Form 5000.30 Supplemental Information on Water Quality Consideration

OMB No. 1140-0097 (xx/xx/xxxx)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Supplemental Information on Water Quality
Considerations - Under 33 U.S.C. 1341(a)
Instructions

1. Completion. Answer all items in sufficient detail if applicable to your activity. If necessary, continue on reverse side of this form or a separate
sheet. Your answers are evaluated to determine if a certification or waiver by the applicable State Water Quality Agency is required under Section
21 is of the Federal Water Pollution Control Act (33 U.S.C. 1341(a)).
2. Filing. Submit two copies of this form with the related application or other document, to the Director of Industry Operations, Bureau of Alcohol,
Tobacco, Firearms and Explosives. This form may be scanned and e-mailed to [email protected] or faxed to 304-616-4401. It must be completed
and submitted even though three copies of the required certification or waiver has been sent to the Director of Industry Operations or is attached to
this form.
3. Disposition. After final action taken on the related application or other document, the copy of this form will be returned to the applicant.
Application Related to this Rider
1. Form Number

2. Application Date

4. Name and Principal Business Address or Applicant (Number, street, city,
county, State, and Zip code)

3. Serial Number

5. Plant Address (If different from address in item 4)

AF
T

6. Describe Activity to be Conducted in Which the Bureau of Alcohol, Tobacco, Firearms and Explosives Has an Interest.

D

R

7. Describe Any Direct or Indirect Discharge into Navigable Waters Which May Result from the Conduct of the Activity Described in Item 6,
Including the Biological, Chemical, Thermal, or Other Characteristic of the Discharge and the Locations at Which Such Discharge May Enter
Navigable Waters.

8. Give the Date or Dates on Which the Activity Will Begin and End, If Known, and on Which the Discharge Will Take Place.

9. Describe the Methods and Means Used or to be Used to Monitor the Quality and Characteristics of the Discharge and the Operation of Equipment
or Facilities Employed in the Treatment or Control of Wastes or Other Effluents.

10. I certify that I have examined this rider and to the best of my knowledge and belief, it is true, correct, and complete and that copies of this rider
may be furnished to the applicable State Water Quality Agency and the Regional Administrator, Environmental Protection Agency.
11. Applicant
12. By (Signature and title)
Paperwork Reduction Act Notice - This request is in accordance with Section 3507, Public Law 96-511, Paperwork Reduction Act of 1995. This information collection is used by ATF to determine whether a certification from a State of multi-state authority is needed for discharge of effluent into navigable
water of the U.S. This information is required to obtain a benefit. The estimated average burden associated with this collection of information is 30 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions
for reducing this burden should be addressed to Reports Management Officer, Document Services, Bureau of Alcohol, Tobacco, Firearms and Explosives,
Washington, DC 20226. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
ATF Form 5000.30
currently valid OMB control number.
Revised March 2012