3510-15 Request for Chemical Treatment Form

Appendix J - Suggested Format for Request for Chemical Treatment

If you plan to add “cationic treatment chemicals” (as defined in Appendix A) to stormwater and/or authorized non-stormwater prior to discharge, Part 1.1.9 requires you to notify your applicable EPA Regional Office in advance of submitting your NOI. The EPA Regional Office will authorize coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to an exceedance of water quality standards. To notify your EPA Regional Office, you may use following form.

NPDES Form XXXX-XX

U.S. Environmental Protection Agency Washington, DC 20460 Suggested Form for Notifying EPA about Proposed Use of Cationic Treatment Chemicals under the 2022 NPDES Construction General Permit

OMB No. 2040-NEW Exp. Date 02/16/2027

Under Part 1.1.9 of the 2022 CGP, if you plan to add “cationic treatment chemicals” (as defined in Appendix A) to stormwater and/or authorized non-stormwater prior to discharge, you may not submit your Notice of Intent (NOI) until you notify your applicable EPA Regional Office in advance and the EPA Regional Office authorizes coverage under this permit after you have included appropriate controls and implementation procedures designed to ensure that your use of cationic treatment chemicals will not lead to discharges that do not meet water quality standards. You may use this suggested form to notify your EPA Regional Office about your proposed use of cationic treatment chemicals.

Section I. OPerator Information

Operator Information

Operator Name

Mailing Address

Street

City

State

ZIP Code

County or Similar Government Division

Phone Number

Email Address

Section II. Project/Site Information

Project/Site Information

Project/Site Name

Project/Site Address

Street/Location

City

State

ZIP Code

County or Similar Government Division:

Site Contact Information (if different from operator)

First Name

Middle Initial

Last Name

Phone Number

Receiving Waterbodies

Name(s) of Receiving Waterbodies:

Section III. Map

Map

Attach a map that illustrates the entire site including all of the below items. Include this map in your Stormwater Pollution Prevention Plan (SWPPP). - All receiving waterbodies - All proposed location(s) of chemical treatment system(s) - All proposed point(s) of discharge to receiving waterbodies - All soil types within areas to be disturbed - All areas of earth disturbance - Sufficient indication of topography to indicate where stormwater flows

Attach a schematic drawing of the proposed treatment system(s). Include all components of the treatment train, sample points, and pipe configurations. In addition to sufficient holding capacity upstream of treatment, the system must have the capacity to hold water for testing and to re-treat water that does not meet water quality standards.

Section IV. Responsible Personnel

Responsible Personnel

Treatment System Operator or Company Name (if subcontracted out):

Street/Location

City

State

ZIP Code

Responsible Personnel

List personnel who will be responsible for operating the chemical treatment systems and application of the chemicals.

Cite the training that the personnel have received in operation and maintenance of the treatment system(s) and use of the specific chemical(s) proposed.

Section V. Proposed Treatment

Proposed Treatment

Check proposed treatment system to be used:

¨

Chitosan enhanced sand filtration with discharge to infiltration (ground water).

¨

Chitosan enhanced sand filtration with discharge to temporary holding ponds (batch).

¨

Chitosan enhanced sand filtration with discharge to surface waters (flow-through).

¨

Other (describe below and submit documentation that the proposed system and chemical(s) demonstrate the ability to remove turbidity and produce non-toxic effluent/discharge):

Check proposed cationic chemical(s) to be used:

¨

FlocClearTM (2% chitosan acetate solution).

¨

StormKlearTM LiquiFlocTM (1% chitosan acetate solution).

¨

ChitoVanTM (1% chitosan acetate solution).

¨

StormKlearTM LiquiFlocTM (3% Chitosan acetate solution).

¨

Other (Specify):

Estimated Treatment Period Start Date (MM/DD/YYYY)

Estimated Treatment Period End Date (MM/DD/YYYY)

Describe sampling and recordkeeping schedule. Attach additional sheets as needed:

Proposed Treatment	Explain why you have selected this proposed treatment system and chemicals. Include an explanation of why the use of cationic treatment chemicals is necessary at the site. Reference how the soil types on your site influenced your choices. Describe or provide an illustration of how the site of the discharge will be stabilized and why the discharge location will not cause erosion of the discharge water’s bank or bed (please note that a permit from the Corps and state agencies may be necessary to place rock in the water body for this stabilization). Attach as many additional sheets as needed for a full explanation. If you have a report from a chemical treatment contractor describing their recommended approach you may attach that.
Section VI. Certification Information
Certification Information		I have documented and hereby certify that the following information is correct and has been documented in the SWPPP for this project: The SWPPP includes a complete site-specific description of the chemical treatment system herein proposed for use, including specifications, design, and Material Safety Data Sheets for all chemicals to be used. The controls to be used on the site are compatible with the safe and effective use of cationic chemical treatment. I verified through jar tests that the site soil is conducive to chemical treatment. I verified that the chemical treatment system operators for this project received training. I read, understand, and will follow all conditions and design criteria in the applicable use designation(s). If the discharge is to tribal waters, I notified the appropriate tribal government of the intent to use chemical treatment on a site located within that jurisdiction. I will keep the use level designation, operation and maintenance manual, and training certificate on site prior to and during use of chemical treatment. A licensed engineer designed the system for this project including system sizing, pond sizing, and flow requirements. I verify that the discharge will not adversely affect downstream conveyance systems or stream channels (e.g., cause erosion). I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
		Authorized Official
		First Name	Middle Initial	Last Name
		Title
		Signature			Date (MM/DD/YYYY)
		Email Address

Instructions for Submitting EPA Form XXXX-XX

Suggested Form for Notifying EPA about Proposed Use of Cationic Treatment Chemicals under the 2022 NPDES Construction General Permit

NPDES Form Date (02/22) Form Approved OMB No. 2040-NEW

Section I. Operator Information

Provide the legal name of the person, firm, public organization, or any other entity that operates the project. Refer to Appendix A of the permit for the definition of “operator.” Provide the operator’s mailing address, county, telephone number, and e-mail address.

Section II. Project/Site Information

Enter the official or legal name and complete street address, including city, state, ZIP code, and county or similar government subdivision of the project or site. If the project or site lacks a street address, indicate the general location of the site (e.g., Intersection of State Highways 61 and 34).

Provide site contact information, if different from the operator.

Provide the name of the receiving waterbodies to which your site/project will discharge.

Section III. Map

Attach a map of the entire site that includes the identified items. Attach a schematic of the proposed treatment system(s) that includes the identified items.

Section IV. Responsible Personnel

Provide the legal name of the treatment system operator or company and complete street address, including city, state, including city, state, and ZIP code.

List personnel who will be responsible for operating the chemical treatment systems and application of the chemicals. For each personnel listed, cite the training that the personnel have received in operation and maintenance of the treatment system(s) and use of the specific chemical(s) proposed.

Section V. Proposed Treatment

Indicate the proposed treatment system and proposed cationic chemicals to be used. Indicate the estimated treatment start and end dates. Describe the sampling and recordkeeping schedule. Explain why you have selected the proposed treatment system and chemicals.

Section VI. Certification Information

The form must be signed as follows:

For a corporation: By a responsible corporate officer. For the purpose of this Section, a responsible corporate officer means:

(i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

For a partnership or sole proprietorship: By a general partner or the proprietor, respectively; or

For a municipality, state, federal, or other public agency: By either a principal executive officer or ranking elected official. For purposes of this Part, a principal executive officer of a federal agency includes (i) the chief executive officer of the agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrator of EPA). Include the name and title of the person signing the form and the date of signing.

Submitting Your Form

Submit this form to your applicable EPA Regional Office. Contact information can be found at:
https://www.epa.gov/npdes/contact-us-stormwater#regional