facility and with the facts
following columns, indicate the amount of sewage sludge used or
reported in this application.
disposed of, the pathogen class and reduction alternative, and the
vector attraction reduction option associated with the practice. To
Include a complete location address for the facility if different
determine the applicable pathogen class and reduction alternative,
from the mailing address. If the facility or site lacks a street
see 40 CFR 503.32. To determine the applicable vector attraction
name or route number, give the most accurate alternative
reduction option, see 40 CFR 503.33. Vector attraction reduction
geographic information (e.g., section number or quarter section
options 1 through 8 are typically met at the point where sewage
number from county records or “at intersection of Routes 425
sludge is generated or where a material is derived from sewage
and 22”).
sludge, and options 9 through 11 are typically met at the point of
Item 1.2. Indicate the legal status of the owner of the facility by
use or disposal. Complete Item 5.1 for each sewage sludge use or
marking the appropriate box. If the facility is a federal facility
disposal practice by attaching additional sheets, as necessary.
(i.e., owned by the U.S. government), check the box for
Item 5.2. For each use or disposal practice indicated in Item 5.1,
“Public—federal.” If the facility is owned by a state government,
identify the treatment process(es) used at your facility to reduce
check the box for “Public—state.” If the facility is owned by a
pathogens or vector attraction properties in sewage sludge. If you
county government, municipal (e.g., city or town) government,
check “Other,” specify the treatment process(es) in the space
tribal government, school district, water district, or other local
provided or in a separate attachment.
government entity, check the box for “Other public” and specify
the type of government entity. If the facility is owned by a
Section 6. Sewage Sludge Sent to Other Facilities
corporation or other private entity, check the box for “Private.” If
Item 6.1. Indicate whether the sewage sludge meets ceiling
the facility has mixed ownership (e.g., public/private) or is not
concentrations in Table 1 of 40 CFR 503.13, pollutant
owned by an entity previously listed, check the box for “Other”
concentrations in Table 3 of 40 CFR 53.13, Class A pathogen
and specify the type of entity.
reduction requirements at 40 CFR 503.32(a), and one of the vector
Section 2. Applicant Information
attraction reduction requirements at 40 CFR 503.33(b)(1)–(8). If yes,
skip to Item 8.1 (Part 1, Section 8). If no, continue to Item 6.2.
Item 2.1. Indicate if the applicant is different from the entity
listed under Item 1.1. If yes, continue to Item 2.2. If no, skip to
Item 6.2. Indicate whether sewage sludge from your facility is
Item 2.3 (Part 1, Section 2).
provided to another facility for treatment, distribution or disposal. If
yes, continue to Item 6.3. If no, skip to Item 7.1 (Part 1, Section 7).
Item 2.2. Enter the applicant’s name and mailing address.
Provide the name (first and last), title, work telephone number,
Item 6.3. Enter the name and mailing address of the receiving
and email address of the contact person for the applicant.
facility. Provide the name (first and last), title, work telephone
Item 2.3. Indicate if the applicant is the facility’s owner, operator, number, and email address of the contact person for the receiving
facility.
or both.
Item 2.4. Specify whether the NPDES permitting authority
should send correspondence to the facility or the applicant.
Section 3. Sewage Sludge Amount
Item 3.1. Provide the total dry metric tons of sewage sludge
generated, treated, used (i.e., received from off site), and
disposed over the last 365-day period.
Section 4. Pollutant Concentrations
Item 4.1. Provide the most recent sewage sludge monitoring
data available on the quality of the sewage sludge, including for
pollutants for which limits in sewage sludge have been
established in 40 CFR 503 for your facility’s expected use or

Item 6.4. Indicate the activities provided by the receiving facility. If
you check “Other,” provide a description in the space provided or in
a separate attachment.
Section 7. Use and Disposal Sites
Complete Items 7.1 through 7.2 for each site on which sewage
sludge from the facility is used or disposed of. Check the box to
indicate that this information has been attached to the application
package.
Item 7.1. Specify the site name or number and mailing address.
Provide the name (first and last), title, work telephone number, and
email address of the contact person for the use or disposal site.

2S-5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—PART 1 LINE-BY-LINE INSTRUCTIONS CONTINUED
Include a complete location address for the site if different from
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
the mailing address. If the facility or site lacks a street name or
APPLICATION TO BE SIGNED AS FOLLOWS:
route number, give the most accurate alternative geographic
A. For a corporation, by a responsible corporate officer. For the
information (e.g., section number or quarter section number
purpose of this section, a responsible corporate officer means:
from county records or “at intersection of Routes 425 and 22”).
(1) a president, secretary, treasurer, or vice-president of the
Item 7.2. Identify the type of use or disposal site (e.g.,
corporation in charge of a principal business function, or any
agricultural, surface disposal, reclamation, lawn or home
other person who performs similar policy- or decision-making
garden, public contact, municipal solid waste landfill, forest,
functions for the corporation, or (2) the manager of one or more
incineration). If you check “Other,” provide a description in the
manufacturing, production, or operating facilities, provided the
space provided or in a separate attachment.
manager is authorized to make management decisions which
govern the operation of the regulated facility including having
Section 8. Checklist and Certification Statement
the explicit or implicit duty of making major capital investment
Item 8.1. Review the checklist provided. In Column 1, mark the
recommendations, and initiating and directing other
sections of Form 2S, Part 1, that you have completed and are
comprehensive measures to assure long term environmental
submitting with your application. For each section that you have
compliance with environmental laws and regulations; the
completed, indicate in Column 2 whether you are submitting
manager can ensure that the necessary systems are
attachments.
established or actions taken to gather complete and accurate
information for permit application requirements; and where
Item 8.2. The CWA provides for severe penalties for submitting
authority to sign documents has been assigned or delegated to
false information on this application form. CWA Section
the manager in accordance with corporate procedures.
309(c)(2) provides that “Any person who knowingly makes any
B. For a partnership or sole proprietorship, by a general partner or
false statement, representation, or certification in any
the proprietor, respectively.
application, …shall upon conviction, be punished by a fine of no
more than $10,000 or by imprisonment for not more than six
C. For a municipality, state, federal, or other public facility, by
months, or both.”
either a principal executive officer or ranking elected official.
For purposes of this section, a principal executive officer of a
federal agency includes: (1) The chief executive officer of the
agency, or (2) a senior executive officer having responsibility
for the overall operations of a principal geographic unit of the
agency (e.g., Regional Administrators of EPA).
END OF PART 1

Submit your completed Part 1 of Form 2S
and all associated attachments
to your NPDES permitting authority.

2S-6

Contains Nonbinding Recommendations
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FORM 2S—PART 2 LINE-BY-LINE INSTRUCTIONS
Part 2—Permit Application Information
Item 1.7. Enter the applicant’s name and mailing address. Provide
the
name (first and last), title, work telephone number, and email
Complete Part 2 if you have an effective NPDES permit or have
address
of the contact person for the applicant.
been directed by the NPDES permitting authority to submit a
full permit application. Part 2 is divided into five sections.
Item 1.8. Indicate if the applicant is the facility’s owner, operator, or
Section 1 pertains to all applicants. The applicability of Sections both.
2 to 5 depends on your facility’s sewage sludge use or disposal
Item 1.9. Specify whether the NPDES permitting authority should
practices. See Exhibit 2S–2 at the end of the general
send correspondence to the facility or the applicant.
instructions to determine the sections that you are required to
complete.
Permit Information

Item 1.11. Indicate all other federal, state, and local permits or
construction approvals received or applied for that regulate the
facility’s sewage sludge management practices. If you check “Other,”
specify the permit or approval in the space provided. You may list
permits or approvals and corresponding permit numbers in a
separate attachment. If so, check the box to indicate that this
information has been attached to the application package.
Indian Country
Item 1.12. Indicate whether any generation, treatment, storage,
application to land, or disposal of sewage sludge from the facility
occurs in Indian Country. If yes, continue to Item 1.13. If no, skip to
Item 1.14 (Part 2, Section 1).

Include a complete location address for the facility if different
from the mailing address. If the facility or site 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 Routes 425
and 22”).

Item 1.10. Provide the facility’s NPDES permit number or check the
box to indicate that you do not have an NPDES permit number but
are otherwise required to submit Part 2 of Form 2S by your NPDES
permitting authority.

Section 1. General Information
Facility Information
Item 1.1. Enter the facility’s official or legal name. Do not use a
colloquial name. Provide the mailing address of the facility.
Next, give the name (first and last), title, work telephone
number, and email address of the person who is thoroughly
familiar with the operation of the facility and with the facts
reported in this application.

Item 1.2. Indicate whether the facility is a Class I sludge
management facility.

Item 1.3. Provide the facility design flow rate in million gallons
per day (mgd).

Item 1.4. Provide the total population served by the facility.
Enter the best estimate of the actual population served at the
time of application for all areas served by the treatment works
(municipalities and unincorporated service areas). If another
treatment works discharges into this treatment works, provide
on a separate attachment the name of the other treatment
works and the actual population it serves. It is not necessary to
list the communities served by the other treatment works.

Item 1.5. Indicate the ownership status of the owner of the
facility by marking the appropriate box. If the facility is a federal
facility (i.e., owned by the U.S. government), check the box for
“Public—federal.” If the facility is owned by a state government,
check the box for “Public—State.” If the facility is owned by a
county government, municipal (e.g., city or town) government,
tribal government, school district, water district, or other local
government entity, check the box for “Other public” and specify
the type of government entity. If the facility is owned by a
corporation or other private entity, check the box for “Private.” If
the facility has mixed ownership (e.g., public/private) or is not
owned by an entity previously listed, check the box for “Other”
and specify the type of entity.
Applicant Information
Item 1.6. Indicate if the applicant is different from the entity
listed under Item 1.1. If yes, continue to Item 1.7. If no, skip to
Item 1.18 (Part 2, Section 1).

Item 1.13. In the space provided or in a separate attachment,
describe the generation, treatment, storage, land application, or
disposal of sewage sludge that occurs in Indian Country.
Topographic Map
Item 1.14. Provide a topographic map(s) of the area extending at
least 1 mile beyond the property boundaries of the facility that clearly
shows the following:


The legal boundaries of the facility.



All sewage sludge management facilities, including onsite
treatment, storage, and disposal sites.



Wells, springs, and other surface water bodies that are within
¼ mile of the property boundaries and listed in public records or
otherwise known to applicant.

On the map, include the map scale, a meridian arrow showing north,
and latitude and longitude to the nearest second. Latitude and
longitude coordinates may be obtained in a variety of ways, including
use of hand held devices (e.g., a GPS enabled smartphone), internet
mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps from
trusted sources (e.g., U.S. Geological Survey or USGS).
You may develop your map by going to USGS’s National Map
website at http://nationalmap.gov/. (For a map from this site, use the
traditional 7.5-minute quadrangle format. If none is available, use a
USGS 15-minute series map.) You may also use a plat or other
appropriate map.
2S-7

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—PART 2 LINE-BY-LINE INSTRUCTIONS CONTINUED
Note that you have completed your topographic map and
president of the corporation in charge of a principal business
attached it to the application.
function, or any other person who performs similar policy- or
decision-making functions for the corporation, or (2) the
Line Drawing
manager of one or more manufacturing, production, or
Item 1.15. Provide a line drawing and/or narrative description
operating facilities, provided the manager is authorized to
that identifies all sewage sludge practices that will be employed
make management decisions which govern the operation of
during the permit term, including all units used for collecting,
the regulated facility including having the explicit or implicit duty
dewatering, storing, or treating sewage sludge; the
of making major capital investment recommendations, and
destination(s) of all liquids and solids leaving each such unit;
initiating and directing other comprehensive measures to
and all processes used for pathogen reduction and vector
assure long term environmental compliance with environmental
attraction reduction. Answer “Yes” when a line drawing and/or
laws and regulations; the manager can ensure that the
narrative description containing all required information has
necessary systems are established or actions taken to gather
been attached to the application.
complete and accurate information for permit application
requirements; and where authority to sign documents has been
Contractor Information
assigned or delegated to the manager in accordance with
Item 1.16. Indicate whether contractors have any operational or
corporate procedures.
maintenance responsibilities related to sewage sludge
B. For a partnership or sole proprietorship, by a general partner or
generation, treatment, use, or disposal at the facility. If yes,
the proprietor, respectively.
continue to Item 1.17. If no, skip to Item 1.8 (Part 2, Section 1).
C.
For
a municipality, state, federal, or other public facility, by
Item 1.17. Provide the company name, mailing address, contact
either
a principal executive officer or ranking elected official.
name (first and last), telephone number, and email address for
For
purposes
of this section, a principal executive officer of a
each contractor and describe the contractor’s responsibilities.
federal
agency
includes: (1) The chief executive officer of the
The application form provides reporting space for three
agency,
or
(2)
a
senior executive officer having responsibility
contractors. If your facility has more than three contractors,
for
the
overall
operations
of a principal geographic unit of the
attach additional sheets as necessary.
agency (e.g., Regional Administrators of EPA).
Pollutant Concentrations
Section 2. Generation of Sewage Sludge or Preparation of a
Item 1.18. Provide the most recent sewage sludge monitoring
Material Derived from Sewage Sludge
data available on the quality of the sewage sludge, including for
Complete this section if you are a ‘‘person who prepares sewage
pollutants for which limits in sewage sludge have been
sludge.’’ This section pertains to any POTW or other TWTDS that
established in 40 CFR 503 for your facility’s expected use or
generates sewage sludge, as well as to any facility that derives a
disposal practices. Provide the average monthly concentration
material from sewage sludge (e.g., it composts sewage sludge or
in milligrams per kilogram (mg/kg) dry weight, analytical method,
blends sewage sludge with another material). Simply distributing
and detection level. If available, base data on three or more
sewage sludge or placing it in a bag or other container for sale or
samples taken at least one month apart, no more than 4.5 years
give-away for application to the land is not considered ‘‘deriving a
old. If providing the monitoring data in a separate attachment,
material’’ from sewage sludge (because it does not change sludge
check the box to indicate that this information has been attached
quality), and thus a facility that only distributes or bags a sewage
to the application package.
sludge is not required to provide the information in this section.
Checklist and Certification Statement
Item 2.1. Answer “Yes” or “No” to indicate if the facility generates
Item 1.19. Review the checklist provided. In Column 1, mark the sewage sludge or derives a material from sewage sludge (e.g., it
sections of Form 2S, Part 2, that you have completed and are
composts sewage sludge or blends sewage sludge with another
submitting with your application. For each section that you have material). If yes, continue to Item 2.2. If no, skip to Part 2, Section 3.
completed, indicate in Column 2 whether you are submitting
Amount Generated On Site
attachments.
Item 2.2. Provide the total dry metric tons of sewage sludge
Item 1.20. The CWA provides for severe penalties for submitting
generated at the facility over a 365-day period.
false information on this application form. Section 309(c)(2) of
Amount Received from Offsite Facility
the CWA provides that “Any person who knowingly makes any
false statement, representation, or certification in any
Item 2.3. Indicate whether the facility receives sewage sludge from
application, ...shall upon conviction, be punished by a fine of no
another facility for treatment, use, or disposal. If yes, continue to
more than $10,000 or by imprisonment for not more than six
Item 2.4. If no, skip to Item 2.7 (Part 2, Section 2).
months or both.”
Item 2.4. Indicate the total number of facilities from which your
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS facility receives sewage sludge for treatment, use, or disposal.
APPLICATION TO BE SIGNED AS FOLLOWS:
Item 2.5. Complete Items 2.5 through 2.7 for each facility from
A. For a corporation, by a responsible corporate officer. For
which your facility receives sewage sludge for treatment, use or
the purpose of this section, a responsible corporate officer
means: (1) a president, secretary, treasurer, or vice2S-8

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—PART 2 LINE-BY-LINE INSTRUCTIONS CONTINUED
disposal. Check the box to indicate that this information has
Item 2.11. Indicate whether the sewage sludge meets the ceiling
been attached to the application package.
concentrations in Table 1 of 40 CFR 503.13, the pollutant
concentrations in Table 3 of 40 CFR 503.12, Class A pathogen
Enter the name and mailing address of the facility. Provide the
reduction requirements at 40 CFR 503.32(a), and one of the vector
name (first and last), title, work telephone number, and email
attraction reduction requirements at 40 CFR 503.33(b)(1)–(8) and is
address of the contact person for the facility. Provide a complete
land applied. Sewage sludge meeting all of these criteria is often
location address for the facility if different from the mailing
referred to as “exceptional quality (EQ)” and is exempt from the
address. If the facility or site lacks a street name or route
general requirements of 40 CFR 503.12 and the management
number, give the most accurate alternative geographic
practices of 40 CFR 503.14, and thus fewer permitting and permit
information (e.g., section number or quarter section number
application requirements typically pertain to facilities generating
from county records or “at intersection of Routes 425 and 22”).
such sludge. For this reason, if you check “Yes” for Item 2.11,
complete Items 2.12 and 2.13; then you may skip Items 2.14
Item 2.6. Indicate the amount of sewage sludge received, the
through 2.16, Items 2.17 through 2.26, and Items 2.27 through 2.31
applicable pathogen class and reduction alternative, and the
unless specifically required to complete any of them by the
applicable vector attraction reduction option provided at the
permitting authority. If you check “No,” skip to Item 2.14 (Part 2,
offsite facility. To determine the applicable pathogen class and
Section 2).
reduction alternative, see 40 CFR 503.32. To determine the
applicable vector attraction reduction option, see 40 CFR
Item 2.12. Provide the total dry metric tons of sewage sludge,
503.33. Vector attraction reduction options 1 through 8 are
meeting the requirements specified in Item 2.11 that is applied to
typically met at the point where sewage sludge is generated or
land per 365-day period.
where a material is derived from sewage sludge, and options 9
through 11 are typically met at the point of use or disposal.
Item 2.13. Indicate whether the subject sewage sludge is placed in
a bag or other container and sold or given away for land application.
Item 2.7. Identify the treatment process(es) that are known to
Check the box indicating completion of Items 2.11 through 2.13 and
occur at the offsite facility, including blending activities and
skip to Item 2.32 (Part 2, Section 2).
treatment to reduce pathogens or vector attraction properties in
sewage sludge. If you check “Other,” specify the treatment
Sale or Give-Away in a Bag or Other Container for Application
process(es) in the space provided or in a separate attachment.
to the Land
Item 2.14. Indicate whether the subject sewage sludge is placed in
Treatment Provided at Your Facility
a bag or other container and sold or given away for land application.
Item 2.8. In the “Use or Disposal Practice” column, check the
If yes, continue to Item 2.15. If no, skip to Item 2.17 (Part 2,
sewage sludge use or disposal practice used at your facility. In
Section 2).
the following columns, indicate the pathogen class and
reduction alternative and the vector attraction reduction option
Item 2.15. Provide the dry metric tons of sewage sludge placed in a
associated with the practice. To determine the applicable
bag or other container and sold or given away for land application
pathogen class and reduction alternative, see 40 CFR 503.32.
per 365-day period.
To determine the applicable vector attraction reduction option,
Item 2.16. When sewage sludge is placed in a bag or other
see 40 CFR 503.33. Vector attraction reduction options 1
container for sale or give-away for application to the land, either a
through 8 are typically met at the point where sewage sludge is
label must be affixed to the bag or other container, or an information
generated or where a material is derived from sewage sludge,
sheet must be provided to the person receiving the sewage sludge.
and options 9 through 11 are typically met at the point of use or
The information that must be on the label or information sheet is
disposal. Complete Item 2.8 for each sewage sludge use or
listed at 40 CFR 503.14(e). Attach copies of all labels or notices that
disposal practice by attaching additional sheets, as necessary.
accompany sewage sludge being sold or given away in a bag or
Item 2.9. For each use or disposal practice indicated in Item 2.8, other container for land application. Check the box to indicate that
identify the treatment process(es) used at your facility to reduce these copies have been attached to the application package.
pathogens or vector attraction properties in sewage sludge. If
Check the box indicating completion of Items 2.14 through 2.16 and
you check “Other,” specify the treatment process(es) in the
skip to Item 2.32 (Part 2, Section 2).
space provided or in a separate attachment.
Shipment Off Site for Treatment or Blending
Item 2.10. Use the space provided to describe any other
Item 2.17. Indicate whether another facility provides treatment or
sewage sludge treatment or blending activities not identified in
blending of your facility’s sewage sludge. (This does not pertain to
Items 2.8 and 2.9. Check the box if your description has been
dewatered sludge sent directly to a land application or surface
attached to the application package.
disposal site.) If yes, continue to Item 2.18. If no, skip to Item 2.32
Preparation of Sewage Sludge Meeting Ceiling and
(Part 2, Section 2).
Pollutant Concentrations, Class A Pathogen Requirements,
and One of Vector Attraction Reduction Options 1 to 8
Item 2.18. Indicate the total number of facilities that provide
treatment or blending of your facility’s sewage sludge. Complete
Items 2.19 through 2.26 for each facility that provides treatment or
2S-9

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

blending of your facility’s sewage sludge. Check the box to
indicate if this information has been attached to the application
package.
Item 2.19. Enter the name and mailing address of the receiving
facility. Provide the name (first and last), title, work telephone
number, and email address of the contact person for the
receiving facility. Include a complete location address for the
facility if different from the mailing address. If the facility or site
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
Routes 425 and 22”).

the name (first and last), title, work telephone number, and email
address of the contact person for the surface disposal site.
Item 2.37. Indicate whether the site contact is the owner and/or
operator of the surface disposal site.
Item 2.38. Provide the total dry metric tons of sewage sludge from
your facility placed on the surface disposal site per 365-day period.
Incineration
Item 2.39. Answer “Yes” or “No” to indicate if sewage sludge from
your facility is fired in a sewage sludge incinerator. If yes, continue
to Item 2.40. If no, skip to Item 2.46 (Part 2, Section 2).
Item 2.40. Provide the total dry metric tons of sewage sludge from
your facility fired in all sewage sludge incinerators per 365-day
period.

Item 2.21 Indicate whether the receiving facility provides any
additional treatment to reduce pathogens in, or vector attraction
properties of, the sewage sludge from your facility. If yes,
continue to Item 2.22. If no, skip to Item 2.24 (Part 2, Section 2).

Item 2.41. Answer “Yes” or “No” to indicate if you own or operate all
sewage sludge incinerators to which you send sewage sludge for
firing. If yes, skip to Item 2.46. If no, continue to Item 2.42 (Part 2,
Section 2).
Item 2.42. Indicate the total number of sewage sludge incinerators
used that you do not own or operate. Complete Items 2.43 through
2.45 for each sewage sludge incinerator used that you do not own
or operate. Check the box to indicate that this information has been
attached to the application package.

Item 2.22. Indicate the pathogen class and reduction alternative
and the vector attraction reduction option met for the sewage
sludge at the receiving facility. To determine the applicable
pathogen class and reduction alternative, see 40 CFR 503.32.
To determine the applicable vector attraction reduction option,
see 40 CFR 503.33. Vector attraction reduction options 1
through 8 are typically met at the point where sewage sludge is
generated or where a material is derived from sewage sludge,
and options 9 through 11 are typically met at the point of use or
disposal.

Item 2.20. Provide the dry metric tons of sewage sludge
provided to the receiving facility per 365-day period.

Item 2.43. Enter the name or number and mailing address of
sewage sludge incinerator used that you do not own or operate.
Provide the name (first and last), title, work telephone number, and
email address of the contact person for the incinerator.
Include a complete location address for the incinerator if different
from the mailing address. If the incinerator 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 Routes 425 and 22”).

Item 2.24. Attach a copy of any information you provide to the
receiving facility to comply with the “notice and necessary
information” requirement under 40 CFR 503.12(g). Check the
box to indicate that this information has been attached to the
application package.

Item 2.44. Indicate whether the site contact is the owner and/or
operator of the incinerator.

Item 2.25. Indicate whether the receiving facility places sewage
sludge from your facility in a bag or other container to sell or
give away for land application. If yes, continue to Item 2.26. If
no, skip to Item 2.32 (Part 2, Section 2).

Disposal in a Municipal Solid Waste Landfill
Item 2.46. Indicate whether sewage sludge from your facility is
placed on a municipal solid waste landfill. If yes, continue to
Item 2.47. If no, skip to Part 2, Section 3.

Item 2.23. Identify the treatment process(es) used at the
receiving facility to reduce pathogens or vector attraction
properties of sewage sludge from your facility. If you check
“Other,” specify the treatment process(es) in the space provided
or in a separate attachment.

Item 2.26. When sewage sludge is placed in a bag or other
container for sale or give-away for application to the land, either
a label must be affixed to the bag or other container, or an
information sheet must be provided to the person receiving the
sewage sludge. The information that must be on the label or
information sheet is listed at 40 CFR 503.14(e). Attach copies of
all labels or notices that accompany sewage sludge being sold
or given away in a bag or other container for land application.
Check the box to indicate that this information has been
attached to the application package.
Item 2.36. Enter the site name or number and mailing address
of the surface disposal site you do not own or operate. Provide

Item 2.45. Provide the total dry metric tons of sewage sludge from
your facility fired in the sewage sludge incinerator per 365-day
period.

Item 2.47. Provide the total number of municipal solid waste landfills
to which you send sewage sludge. Complete Items 2.48 through
2.52 for each landfill used. Check the box to indicate that this
information has been attached to the application package.
Item 2.48. Enter the name and mailing address of the municipal
solid waste landfill. Provide the name (first and last), title, work
telephone number, and email address of the contact person for the
landfill.
Include a complete location address for the landfill if different from
the mailing address. If the landfill lacks a street name or route
2S-10

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation



You provide the sewage sludge to another facility for treatment
or blending.

If yes, skip to Part 2, Section 4. If no, continue to Item 3.3.

Item 2.54. Sewage sludge placed on a municipal solid waste
landfill must meet requirements in 40 CFR 258 concerning the
quality of materials placed on a landfill unit. Part 258 specifies
minimum federal criteria for municipal solid waste landfills,
including landfills that accept sewage sludge along with
household waste. In contrast to 40 CFR 503, 40 CFR 258
controls sewage sludge placed in municipal solid waste landfills
through a facility design and management practice approach. In
40 CFR 503, EPA has adopted the 40 CFR 258 criteria as the
appropriate standard for sewage sludge disposed of with
municipal waste. EPA concluded that if sewage sludge is
disposed of in a municipal solid waste landfill complying with 40
CFR 258 criteria, public health and the environment are
protected. Note that the POTW is legally responsible for
knowing whether a municipal solid waste landfill is in
compliance with 40 CFR 258 and may be liable if it sends
sludge to a municipal solid waste landfill that is not in
compliance with 40 CFR 258. Indicate whether the municipal
solid waste landfill complies with applicable criteria set forth in
40 CFR 258.

FORM 2S—PART 2 LINE-BY-LINE INSTRUCTIONS CONTINUED
number, give the most accurate alternative geographic
Provide the information in this section for each land application site
information (e.g., section number or quarter section number
that has been identified at the time of permit application. In cases
from county records or “at intersection of Routes 425 and 22”).
where the sewage sludge is applied to numerous sites with similar
characteristics, you may combine the information for several sites
Item 2.49. Provide the total dry metric tons of sewage sludge
under a single response (the name and address of each site must
from your facility placed in each municipal solid waste landfill
still be provided, however).
per 365-day period.
Item 3.1. Indicate whether your facility applies sewage sludge to
Item 2.50. In the space provided or in a separate attachment,
land. If yes, continue to Item 3.2. If no, skip to Part 2, Section 4.
list the number and type of all other federal, state, and local
permits that regulate the operation of this municipal solid waste
Item 3.2. Indicate if any of the following conditions apply:
landfill.
 The sewage sludge meets the ceiling concentrations in Table 1
Item 2.51. Attach information to determine whether the sewage
of 40 CFR 503.13, the pollutant concentrations in Table 3 of
sludge meets applicable requirements for disposal in a
40 CFR 503.13, Class A pathogen requirements at 40 CFR
municipal solid waste landfill (e.g., results of paint filter liquids
503.32(a), and one of the vector attraction reduction
test and toxicity characteristic leaching procedure, or TCLP,
requirements at 40 CFR 503.33(b)(1)–(8).
test). Check the box to indicate that this information has been
 The sewage sludge is sold or given away in a bag or other
attached to the application package.
container for application to the land.

Section 3. Land Application of Bulk Sewage Sludge
Complete this section if you completed Section B, Items 2.27
through 2.31. Unless the NPDES permitting authority specifically
requires you to complete this section, you may skip this section
for sewage sludge that is covered in any of the following
portions of this application:




Section B, Items 2.11 through 3.13. Such sewage sludges
are exempt from the general requirements and
management practices of 40 CFR 503 when they are land
applied (unless the permitting authority requires otherwise),
and thus the site information in Section C is not required for
permitting.
Section B, Items 2.17 through 2.26. Section C does not
apply to a generator that sends sewage sludge to another
facility for treatment or for blending, because the 40 CFR
503 requirements addressed by Section C will largely be
the responsibility of the receiving facility.

Item 3.3. Complete the remainder of Section 3 for each site on
which sewage sludge is applied. Check the box to indicate if this
information has been attached to the application package.
Identification of Land Application Site
Item 3.4. Enter the name or number and location address for the
land application site. If the site 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 Routes 425 and 22”).
Provide the latitude and longitude to the nearest second for the site
and method of determination. The location of the land application
site (i.e., where the coordinates are collected) shall be the
approximate center of the area where the sewage sludge is directly
released to the environment. Latitude and longitude coordinates
may be obtained in a variety of ways, including use of hand held
devices (e.g., a GPS enabled smartphone), internet mapping tools
(e.g., https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps from
trusted sources (e.g., USGS). For further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.
Item 3.5. Check the box to indicate that a topographic map (or other
appropriate map if a topographic map is unavailable) showing the
site location has been attached to the application. See Item 1.14
(Part 2, Section 1) for guidance on obtaining a topographic map.
Owner Information
Item 3.6. Indicate whether you are the owner of the land application
site. If yes, skip to Item 3.8 (Part 2, Section 3). If no, continue to
Item 3.7.

Item 3.7. Enter the name and mailing address of the owner of the
land application site. Provide the name (first and last), title, work
telephone number, and email address of the contact person for the
owner.
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Item 3.9. Enter the name and mailing address of the applier.
Provide the name (first and last), title, work telephone number,
and email address of the contact person for the applier.
Site Type
Item 3.10. Identify the type of land application site (e.g.,
agricultural land, forest, reclamation site, public contact site, or
other). If you check “Other,” provide a description in the space
provided or in a separate attachment.
Crop or Other Vegetation Grown on Site
Item 3.11. In the space provided or in a separate attachment,
describe the type of crop or other vegetation that is grown on
the site. If the crop or vegetation to be grown on the site is not
yet known, or is likely to change in an unforeseeable manner
during the life of the permit, you may so indicate instead of
providing the type of crop or other vegetation.

Item 3.19. Indicate, based on your inquiry, whether bulk sewage
sludge subject to CPLRs has been applied to the site since
July 20, 1993. If yes, continue to Item 3.20. If no, skip to Part 2,
Section 4.
Item 3.20. Provide the name and mailing address for every facility
other than yours that is sending, or has sent, bulk sewage sludge
subject to CPLRs to this site since July 20, 1993, Give the name
(first and last), title, work telephone number, and email address of
the contact person for the facility that is sending, or has sent, bulk
sewage sludge subject to CPLRs to this site since July 20, 1993.
Section 4. Surface Disposal
Complete this section if you own or operate a surface disposal site
and are required to submit a full permit application (i.e., Part 2 of
Form 2S) at this time. A sewage sludge surface disposal site is, by
definition, a TWTDS, and the owner/operator of the site is required
to apply for a permit.
Item 4.1. Indicate whether you own or operate a surface disposal
site. If yes, continue to Item 4.2. If no, skip to Part 2, Section 5.
Item 4.2. Complete the remainder of Section 4 for each active
sewage sludge unit you own or operate. Check the box to indicate
that this information has been attached to the application package.

Item 3.12. In the space provided or in a separate attachment,
indicate the nitrogen requirement for the crop or other
vegetation identified in Item 3.11. You can get information on
the nitrogen content of vegetation grown on the site from local
agricultural extension services, a local Farm Advisor’s Office, or
published sources.

Item 3.18. Provide your NPDES permitting authority’s name, contact
person, telephone number, and email address.

Applier Information
Item 3.8. Indicate whether you are the person who applies, or is
responsible for application of, sewage sludge to this land
application site. If yes, skip to Item 3.10 (Part 2, Section 3). If
no, continue to Item 3.9.

Vector Attraction Reduction
Item 3.13. Indicate whether the vector attraction reduction
requirements at 40 CFR 503.33(b)(9) and (b)(10) are met when
sewage sludge is applied to the land application site. If yes,
continue to Item 3.14. If no, skip to Item 3.16 (Part 2, Section 3).

Item 3.14. Indicate which vector attraction option (Option 9,
injection below land surface, or Option 10, incorporation into soil
within 6 hours) is met when sewage sludge is applied to the land
application site.

Item 3.15. In the space provided or in a separate attachment,
describe any treatment processes used at the land application
site to reduce vector attraction properties of sewage sludge.
Check the box to indicate that your description has been
attached to the application package.

Cumulative Loadings and Remaining Allotments
Item 3.16. Indicate whether the sewage sludge applied to this
site since July 20, 1993, is subject to the cumulative pollutant
loading rates (CPLRs) at 40 CFR 503.13(b)(2). If yes, continue
to Item 3.17. If no, skip to Part 2, Section 4.
Item 3.17. Indicate whether you have contacted the NPDES
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. If yes, continue to Item 3.18. If no,
because sewage sludge subject to CPLRs may not be applied
to this site, skip to Part 2, Section 4.

Information on Active Sewage Sludge Units
Most requirements for surface disposal of sewage sludge under 40
CFR 503 pertain to individual active sewage sludge units at a
surface disposal site. The information required in Items 4.3 through
4.15 may be developed on a unit-by-unit basis, or may be
developed for the entire surface disposal site if all units are
sufficiently similar.
Item 4.3. Enter the name or number and mailing address of the
active sewage sludge unit. Provide the name (first and last), title,
work telephone number, and email address of the contact person for
the active sewage sludge unit.
Include a complete location address for the unit if different from the
mailing address. If the unit 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 Routes 425 and 22”).
Provide the latitude and longitude to the nearest second for the unit
and method of determination. The location of the unit (i.e., where
the coordinates are collected) shall be the approximate center of the
area where the sewage sludge is directly released to the
environment. Latitude and longitude coordinates may be obtained in
a variety of ways, including use of hand held devices (e.g., a GPS
enabled smartphone), internet mapping tools (e.g.,
https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
geographic information systems (e.g., ArcView), or paper maps from
trusted sources (e.g., USGS). For further guidance, refer to
http://www.epa.gov/geospatial/latitudelongitude-data-standard.
Item 4.4. Check the box to indicate that a topographic map (or other
appropriate map if a topographic map is unavailable)

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showing the site location has been attached to the application.
Provide the name (first and last), title, work telephone number, and
See Item 1.14 (Part 2, Section 1) for guidance on obtaining a
email address of the contact person for the facility.
topographic map.
Item 4.19. Indicate the pathogen class and reduction alternative and
Item 4.5. Provide the total dry metric tons of sewage sludge
the vector attraction reduction option met for the sewage sludge
placed on the active sewage sludge unit per 365-day period.
before leaving the other facility. To determine the applicable
pathogen class and reduction alternative, see 40 CFR 503.32. To
Item 4.6. Provide the total dry metric tons of sewage sludge
determine the applicable vector attraction reduction option, see 40
placed on the active sewage sludge unit over the life of the unit.
CFR 503.33. Vector attraction reduction options 1 through 8 are
typically met at the point where sewage sludge is generated or
Item 4.7. Indicate whether the active sewage sludge unit has a
where a material is derived from sewage sludge, and options 9
liner with a maximum permeability of 10-7 centimeters per
through 11 are typically met at the point of use or disposal.
second (cm/sec). If yes, continue to Item 4.8. If no, skip to
Item 4.9 (Part 2, Section 4).
Item 4.20. Identify the treatment process(es) used at the other
facility to reduce pathogens or vector attraction properties of
Item 4.8. In the space provided or in a separate attachment,
sewage sludge before leaving the other facility. If you check “Other,”
describe the liner. Check the box to indicate that a description
specify the treatment process(es) in the space provided or in a
has been attached to the application package.
separate attachment.
Item 4.9. Indicate whether the active sewage sludge unit has a
Vector Attraction Reduction
leachate collection system. If yes, continue to Item 4.10. If no,
skip to Item 4.11 (Part 2, Section 4).
Item 4.21. Indicate which, if any, vector attraction reduction option
(Option 9, injection below land surface; Option 10, incorporation into
Item 4.10. In the space provided or in a separate attachment,
soil within 6 hours; Option 11, covering active sewage sludge unit
describe the leachate collection system and the leachate
disposal method. Also provide the numbers of any federal, state, daily; or none) is met when sewage sludge is placed on this active
sewage sludge unit.
or local permit(s) for leachate disposal. Check the box to
indicate that this description has been attached to the
Item 4.22. In the space provided or in a separate attachment,
application package.
describe any treatment processes used at the active sewage sludge
unit to reduce vector attraction properties of sewage sludge. Check
Item 4.11. Indicate if the boundary of the active sewage sludge
site is less than 150 meters from the property line of the surface the box to indicate that this description has been attached to the
application package.
disposal site. If yes, continue to Item 4.12. If no, skip to
Item 4.13 (Part 2, Section 4).
Groundwater Monitoring

Item 4.12. Provide the distance, in meters, between the active
sewage sludge site boundary and the surface disposal site
property line.
Item 4.13. Provide the remaining capacity of active sewage
sludge in dry metric tons.

Item 4.14. List the anticipated closure date for the active
sewage sludge unit, using the format MM/DD/YYYY, if known.

Item 4.15. Submit a copy of any closure plan that has been
developed for this active sewage sludge unit. Check the box to
indicate that you have attached a copy to the application
package.

Sewage Sludge from Other Facilities
Item 4.16. Indicate whether sewage sludge is sent to this active
sewage sludge unit from any facilities other than yours. If yes,
continue to Item 4.17. If no, skip to Item 4.21 (Part 2, Section 4).
Item 4.17. Indicate the total number of facilities, other than
yours, that send sewage sludge to this active sewage sludge
unit. Complete Items 4.18 through 4.20 for each such facility.
Check the box to indicate that this information has been
attached to the application package.

Item 4.18. Enter the name and mailing address of the facility
that sends sewage sludge to this active sewage sludge unit.

Placement of sewage sludge on an active sewage sludge unit must
not contaminate an aquifer. Compliance must be demonstrated
through either (1) the results of a groundwater monitoring program
developed by a qualified groundwater scientist or (2) certification by
a qualified groundwater scientist that contamination has not
occurred. This section solicits existing groundwater monitoring data
and other documentation to indicate the potential for contamination
of an aquifer at the active sewage sludge unit, and the capability of
the owner/operator of the surface disposal site to demonstrate that
contamination has not occurred.
Item 4.23. Indicate whether groundwater monitoring is currently
conducted at, or ground monitoring data is otherwise available for,
this active sewage sludge unit. If yes, continue to Item 4.24. If no,
skip to Item 4.26 (Part 2, Section 4).
Item 4.24. Provide a copy of available groundwater monitoring data.
Check the box to indicate that the data have been attached to the
application package.
Item 4.25. In the space provided or in a separate attachment,
describe the well locations, the approximate depth to groundwater,
and the groundwater monitoring procedures used to obtain the data.

Check the box to indicate that the descriptions have been attached
to the application package.
Item 4.26. Indicate whether a groundwater monitoring program has
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been prepared for this active sewage sludge unit. If yes,
Item 5.3. Enter the incinerator’s name or number. Include a
continue to Item 4.27. If no, skip to Item 4.28 (Part 2, Section 4). complete location address for the incinerator. If the incinerator lacks
a street name or route number, give the most accurate alternative
Item 4.27. Submit a copy of the groundwater monitoring
geographic information (e.g., section number or quarter section
program that has been developed for this active sewage sludge
number from county records or “at intersection of Routes 425 and
unit. Check the box to indicate that this documentation has been
22”).
attached to the application package.
Provide the latitude and longitude to the nearest second for the
Item 4.28. Indicate whether you have obtained certification from
incinerator and method of determination. The location of the
a qualified groundwater scientist that the aquifer below the
incinerator (i.e., where the coordinates are collected) shall be the
active sewage sludge unit has not been contaminated. If yes,
approximate center of the area where the sewage sludge is directly
continue to Item 4.29. If no, skip to Item 4.30 (Part 2, Section 4).
released to the environment. Latitude and longitude coordinates
may be obtained in a variety of ways, including use of hand held
Item 4.29. Submit a copy of the certification indicating that the
devices (e.g., a GPS enabled smartphone), internet mapping tools
aquifer below the active sewage sludge unit has not been
(e.g., https://mynasadata.larc.nasa.gov/latitudelongitude-finder/),
contaminated. Check the box to indicate that this certification
geographic information systems (e.g., ArcView), or paper maps from
has been attached to the application package.
trusted sources (e.g., U.S. Geological Survey or USGS). For further
Site-Specific Limits
guidance, refer to http://www.epa.gov/geospatial/latitudelongitudeAfter August 18, 1993, you are allowed to seek site-specific
data-standard.
pollutant limits only for good cause, and must do so within
Amount Fired
180 days of becoming aware that good cause exists. If you
Item 5.4. Provide the dry metric tons of sewage sludge fired in the
request site-specific pollutant limits with this permit application,
sewage sludge incinerator per 365-day period.
you are required to submit information supporting the request,
including a demonstration that existing values for site
Beryllium NESHAP
parameters specified by the permitting authority differ from the
The firing of sewage sludge in a sewage sludge incinerator must not
values for those parameters used to develop the pollutant limits
violate the National Emission Standard for Hazardous Air Pollutants
in Table 1 of 40 CFR 503.23. You must also submit follow-up
(NESHAP) for beryllium as established in Subpart C of 40 CFR 61.
information at the request of the NPDES permitting authority. If
The beryllium NESHAP only applies, however, to sewage sludge
the NPDES permitting authority determines that site-specific
incinerators firing ‘‘beryllium-containing waste.’’ The beryllium
pollutant limits are appropriate, he or she may specify siteNESHAP is 10 grams of beryllium in the exit gas over a 24-hour
specific limits in the permit as long as the existing
period, unless the incinerator owner/operator has been approved to
concentrations of the pollutants in the sewage sludge are not
meet a 30-day average ambient concentration limit on beryllium in
exceeded.
the vicinity of the sewage sludge incinerator of 0.01 μg/m3.
Item 4.30. Indicate whether you are seeking site-specific
Complete this section to demonstrate compliance with the beryllium
pollutant limits for the sewage sludge placed on the active
NESHAP.
sewage sludge unit. If yes, continue to Item 4.31. If no, skip to
Item 5.5. Submit information, test data, and a description of
Part 2, Section 5.
measures taken that demonstrate whether the sewage sludge
Item 4.31. Submit information to support the request for siteincinerated is beryllium-containing waste and will continue to remain
specific pollutant limits. Check the box to indicate that this
as such. Check the box to indicate that this material has been
information has been attached to the application package.
attached to the application package.
Section 5. Incineration
Item 5.6. Indicate whether the sewage sludge fired in the incinerator
Complete this section if you own or operate a sewage sludge
is beryllium-containing waste as defined at 40 CFR 61.31. If yes,
incinerator. A sewage sludge incinerator is, by definition, a
continue to Item 5.7. If no, skip to Item 5.8 (Part 2, Section 5).
treatment works treating domestic sewage, and the owner/
Item 5.7. Submit a complete report of the latest beryllium emission
operator of a sewage sludge incinerator is required to submit a
testing and documentation of ongoing incinerator operating
full permit application.
parameters indicating that the NESHAP emission rate limit for
Incinerator Information
beryllium has been and will continue to be met. Check the box to
indicate that this documentation has been attached to the
Item 5.1. Indicate whether you fire sewage sludge in a sewage
application package.
sludge incinerator. If yes, continue to Item 5.2. If no, skip to the
end.
Mercury NESHAP
Item 5.2. Indicate the total number of incinerators used at your
The firing of sewage sludge in a sewage sludge incinerator must not
violate the NESHAP for mercury as established in Subpart E of 40
facility. Complete the remainder of Section 5 for each
CFR 61. Complete this section to demonstrate compliance with the
incinerator. Check the box to indicate that you have attached
mercury NESHAP. Information on stack testing and sewage sludge
information for one or more incinerators.
sampling can be found at 40 CFR 61.53 and 61.54.
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FORM 2S—PART 2 LINE-BY-LINE INSTRUCTIONS CONTINUED
Item 5.8. Indicate whether compliance with the mercury
Item 5.21. Indicate whether the RSC was determined using Table 2
NESHAP is being demonstrated via stack testing. If yes,
at 40 CFR 503.43 (site-specific determination). If yes, continue to
continue to Item 5.9. If no, skip to Item 5.11 (Part 2, Section 5).
Item 5.22. If no, skip to Item 5.23 (Part 2, Section 5).

Item 5.10. Provide copies of mercury emission rate tests for the
two most recent years in which testing was conducted. Check
the box to indicate that this information has been attached to the
application package.
Item 5.11. Indicate whether you demonstrate compliance with
the mercury NESHAP by performing sewage sludge sampling. If
yes, continue to Item 5.12. If no, skip to Item 5.13 (Part 2,
Section 5).

Item 5.23. Submit the results of incinerator stack testing for
hexavalent and total chromium concentrations, including test dates.
Check the box to indicate that these results have been attached to
the application package, or check “Not applicable.”
Incinerator Parameters
Item 5.24. Indicate whether you monitor total hydrocarbons (THC) in
the exit gas of the sewage sludge incinerator.
Item 5.25. Indicate whether you monitor carbon monoxide (CO) in
the exit gas of the sewage sludge incinerator.
Item 5.26. Specify the type of sewage sludge incinerator used.
Item 5.27. Provide the incinerator stack height in meters.
Item 5.28. Indicate whether the value submitted in Item 5.27 is the
actual stack height or creditable stack height.

Item 5.12. Submit a complete report of sewage sludge sampling
and documentation of ongoing incinerator operating parameters
indicating that the incinerator has been meeting and will
continue to meet the NESHAP emission rate limit for mercury.
Check the box to indicate that this documentation has been
attached to the application package.

Item 5.22. Provide the decimal fraction of hexavalent chromium to
total chromium concentration in the stack exit gas.

Item 5.9. Submit a complete report of stack testing and
documentation of ongoing incinerator operating parameters
indicating that the NESHAP emission rate limit for mercury has
been and will continue to be met. Check the box to indicate that
this documentation has been attached to the application
package.

Dispersion Factor
Item 5.13. Provide the dispersion factor in micrograms/cubic
meter per gram/second.

Performance Test Operating Parameters
Item 5.29. Provide the maximum performance test combustion
temperature.
Item 5.30. Provide the performance test sewage sludge feed rate, in
dry metric tons/day.
Item 5.31. Indicate whether the value submitted in Item 5.30 is the
average use rate or maximum design rate.

Item 5.15 Submit a copy of the modeling results and supporting
documentation. Check the box to indicate that the
documentation has been attached to the application package.

Item 5.32. Supply supporting documentation describing how the
feed rate was calculated. Check the box to indicate that this
documentation has been attached to the application package.

Control Efficiency
Item 5.16. Provide the control efficiency, in hundredths, for
arsenic, cadmium, chromium, lead, and nickel.

Item 5.33. Submit information documenting the performance test
operating parameters for the air pollution control device(s) used for
this sewage sludge incinerator. Check the box to indicate that this
information has been attached to the application package.

Item 5.14. Specify the name and type of dispersion model.

Item 5.17. Submit the results of performance testing and
supporting documentation, including test dates. Check the box
to indicate that this documentation has been attached to the
application package.
Risk-specific Concentration for Chromium
Item 5.18. Provide the risk-specific concentration (RSC) used
for chromium in micrograms per cubic meter.
Item 5.19. Indicate whether the RSC was determined using
Table 2 at 40 CFR 503.43. If yes, continue to Item 5.20. If no,
skip to Item 5.21 (Part 2, Section 5).

Monitoring Equipment
Item 5.34. Use the table provided or a separate attachment, to
indicate the equipment in place to monitor total hydrocarbons or
carbon monoxide, percent oxygen, percent moisture, combustion
temperature, and any other parameters not listed.
Air Pollution Control Equipment
Item 5.35. List all air pollution control equipment used with this
sewage sludge incinerator. Check the box to indicate that the list
has been attached to the application package.
END OF PART 2

Item 5.20. Identify the incinerator used as the basis, as either
fluidized bed with wet scrubber, other types with wet scrubber,
fluidized bed with wet scrubber and wet electrostatic
precipitator, or other types with wet scrubber and wet
electrostatic precipitator.

Submit your completed Part 2 of Form 2S
and all associated attachments
to your NPDES permitting authority.

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FORM 2S—GLOSSARY
Note: This glossary includes terms used in the various NPDES application forms, including Form 2S. The definitions are from the NPDES
regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms, contact
your NPDES permitting authority.
ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (other than an aquatic animal production facility) where the
following conditions are met;


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



Crops, vegetation, forage growth, or post-harvest residues are not sustained in the normal growing season over any portion of the lot
or facility.

BIOSOLIDS (see sewage sludge).

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FORM 2S—GLOSSARY CONTINUED
8.
9.
10.
11.
12.
13.
B.

Closed ponds which discharge only during periods of excess runoff; or

Facilities which produce less than 45,454 harvest weight kilograms (approximately 100,000 pounds) of aquatic animals per year.

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FORM 2S—GLOSSARY CONTINUED
DAILY DISCHARGE means the “discharge of a pollutant” measured during a calendar day or any 24-hour period that reasonably
represents the calendar day for purposes of sampling. For pollutants with limitations expressed in units of mass, the “daily discharge” is
calculated as the total mass of the pollutant discharged over the day. For pollutants with limitations expressed in other units of
measurement, the “daily discharge” is calculated as the average measurement of the pollutant over the day.
DIRECT DISCHARGE means the “discharge of a pollutant.”
DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an authorized representative. When there
is no “approved State program,” and there is an EPA administered program, “Director” means the Regional Administrator. When there is
an approved State program, “Director” normally means the State Director. In some circumstances, however, EPA retains the authority to
take certain actions even when there is an approved State program. (For example, when EPA has issued an NPDES permit prior to the
approval of a State program, EPA may retain jurisdiction over that permit after program approval, see § 123.1.) In such cases, the term
“Director” means the Regional Administrator and not the State Director.
DISCHARGE (OF A POLLUTANT) means:
Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or



All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same.

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LARGE MUNICIPAL SEPARATE STORM SEWER SYSTEM (defined at § 122.26(b)(4)) means all municipal separate storm sewers that
are either:
(i) Located in an incorporated place with a population of 250,000 or more as determined by the 1990 Decennial Census by the Bureau of
the Census (Appendix F of 40 CFR 122); or
(ii) Located in the counties listed in appendix H of 40 CFR 122, except municipal separate storm sewers that are located in the
incorporated places, townships or towns within such counties; or
(iii) Owned or operated by a municipality other than those described in paragraphs (i) or (ii) and that are designated by the Director as part
of the large or medium municipal separate storm sewer system due to the interrelationship between the discharges of the designated
storm sewer and the discharges from municipal separate storm sewers described under paragraphs (i) or (ii). In making this determination
the Director may consider the following factors:
(A) Physical interconnections between the municipal separate storm sewers;
(B) The location of discharges from the designated municipal separate storm sewer relative to discharges from municipal separate storm
sewers described in paragraph (i);
(D) The nature of the receiving waters; and
(E) Other relevant factors; or

2S-19

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GLOSSARY CONTINUED
MUNICIPALITY means a city, 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 the CWA.
MUNICIPAL SEPARATE STORM SEWER (defined at § 122.26(b)(8)) means a conveyance or system of conveyances (including roads
with drainage systems, municipal streets, catch basins, curbs, gutters, ditches, man-made channels, or storm drains):




Designed or used for collecting or conveying stormwater.



Which is not a combined sewer; and



Which is not part of a POTW as defined at 40 CFR 122.2.

MUNICIPAL SLUDGE (see sewage sludge)



That did not commence the “discharge of pollutants” at a particular “site” prior to August 13, 1979;



Which is not a “new source;” and



Which has never received a finally effective NPDES permit for discharges at that “site.”



OWNER OR OPERATOR means the owner or operator of any “facility or activity” subject to regulation under the NPDES program.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GLOSSARY CONTINUED
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, landfill leachate collection system, vessel or
other floating craft from which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture or
agricultural stormwater runoff. (See § 122.3).
POLLUTANT means dredged spoil, solid waste, incinerator residue, filter backwash, sewage, garbage, sewage sludge, munitions,
chemical wastes, biological materials, radioactive materials (except those regulated under the Atomic Energy Act of 1954, as amended (42
U.S.C. 2011 et seq.)), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste
discharged into water. It does not mean:


Sewage from vessels; or



SECONDARY INDUSTRY CATEGORY means any industry category which is not a primary industry category.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GLOSSARY CONTINUED
SITE means the land or water area where any “facility or activity” is physically located or conducted, including adjacent land used in
connection with the facility or activity.
SLUDGE-ONLY FACILITY means any “treatment works treating domestic sewage” whose methods of sewage sludge use or disposal are
subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2).
STANDARDS FOR SEWAGE SLUDGE USE OR DISPOSAL means the regulations promulgated pursuant to section 405(d) of the CWA
which govern minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage sludge
or the use or disposal of sewage sludge by any person.
STATE means any of the 50 States, the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, the Commonwealth of the Northern Mariana Islands, the Trust Territory of the Pacific Islands, or an Indian Tribe as defined in
these regulations which meets the requirements of § 123.31 of this chapter.
STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an “approved program,” or the
delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, “State Director”
means the chief administrative officer of the State or interstate agency authorized to perform the particular procedure or function to which
reference is made.

STORMWATER (or STORM WATER) (defined at § 122.26(b)(13)) means stormwater runoff, snow melt runoff, and surface runoff and
drainage.

4.
5.
6.

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

FORM 2S—GLOSSARY CONTINUED
Steam electric power generating facilities, including coal handling sites;
Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221–25), 43, 44, 45, and 5171 which have
vehicle maintenance shops, equipment cleaning operations, or airport deicing operations. Only those portions of the facility that are
either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication),
equipment cleaning operations, airport deicing operations, or which are otherwise identified under paragraphs 1–7 or 9–11 are
associated with industrial activity;
9. Treatment works treating domestic sewage or any other sewage sludge or wastewater treatment device or system, used in the
storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage
sludge that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved
pretreatment program under 40 CFR 403. Not included are farm lands, domestic gardens or lands used for sludge management
where sludge is beneficially reused and which are not physically located in the confines of the facility, or areas that are in compliance
with section 405 of the CWA;
10. Construction activity including clearing, grading and excavation, except operations that result in the disturbance of less than five acres
of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a part of a larger
common plan of development or sale if the larger common plan will ultimately disturb five acres or more;
11. Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34
(except 3441), 35, 36, 37 (except 373), 38, 39, and 4221–25.

7.
8.

WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test.

2S-23

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

U.S Environmental Protection Agency
Application for NPDES Permit for Sewage Sludge Management

Form
2S
NPDES

NEW AND EXISTING TREATMENT WORKS TREATING DOMESTIC SEWAGE
PRELIMINARY INFORMATION
Does your facility currently have an effective NPDES permit or have you been directed by your NPDES permitting authority to submit a
full Form 2S permit application?
 Yes  Complete Part 2 of application package (begins p. 7).
 No  Complete Part 1 of application package (below).
PART 1
LIMITED BACKGROUND INFORMATION (40 CFR 122.21(c)(2)(ii))
Complete this part only if you are a “sludge-only” facility (i.e., a facility that does not currently have, and is not applying for, an NPDES
permit for a direct discharge to a surface body of water).
PART 1, SECTION 1. FACILITY INFORMATION (40 CFR 122.21(c)(2)(ii)(A))
Facility name
1.1
Mailing address (street or P.O. box)

Contact name (first and last)

State

ZIP code

Phone number

Email address

Facility Information

City or town
Title

Location address (street, route number, or other specific identifier)

1.2

State

City or town

 Same as mailing address
ZIP code

Ownership Status

 Public—federal
 Private

 Public—state
 Other public (specify)___________________
 Other (specify) _________

PART 1, SECTION 2. APPLICANT INFORMATION (40 CFR 122.21(c)(2)(ii)(B))
2.1

No  SKIP to Item 2.3 (Part 1, Section 2).

Applicant address (street or P.O. box)
City or town

Contact name (first and last)

2.3

Title

2.4

State

ZIP code

Phone number

Email address

Is the applicant the facility’s owner, operator, or both? (Check only one response.)
 Owner
 Operator


Applicant Information

2.2

Is applicant different from entity listed under Item 1.1 above?
 Yes

Applicant name

Both

To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
Facility and applicant
Facility
Applicant



(they are one and the same)

PART 1, SECTION 3. SEWAGE SLUDGE AMOUNT (40 CFR 122.21(c)(2)(ii)(D))
Sewage Sludge Amount

3.1

Provide the total dry metric tons per the latest 365-day period of sewage sludge generated, treated, used, and
disposed of:
Dry Metric Tons per
Practice
365-Day Period
Amount generated at the facility
Amount treated at the facility
Amount used (i.e., received from off site) at the facility
Amount disposed of at the facility

EPA Form 3510-2S (Revised )

Page 1

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 1, SECTION 4. POLLUTANT CONCENTRATIONS (40 CFR 122.21(c)(2)(ii)(E))
4.1

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 503 for your 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
4.5 years old.

 Check here if you have provided a separate attachment with this information.
Pollutant

Concentration
(mg/kg dry weight)

Analytical Method

Detection Level
for Analysis

Arsenic
Cadmium
Chromium

Lead

Nickel

Molybdenum

Selenium
Zinc

Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________
Other (specify)
___________________

Pollutant Concentrations

Mercury

Copper

EPA Form 3510-2S (Revised )

Page 2

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires






Treatment Provided at Your Facility

PART 1, SECTION 5. TREATMENT PROVIDED AT YOUR FACILITY (40 CFR 122.21(c)(2)(ii)(C))
For each sewage sludge use or disposal practice, indicate the amount of sewage sludge used or disposed of, the
5.1
applicable pathogen class and reduction alternative, and the applicable vector attraction reduction option. Attach
additional pages, as necessary.
Use or Disposal Practice
Amount
Pathogen Class and
Vector Attraction
(check one)
(dry metric tons)
Reduction Alternative
Reduction Option
 Land application of bulk sewage
 Not applicable
 Not applicable
 Land application of biosolids
 Class A, Alternative 1
 Option 1
(bulk)
 Class A, Alternative 2
 Option 2
 Land application of biosolids
 Class A, Alternative 3
 Option 3
(bags)
 Class A, Alternative 4
 Option 4
 Surface disposal in a landfill
 Class A, Alternative 5
 Option 5
 Other surface disposal
 Class A, Alternative 6
 Option 6
 Incineration
 Class B, Alternative 1
 Option 7
 Class B, Alternative 2
 Option 8
 Class B, Alternative 3
 Option 9
 Class B, Alternative 4
 Option 10
 Domestic septage, pH  Option 11
adjustment
For
each
of
the
use
and
disposal
practices
specified
in
Item
5.1,
identify the treatment process(es) used at your
5.2
facility to reduce pathogens in sewage sludge or reduce the vector attraction properties of sewage sludge. (Check
all that apply.)
Preliminary operations (e.g., sludge

 Thickening (concentration)
grinding and degritting)
Stabilization

 Anaerobic digestion
Composting
Disinfection (e.g., beta ray irradiation,
gamma ray irradiation, pasteurization)
Heat drying
Methane or biogas capture and recovery






Conditioning
Dewatering (e.g., centrifugation, sludge drying
beds, sludge lagoons)
Thermal reduction
Other (specify) _____________________________

PART 1, SECTION 6. SEWAGE SLUDGE SENT TO OTHER FACILITIES (40 CFR 122.21(c)(2)(ii)(C))
Does the sewage sludge from your facility meet the ceiling concentrations in Table 1 of 40 CFR 503.13, the
pollutant concentrations in Table 3 of 40 CFR 503.13, Class A pathogen reduction requirements at 40 CFR
503.32(a), and one of the vector attraction reduction requirements at 40 CFR 503.33(b)(1)–(8)?

6.1

6.2

Yes  SKIP to Part 1, Section 8 (Certification).



6.3



Is sewage sludge from your facility provided to another facility for treatment, distribution, use, or disposal?
Yes

Sewage Sludge Sent to Other Facilities



No  SKIP to Part 1, Section 7.

Receiving facility name

Mailing address (street or P.O. box)
City or town

Contact name (first and last)

6.4

Title

State

ZIP code

Phone number

Email address

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
Incineration




Surface disposal
Other (describe)

Composting

EPA Form 3510-2S (Revised )

Page 3

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 1, SECTION 7. USE AND DISPOSAL SITES (40 CFR 122.21(c)(2)(ii)(C))
Provide the following information for each site on which sewage sludge from this facility is used or disposed of.
 Check here if you have provided separate attachments with this information.
7.1
Site name or number
Mailing address (street or P.O. box)

Use and Disposal Sites

City or town
Contact name (first and last)

Title

State

ZIP code

Phone number

Email address

Location address (street, route number, or other specific identifier)

County

County code

Site type (check all that apply)





Agricultural
Surface disposal
Reclamation





ZIP code
 Not available

State

Lawn or home garden
Public contact

Municipal solid waste landfill





Forest

Incineration

Other (describe)

7.2

City or town

 Same as mailing address

PART 1, SECTION 8. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))

In Column 1 below, mark the sections of Form 2S, Part 1, that you have completed and are submitting with your
application. For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting
authority. Note that not all applicants are required to provide attachments.
Column 1
Column 2
Section 1: Facility Information



w/ attachments



Section 2: Applicant Information



w/ attachments




Section 3: Sewage Sludge Amount



w/ attachments



Section 4: Pollutant Concentrations



w/ attachments




Section 5: Treatment Provided at Your Facility



w/ attachments

Section 6: Sewage Sludge Sent to Other
Facilities



w/ attachments



Section 7: Use and Disposal Sites



w/ attachments



Section 8: Checklist and Certification Statement

Checklist and Certification Statement

8.1

EPA Form 3510-2S (Revised )

Page 4

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Checklist and Certification Statement
Continued

8.2

Form Approved
OMB No.
Form Expires

Certification Statement
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.
Name (print or type first and last name)
Official title
Phone number

Signature

Date signed

PART 1 APPLICANTS STOP HERE.

Submit completed application package to your NPDES permitting authority.

EPA Form 3510-2S (Revised )

Page 5

Contains Nonbinding Recommendations
Draft Application Forms - Not for Implementation

This page intentionally left blank.

EPA Form 3510-2S (Revised )

Page 6

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 2
PERMIT APPLICATION INFORMATION (40 CFR 122.21(q))
Complete this part if you have an effective NPDES permit or have been directed by the NPDES permitting authority to submit a full
permit application. In other words, complete this part if your facility has, or is applying for, an NPDES permit.
Part 2 is divided into five sections. Section 1 pertains to all applicants. The applicability of Sections 2 to 5 depends on your facility’s
sewage sludge use or disposal practices. See the instructions to determine which sections you are required to complete.
PART 2, SECTION 1. GENERAL INFORMATION (40 CFR 122.21(q)(1–7) AND (q)(13))
All Part 2 applicants must complete this section.
Facility Information
1.1 Facility name
Mailing address (street or P.O. box)
City or town

State

ZIP code

Contact name (first and last)

Title

Email address

City or town

Facility Design Flow Rate
Total Population Served
Ownership Status

ZIP code



1.3
1.4
1.5

Is this facility a Class I sludge management facility?
 Yes

 Public—federal
 Private

million gallons per day (mgd)

 Public—state
 Other public (specify) ____________
 Other (specify) ____________

Applicant Information
1.6 Is applicant different from entity listed under Item 1.1 above?
 Yes
1.7 Applicant name

General Information

1.2

State

 Same as mailing address

Location address (street, route number, or other specific identifier)

Phone number



No  SKIP to Item 1.18 (Part 2, Section 1).

Applicant mailing address (street or P.O. box)
City or town

Contact name (first and last)

ZIP code

Phone number

Email address

Is the applicant the facility’s owner, operator, or both? (Check only one response.)

1.8

Title

State



1.9

Operator
 Owner
 Both
To which entity should the NPDES permitting authority send correspondence? (Check only one response.)
 Facility
 Applicant
 Facility and applicant

EPA Form 3510-2S (Revised )

(they are one and the same)

Page 7

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Permit Information
NPDES Permit Number
1.10 Facility’s NPDES permit number
Check here if you do not have an NPDES permit but are otherwise required
 to submit Part 2 of Form 2S.
1.11 Indicate all other federal, state, and local permits or construction approvals received or applied for that regulate this
facility’s sewage sludge management practices below.



Check here if you have provided a separate attachment with this information.

Existing Environment Permits (check all that apply and print or type the corresponding permit number for each)
RCRA (hazardous wastes)



_________________________



PSD (air emissions)




Dredge or fill (CWA Section
404)
_________________________

NESHAPs (CAA)
_________________________



UIC (underground injection of
fluids)
_________________________

Other (specify)
_________________________
_________________________

_________________________
Indian Country
1.12 Does any generation, treatment, storage, application to land, or disposal of sewage sludge from this facility occur in
Indian Country?
 SKIP to Item 1.14 (Part 2, Section 1)
 Yes
 No
below.
1.13 Provide a description of the generation, treatment, storage, land application, or disposal of sewage sludge that
occurs.
Topographic Map
1.14 Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
 Yes
 No
Line Drawing
1.15 Have you attached a line drawing and/or a narrative description that identifies all sewage sludge practices that will be
employed during the term of the permit containing all the required information to this application? (See instructions for
specific requirements.)

General Information Continued

Ocean dumping (MPRSA)



_________________________



Nonattainment program (CAA)



Yes



Contractor Information
1.16 Do contractors have any operational or maintenance responsibilities related to sewage sludge generation, treatment,
use, or disposal at the facility?
 SKIP to Item 1.18 (Part 2, Section 1)
 Yes
 No
below.
1.17 Provide the following information for each contractor.
 Check here if you have attached additional sheets to the application package.
Contractor 1

Contractor 2

Contractor 3

Contractor company name
Mailing address (street or
P.O. box)
City, state, and ZIP code
Contact name (first and last)
Telephone number
Email address
EPA Form 3510-2S (Revised )

Page 8

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

1.17
cont.

Contractor 1

Form Approved
OMB No.
Form Expires

Contractor 2

Contractor 3

Responsibilities of contractor

Pollutant 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 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 4.5 years old.



Check here if you have attached additional sheets to the application package.

1.18

Pollutant

Average Monthly
Concentration

Analytical Method

Detection Level

Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Molybdenum
Nickel
Selenium
Zinc
Checklist and Certification Statement
1.19 In Column 1 below, mark the sections of Form 2S, Part 2, that you have completed and are submitting with your
application. For each section, specify in Column 2 any attachments that you are enclosing. Note that not all
applicants are required to complete all sections or provide attachments. See Exhibit 2S–2 in the Instructions.
Column 1
Column 2
 Section 1 (General Information)
 w/ attachments
Section 2 (Generation of Sewage Sludge or Preparation of a Material
 Derived from Sewage Sludge)
 w/ attachments
 Section 3 (Land Application of Bulk Sewage Sludge)
 w/ attachments

General Information Continued

(mg/kg dry weight)




Section 5 (Incineration)

Certification Statement

1.20

 w/ attachments
 w/ attachments

Section 4 (Surface Disposal)

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.
Name (print or type first and last name)
Official title
Signature

Date signed

Telephone number
Upon the request of the NPDES permitting authority, you must submit any other information the authority deems necessary to
assess sewage sludge use or disposal practices at your facility and identify appropriate permitting requirements.

EPA Form 3510-2S (Revised )

Page 9

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 2, SECTION 2. GENERATION OF SEWAGE SLUDGE OR PREPARATION OF A MATERIAL DERIVED FROM SEWAGE
SLUDGE (40 CFR 122.21(q)(8) THROUGH (12))
2.1 Does your facility generate sewage sludge or derive a material from sewage sludge?



Yes
 No  SKIP to Part 2, Section 3.
Amount Generated Onsite
2.2 Total dry metric tons per 365-day period generated at your facility:

Mailing address (street or P.O. box)
City or town
Title

State

ZIP code

Phone number

Email address

Contact name (first and last)

Provide the following information for each of the facilities from which you receive sewage sludge.
 Check here if you have attached additional sheets to the application package.
2.5 Name of facility

Location address (street, route number, or other specific identifier)
City or town
County

County code

ZIP code
 Not available

Indicate the amount of sewage sludge received, the applicable pathogen class and reduction alternative, and the
applicable vector reduction option provided at the offsite facility.
Amount
Pathogen Class and Reduction
Vector Attraction Reduction
(dry metric tons)
Alternative
Option
 Not applicable
 Not applicable
 Class A, Alternative 1
 Option 1
 Class A, Alternative 2
 Option 2
 Class A, Alternative 3
 Option 3
 Class A, Alternative 4
 Option 4
 Class A, Alternative 5
 Option 5
 Class A, Alternative 6
 Option 6
 Class B, Alternative 1
 Option 7
 Class B, Alternative 2
 Option 8
 Class B, Alternative 3
 Option 9
 Class B, Alternative 4
 Option 10
 Domestic septage, pH adjustment  Option 11
Identify the treatment process(es) that are known to occur at the offsite facility, including blending activities and
treatment to reduce pathogens or vector attraction properties. (Check all that apply.)
operations (e.g., sludge grinding and
 Preliminary
 Thickening (concentration)
degritting)

2.6

State

 Same as mailing address

Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge

Amount Received from Off Site Facility
2.3 Does your facility receive sewage sludge from another facility for treatment use or disposal?
 Yes
 No  SKIP to Item 2.7 (Part 2, Section 2) below.
2.4 Indicate the total number of facilities from which you receive sewage sludge for
treatment, use, or disposal:

2.7




Stabilization

Anaerobic digestion

Composting






Disinfection (e.g., beta ray irradiation, gamma ray
irradiation, pasteurization)



Dewatering (e.g., centrifugation, sludge drying
beds, sludge lagoons)




Heat drying




Thermal reduction

Methane or biogas capture and recovery

EPA Form 3510-2S (Revised )

Conditioning

Other (specify) ___________________________
Page 10

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

Form Approved
OMB No.
Form Expires

Composting
Disinfection (e.g., beta ray irradiation, gamma ray
irradiation, pasteurization)
Heat drying
Methane or biogas capture and recovery

Conditioning
Dewatering (e.g., centrifugation, sludge drying
beds, sludge lagoons)
Thermal reduction

Describe any other sewage sludge treatment or blending activities not identified in Items 2.8 and 2.9 (Part 2, Section
2) above.
 Check here if you have attached the description to the application package.

2.10










Treatment Provided at Your Facility
2.8 For each sewage sludge use or disposal practice, indicate the applicable pathogen class and reduction alternative
and the applicable vector attraction reduction option provided at your facility. Attach additional pages, as necessary.
Use or Disposal Practice
Pathogen Class and Reduction
Vector Attraction Reduction
Alternative
Option
(check one)
 Land application of bulk sewage
 Not applicable
 Not applicable
 Land application of biosolids
 Class A, Alternative 1
 Option 1
(bulk)
 Class A, Alternative 2
 Option 2
 Land application of biosolids
 Class A, Alternative 3
 Option 3
(bags)
 Class A, Alternative 4
 Option 4
 Surface disposal in a landfill
 Class A, Alternative 5
 Option 5
 Other surface disposal
 Class A, Alternative 6
 Option 6
 Incineration
 Class B, Alternative 1
 Option 7
 Class B, Alternative 2
 Option 8
 Class B, Alternative 3
 Option 9
 Class B, Alternative 4
 Option 10
 Domestic septage, pH adjustment  Option 11
2.9 Identify the treatment process(es) used at your facility to reduce pathogens in sewage sludge or reduce the vector
attraction properties of sewage sludge? (Check all that apply.)
operations (e.g., sludge grinding and
 Preliminary
 Thickening (concentration)
degritting)
 Stabilization
 Anaerobic digestion

Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge Continued

EPA Identification Number

Preparation of Sewage Sludge Meeting Ceiling and Pollutant Concentrations, Class A Pathogen Requirements, and
One of Vector Attraction Reduction Options 1 to 8
2.11 Does the sewage sludge from your facility meet the ceiling concentrations in Table 1 of 40 CFR 503.13, the pollutant
concentrations in Table 3 of 40 CFR 503.13, Class A pathogen reduction requirements at 40 CFR 503.32(a), and one
of the vector attraction reduction requirements at 40 CFR 503.33(b)(1)–(8) and is it land applied?
 Yes
 No  SKIP to Item 2.14 (Part 2, Section 2)
below.
2.12 Total dry metric tons per 365-day period of sewage sludge subject to this
subsection that is applied to the land:
2.13

Is sewage sludge subject to this subsection placed in bags or other containers for sale or give-away for application to
the land?
 No
 Yes

 Check here once you have completed Items 2.11 to 2.13, then  SKIP to Item 2.32 (Part 2, Section 2) below.

EPA Form 3510-2S (Revised )

Page 11

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Sale or Give-Away in a Bag or Other Container for Application to the Land
2.14 Do you place sewage sludge in a bag or other container for sale or give-away for land application?
 SKIP to Item 2.17 (Part 2, Section 2)
 Yes
 No
below.
2.15 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:
2.16

Attach 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.
Check here to indicate that you have attached all labels or notices to this application package.

 Check here once you have completed Items 2.14 to 2.16, then  SKIP to Part 2, Section 2, Item 2.32.

Shipment Off Site for Treatment or Blending
2.17 Does another facility provide treatment or blending of your facility’s sewage sludge? (This question does not pertain to
dewatered sludge sent directly to a land application or surface disposal site.)
 SKIP to Item 2.32 (Part 2, Section 2)
 Yes
 No
below.
2.18 Indicate the total number of facilities that provide treatment or blending of your facility’s
sewage sludge. Provide the information in Items 2.19 to 2.26 (Part 2, Section 2) below
for each facility.
 Check here if you have attached additional sheets to the application package.
2.19 Name of receiving facility
Mailing address (street or P.O. box)
City or town

Contact name (first and last)

Title

State

ZIP code

Phone number

Email address

Location address (street, route number, or other specific identifier)

 Same as mailing address

City or town

ZIP code

State

Total dry metric tons per 365-day period of sewage sludge provided to receiving
facility:

2.21

Does the receiving facility provide additional treatment to reduce pathogens in sewage sludge from your facility or
reduce the vector attraction properties of sewage sludge from your facility?
 SKIP to Item 2.24 (Part 2, Section 2)
 Yes
 No
below.
Indicate the pathogen class and reduction alternative and the vector attraction reduction option met for the sewage
sludge at the receiving facility.
Pathogen Class and Reduction Alternative
Vector Attraction Reduction Option
 Not applicable
 Not applicable
 Class A, Alternative 1
 Option 1
 Class A, Alternative 2
 Option 2
 Class A, Alternative 3
 Option 3
 Class A, Alternative 4
 Option 4
 Class A, Alternative 5
 Option 5
 Class A, Alternative 6
 Option 6
 Class B, Alternative 1
 Option 7
 Class B, Alternative 2
 Option 8
 Class B, Alternative 3
 Option 9
 Class B, Alternative 4
 Option 10
 Domestic septage, pH adjustment
 Option 11

2.20

2.22

Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge Continued



EPA Form 3510-2S (Revised )

Page 12

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

2.25

2.26




Stabilization

Anaerobic digestion

Composting






Disinfection (e.g., beta ray irradiation, gamma ray
irradiation, pasteurization)



Dewatering (e.g., centrifugation, sludge drying
beds, sludge lagoons)




Heat drying




Thermal reduction

Methane or biogas capture and recovery

Conditioning

Other (specify) ____________________________

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).
 Check here to indicate that you have attached material.
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?
 SKIP to Item 2.32 (Part 2, Section 2)
 Yes
 No
below.
Attach a copy of all labels or notices that accompany the product being sold or given away.
 Check here to indicate that you have attached material.

2.24

Which treatment process(es) are used at the receiving facility to reduce pathogens in sewage sludge or reduce the
vector attraction properties of sewage sludge from your facility? (Check all that apply.)
operations (e.g., sludge grinding and
 Preliminary
 Thickening (concentration)
degritting)

 Check here once you have completed Items 2.17 to 2.26 (Part 2, Section 2), then  SKIP to Item 2.32 (Part 2, Section 2)
below.
Land Application of Bulk Sewage Sludge
2.27 Is sewage sludge from your facility applied to the land?
 Yes
2.28

Did you identify all land application sites in Part 2, Section 3 of this application?
 Submit a copy of the land application plan
 Yes
 No
with your application.
Are any land application sites located in states other than the state where you generate sewage sludge or derive a
material from sewage sludge?
 SKIP to Item 2.32 (Part 2, Section 2)
 Yes
 No
below.
Describe how you notify the NPDES permitting authority for the states where the land application sites are located.
Attach a copy of the notification.

2.29

No  SKIP to Item 2.32 (Part 2, Section 2)
below.
Total dry metric tons per 365-day period of sewage sludge applied to all land
application sites:



2.30

2.31

Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge Continued

2.23

Form Approved
OMB No.
Form Expires




Check here if you have attached the explanation to the application package.

Check here if you have attached the notification to the application package.
Surface Disposal
2.32 Is sewage sludge from your facility placed on a surface disposal site?
 SKIP to Item 2.39 (Part 2, Section 2)
 Yes
 No
below.
2.33 Total dry metric tons of sewage sludge from your facility placed on all surface
disposal sites per 365-day period:
2.34 Do you own or operate all surface disposal sites to which you send sewage sludge for disposal?
Yes  SKIP to Item 2.39 (Part 2, Section 2)
 No
below.
Indicate the total number of surface disposal sites to which you send your sewage
sludge.
(Provide the information in Items 2.36 to 2.38 of Part 2, Section 2, for each facility.)



2.35

 Check here if you have attached additional sheets to the application package.
EPA Form 3510-2S (Revised )

Page 13

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

2.36

Form Approved
OMB No.
Form Expires

Site name or number of surface disposal site you do not own or operate
Mailing address (street or P.O. box)
City or Town
Contact Name (first and last)

Site Contact (Check all that apply.)
 Owner

ZIP Code

Phone Number

Email Address



Operator

2.38

2.42

Do you own or operate all sewage sludge incinerators in which sewage sludge from your facility is fired?
 SKIP to Item 2.46 (Part 2, Section 2)
 Yes
 No
below.
Indicate the total number of sewage sludge incinerators used that you do not own or
operate. (Provide the information in Items 2.43 to 2.45 directly below for each facility.)

2.41

Total dry metric tons of sewage sludge from your facility placed on this surface
disposal site per 365-day period:
Incineration
2.39 Is sewage sludge from your facility fired in a sewage sludge incinerator?
 Yes
 No  SKIP to Item 2.46 (Part 2, Section 2)
below.
2.40 Total dry metric tons of sewage sludge from your facility fired in all sewage
sludge incinerators per 365-day period:

 Check here if you have attached additional sheets to the application package.
2.43

Incinerator name or number

Mailing address (street or P.O. box)
City or town

Title

Contact name (first and last)

2.44

State

ZIP code

Phone number

Email address

Location address (street, route number, or other specific identifier)

 Same as mailing address

City or town

ZIP code

State

Contact (check all that apply)
 Incinerator owner
 Incinerator operator
Total dry metric tons of sewage sludge from your facility fired in this sewage
sludge incinerator per 365-day period:

Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge Continued

2.37

Title

State

2.45

Disposal in a Municipal Solid Waste Landfill
2.46 Is sewage sludge from your facility placed on a municipal solid waste landfill?
 Yes
 No  SKIP to Part 2, Section 3.
2.47 Indicate the total number of municipal solid waste landfills used. (Provide the
information in Items 2.48 to 2.52 directly below for each facility.)

 Check here if you have attached additional sheets to the application
package.

EPA Form 3510-2S (Revised )

Page 14

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Name of landfill
Mailing address (street or P.O. box)
City or town
Contact name (first and last)

Title

State

ZIP code

Phone number

Email address

Location address (street, route number, or other specific identifier)
County

County code

City or town

State

 Same as mailing address
 Not available
ZIP code

Total dry metric tons of sewage sludge from your facility placed in this
municipal solid waste landfill per 365-day period:

2.50

List 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

2.51

Attach to the 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).


2.52

2.49

Check here to indicate you have attached the requested information.

Does the municipal solid waste landfill comply with applicable criteria set forth in 40 CFR 258?



Yes



Generation of Sewage Sludge or Preparation of a Material Derived from Sewage Sludge
Continued

2.48

Form Approved
OMB No.
Form Expires

EPA Form 3510-2S (Revised )

Page 15

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 2, SECTION 3—LAND APPLICATION OF BULK SEWAGE SLUDGE (40 CFR 122.21(q)(9))
3.1 Does your facility apply sewage sludge to land?


3.2



Yes

No  SKIP to Part 2, Section 4.

Do any of the following conditions apply?
 The sewage sludge meets the ceiling concentrations in Table 1 of 40 CFR 503.12, the pollutant concentrations in
Table 3 of 40 CFR 503.13, Class A pathogen reduction requirements at 40 CFR 503.32(a), and one of the vector
attraction reduction requirements at 40 CFR 503.33(b)(1)–(8);
 The sewage sludge is sold or given away in a bag or other container for application to the land; or
 You provide the sewage sludge to another facility for treatment or blending.


3.3

Yes  SKIP to Part 2, Section 4.
 No
Complete Section 3 for every site on which the sewage sludge is applied.

 Check here if you have attached sheets to the application package for one or more land application sites.

Identification of Land Application Site
3.4 Site name or number
Location address (street, route number, or other specific identifier)

State

 Not available

ZIP code

City or town

County code

Latitude/Longitude of Land Application Site (see instructions)
Latitude

Longitude

Method of Determination

 USGS map
3.5

 Field survey

 Other (specify) ______________

Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site location.



Check here to indicate you have attached a topographic map for this site.
Owner Information
3.6 Are you the owner of this land application site?
 Yes  SKIP to Item 3.8 (Part 2, Section 3) below.  No
3.7 Owner name

Land Application of Bulk Sewage Sludge

County

 Same as mailing address

Mailing address (street or P.O. box)
City or town

Contact name (first and last)

Title

State

ZIP code

Phone number

Email address

Applier Information
3.8 Are you the person who applies, or who is responsible for application of, sewage sludge to this land application site?



3.9

Yes  SKIP to Item 3.10 (Part 2, Section 3) below.
Applier’s name



Mailing address (street or P.O. box)
City or town
Contact name (first and last)

EPA Form 3510-2S (Revised )

Title

State

ZIP code

Phone number

Email address

Page 16

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Site Type
3.10 Type of land application:
 Agricultural land




Reclamation site

Form Approved
OMB No.
Form Expires

Forest
Public contact site

Other (describe)
Crop or Other Vegetation Grown on Site
3.11 What type of crop or other vegetation is grown on this site?
What is the nitrogen requirement for this crop or vegetation?

Check here if you have attached your description to the application package.



Vector Attraction Reduction
3.13 Are the vector attraction reduction requirements at 40 CFR 503.33(b)(9) and (b)(10) met when sewage sludge is
applied to the land application site?
 SKIP to Item 3.16 (Part 2, Section 3)
 Yes
 No
below.
3.14 Indicate which vector attraction reduction option is met. (Check only one response.)
 Option 9 (injection below land surface)
 Option 10 (incorporation into soil within 6 hours)
3.15 Describe any treatment processes used at the land application site to reduce vector attraction properties of sewage
sludge.
Cumulative Loadings and Remaining Allotments
3.16 Is the sewage sludge applied to this site since July 20, 1993, subject to the cumulative pollutant loading rates
(CPLRs) in 40 CFR 503.13(b)(2)?
 Yes
 No  SKIP to Part 2, Section 4.
Have you contacted the NPDES 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?
No  Sewage sludge subject to CPLRs may
not be applied to this site. SKIP to Part 2,
Yes


Section 4.
Provide the following information about your NPDES permitting authority:
NPDES permitting authority name
Contact person
Telephone number
Email address
Based on your inquiry, has bulk sewage sludge subject to CPLRs been applied to this site since July 20, 1993?
 Yes
 No  SKIP to Part 2, Section 4.
Provide the following information for every facility other than yours that is sending, or has sent, bulk sewage sludge
subject 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.

3.17

3.18

Land Application of Bulk Sewage Sludge Continued

3.12

3.19
3.20



Check here to indicate that additional pages are attached.

Facility name
Mailing address (street or P.O. box)
City or town
Contact name (first and last)

EPA Form 3510-2S (Revised )

Title

State

ZIP code

Phone number

Email address

Page 17

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

PART 2, SECTION 4—SURFACE DISPOSAL (40 CFR 122.21(q)(10))
4.1 Do you own or operate a surface disposal site?
 Yes



Form Approved
OMB No.
Form Expires

No  SKIP to Part 2, Section 5.

Complete all items in Section 4 for each active sewage sludge unit that you own or operate.
here to indicate that you have attached material to the application package for one or more active
 Check
sewage sludge units.
Information on Active Sewage Sludge Units
4.3 Unit name or number
4.2

Mailing address (street or P.O. box)
City or town
Contact name (first and last)

Title

State

ZIP code

Phone number

Email address
 Same as mailing address

Location address (street, route number, or other specific identifier)
County

County code

City or town

State

ZIP code

Longitude

Surface Disposal

Latitude/Longitude of Active Sewage Sludge Unit (see instructions)
Latitude

 Not available

Method of Determination

 USGS map
4.4

4.5

 Other (specify) ______________

Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site
location.
 Check here to indicate that you have completed and attached a topographic map.
Total dry metric tons of sewage sludge placed on the active sewage sludge unit
per 365-day period:
Total dry metric tons of sewage sludge placed on the active sewage sludge unit
over the life of the unit:
Does the active sewage sludge unit have a liner with a maximum permeability of 1 × 10-7 centimeters per second
(cm/sec)?
 SKIP to Item 4.9 (Part 2, Section
 Yes
 No
4) below.
Describe the liner.

4.6

 Field survey

4.7

4.8



4.9

4.10

Check here to indicate that you have attached a description to the application package.

Does the active sewage sludge unit have a leachate collection system?
No  SKIP to Item 4.11 (Part 2, Section
4) below.
Describe the leachate collection system and the method used for leachate disposal and provide the numbers of any
federal, state, or local permit(s) for leachate disposal.



Yes



Check here to indicate that you have attached the description to the application package.

EPA Form 3510-2S (Revised )



Page 18

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

4.11

Form Approved
OMB No.
Form Expires

4.12

Is the boundary of the active sewage sludge unit less than 150 meters from the property line of the surface disposal
site?
 SKIP to Item 4.13 (Part 2,
 Yes
 No
Section 4) below.
Provide the actual distance in meters:
meters

4.13

Remaining capacity of active sewage sludge unit in dry metric tons:

4.14

Anticipated closure date for active sewage sludge unit, if known (MM/DD/YYYY):

dry metric tons

Attach a copy of any closure plan that has been developed for this active sewage sludge unit.
 Check here to indicate that you have attached a copy of the closure plan to the application package.
Sewage Sludge from Other Facilities
4.16 Is sewage sludge sent to this active sewage sludge unit from any facilities other than your facility?
 SKIP to Item 4.21 (Part 2, Section
 Yes
 No
4) below.
4.17 Indicate the total number of facilities (other than your facility) that send sewage
sludge to this active sewage sludge unit. (Complete Items 4.18 to 4.20 directly
below for each such facility.)

4.15

4.18

Check here to indicate that you have attached responses for each facility to
the application package.
Facility name
Mailing address (street or P.O. box)
City or town

Contact name (first and last)
4.19

Title

State

ZIP code

Phone number

Email address

Indicate the pathogen class and reduction alternative and the vector attraction reduction option met for the sewage
sludge before leaving the other facility.
Pathogen Class and Reduction Alternative
Vector Attraction Reduction Option
 Not applicable
 Not applicable
 Class A, Alternative 1
 Option 1
 Class A, Alternative 2
 Option 2
 Class A, Alternative 3
 Option 3
 Class A, Alternative 4
 Option 4
 Class A, Alternative 5
 Option 5
 Class A, Alternative 6
 Option 6
 Class B, Alternative 1
 Option 7
 Class B, Alternative 2
 Option 8
 Class B, Alternative 3
 Option 9
 Class B, Alternative 4
 Option 10
 Domestic septage, pH adjustment
 Option 11
Which treatment process(es) are used at the other facility to reduce pathogens in sewage sludge or reduce the vector
attraction properties of sewage sludge before leaving the other facility? (Check all that apply.)
 Preliminary operations (e.g., sludge grinding and degritting)  Thickening (concentration)

Surface Disposal Continued



4.20







Stabilization
Composting
Disinfection (e.g., beta ray irradiation, gamma ray
irradiation, pasteurization)
Heat drying
Methane or biogas capture and recovery

EPA Form 3510-2S (Revised )







Anaerobic digestion
Conditioning
Dewatering (e.g., centrifugation, sludge
drying beds, sludge lagoons)
Thermal reduction
Other (specify) _____________________

Page 19

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Vector Attraction Reduction
4.21 Which vector attraction reduction option, if any, is met when sewage sludge is placed on this active sewage sludge
unit?
11 (Covering active sewage
 Option 9 (Injection below and surface)
 Option
sludge unit daily)
 Option 10 (Incorporation into soil within 6 hours)
 None
4.22 Describe any treatment processes used at the active sewage sludge unit to reduce vector attraction properties of
sewage sludge.
Check here if you have attached your description to the application package.


4.25

4.27

Check here to indicate you have attached the monitoring data.

Describe the well locations, the approximate depth to groundwater, and the groundwater monitoring procedures used
to obtain these data.



4.26

Groundwater Monitoring
4.23 Is groundwater monitoring currently conducted at this active sewage sludge unit, or are groundwater monitoring data
otherwise available for this active sewage sludge unit?
 SKIP to Item 4.26 (Part 2,
 Yes
 No
Section 4) below.
4.24 Provide a copy of available groundwater monitoring data.

Surface Disposal Continued



Check here if you have attached your description to the application package.

Has a groundwater monitoring program been prepared for this active sewage sludge unit?
 SKIP to Item 4.28 (Part 2,
 Yes
 No
Section 4) below.
Submit a copy of the groundwater monitoring program with this permit application.
Check here to indicate you have attached the monitoring program.



4.28

4.29

Have you obtained a certification from a qualified groundwater scientist that the aquifer below the active sewage
sludge unit has not been contaminated?
 SKIP to Item 4.30 (Part 2,
 Yes
 No
Section 4) below.
Submit a copy of the certification with this permit application.
Check here to indicate you have attached the certification to the application package.



Site-Specific Limits
4.30 Are you seeking site-specific pollutant limits for the sewage sludge placed on the active sewage sludge unit?
 No  SKIP to Part 2, Section 5.
 Yes
4.31

Submit information to support the request for site-specific pollutant limits with this application.



Check here to indicate you have attached the requested information.

EPA Form 3510-2S (Revised )

Page 20

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

PART 2, SECTION 5—INCINERATION (40 CFR 122.21(q)(11))
Incinerator Information
5.1
Do you fire sewage sludge in a sewage sludge incinerator?


5.2



Yes

No  SKIP to END.

Indicate the total number of incinerators used at your facility. (Complete the remainder
of Section 5 for each such incinerator.)



5.3

Check here to indicate that you have attached information for one or more
incinerators.
Incinerator name or number
Location address (street, route number, or other specific identifier)
County

County code

 Not available

City or town

State

ZIP code

Method of Determination

Longitude

 Field survey

 Other (specify) ______________

Incineration

 USGS map

Latitude/Longitude of Incinerator (see instructions)
Latitude

Amount Fired
5.4
Dry metric tons per 365-day period of sewage sludge fired in the sewage sludge
incinerator:
Beryllium NESHAP
5.5
Submit information, test data, and a description of measures taken that demonstrate whether the sewage sludge
incinerated is beryllium-containing waste and will continue to remain as such.


5.6

Check here to indicate that you have attached this material to the application package.

Is the sewage sludge fired in this incinerator “beryllium-containing waste” as defined at 40 CFR 61.31?
Yes



No  SKIP to Item 5.8 (Part 2, Section 5) below.

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.
 Check here to indicate that you have attached this information.
Mercury NESHAP
5.8
Is compliance with the mercury NESHAP being demonstrated via stack testing?
 No  SKIP to Item 5.11 (Part 2, Section 5) below.
 Yes

5.7

5.9

Submit 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.



5.10

Provide copies of mercury emission rate tests for the two most recent years in which testing was conducted.


5.11
5.12

Check here to indicate that you have attached this information.
Check here to indicate that you have attached this information.

Do you demonstrate compliance with the mercury NESHAP by sewage sludge sampling?
No  SKIP to Item 5.13 (Part 2, Section 5)

 Yes
below.
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.



Check here to indicate that you have attached this information.

EPA Form 3510-2S (Revised )

Page 21

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Dispersion Factor
5.13 Dispersion factor in micrograms/cubic meter per gram/second:
5.14

Name and type of dispersion model:

5.15

Submit a copy of the modeling results and supporting documentation.



Check here to indicate that you have attached this information.

Risk-Specific Concentration for Chromium
5.18 Provide the risk-specific concentration (RSC) used for chromium in
micrograms per cubic meter:
5.19 Was the RSC determined via Table 2 in 40 CFR 503.43?


5.20



No  SKIP to Item 5.21 (Part 2, Section 5) below.

Identify the type of incinerator used as the basis.
 Fluidized bed with wet scrubber
 Other types with wet scrubber
Fluidized bed with wet scrubber and wet
types with wet scrubber and wet electrostatic
 electrostatic precipitator
 Other
precipitator
Was the RSC determined via Table 6 in 40 CFR 503.43 (site-specific determination)?
 SKIP to Item 5.23 (Part 2, Section 5)
 Yes
 No
below.
Provide the decimal fraction of hexavalent chromium concentration to total
chromium concentration in stack exit gas:
Attach the results of incinerator stack tests for hexavalent and total chromium concentrations, including the date(s) of
any test(s), with this application.

5.21

Yes

Incineration Continued



Control Efficiency
5.16 Provide the control efficiency, in hundredths, for each of the pollutants listed below.
Pollutant
Control Efficiency, in Hundredths
Arsenic
Cadmium
Chromium
Lead
Nickel
5.17 Attach a copy of the results or performance testing and supporting documentation (including testing dates).

5.22
5.23



Check here to indicate that you have attached this information.



Not applicable

Incinerator Parameters
5.24 Do you monitor total hydrocarbons (THC) in the exit gas of the sewage sludge incinerator?



5.25

Yes



Do you monitor carbon monoxide (CO) in the exit gas of the sewage sludge incinerator?



Yes



5.26

Indicate the type of sewage sludge incinerator.

5.27

Incinerator stack height in meters:

5.28

Indicate whether the value submitted in Item 5.27 is (check only one response):
 Actual stack height
 Creditable stack height

EPA Form 3510-2S (Revised )

Page 22

Contains Nonbinding Recommendations
NPDES
Permit
Number Forms - Not for Implementation
Facility Name
Draft
Application

EPA Identification Number

Form Approved
OMB No.
Form Expires

Performance Test Operating Parameters
5.29 Maximum performance test combustion temperature:
5.30

Performance test sewage sludge feed rate, in dry metric tons/day

5.31

Indicate whether value submitted in Item 5.30 is (check only one response):


5.32
5.33



Average use

Attach supporting documents describing how the feed rate was calculated.
 Check here to indicate that you have attached this information.
Submit information documenting the performance test operating parameters for the air pollution control device(s)
used for this sewage sludge incinerator.



Check here to indicate that you have attached this information.

Equipment in Place for Monitoring

Monitoring Equipment
5.34 List the equipment in place to monitor the listed parameters.
Parameter
Total hydrocarbons or carbon monoxide
Percent oxygen
Percent moisture

Incineration Continued

Maximum design

Combustion temperature
Other (describe)

Air Pollution Control Equipment
5.35 List all air pollution control equipment used with this sewage sludge incinerator.

 Check here if you have attached the list to the application package for the noted incinerator.

END of PART 2
Submit completed application package to your NPDES permitting authority.

EPA Form 3510-2S (Revised )

Page 23

File Type	application/pdf
Author	Audrey.Signorelli
File Modified	2018-11-30
File Created	2018-11-30