# 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– Not for Implementation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 <INSERT DATE>



# Water Permits Division 

# Application Form 2C

Wastewater Discharge

Information

NPDES Permitting Program

NPDES Proposed Application Forms for Public Docket ID No. EPA-HQ-OW-2016-

0145 & Docket ID No. EPA-HQ-OW-2016-0146.

This document is being distributed fo r comment purposes only. Comments and

suggestions regarding this draft document should be submitted through electronic

comments to http://www.regulations.gov.

Note: Complete this form and Form 1 if your facility is an ex isting manufacturing, commercial, mining,

and silvicultural facility that curre ntly discharges pr ocess wastewater.

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation



# Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimate s 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 th e needed data, and completing and reviewing the

collection of information. Send comments regarding th e 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, Of fice of Management and Budget, 725 17 th 

# Street, NW,

Washington, DC 20503, marked “Atten tion: Desk Officer for EPA.”

# 2C-1 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

FORM 2C—INSTRUCTIONS

General Instructions

Who Must Complete Form 2C?

Applicants who answered “yes” to Item 1.2.4 on Form 1 are

required to complete Form 2C. This means that 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 the “General

Instructions” of Form 1 to determine your NPDES permitting

authority.

Public Availability of Submitted Information

EPA will make information provided on the various NPDES permit

application forms available to the public for inspection and copying

upon request. No information on Form 2C (or related attachments)

may be claimed 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

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).

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, usi ng a format consistent with the

form.

Provide your EPA Identification Nu mber 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 the “General Instructions” of Form 1

for contact information. Additiona lly, 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 the item. 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 w ill 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

Definitions of all significant te rms used in these Instructions and

Form 2C are in the “Glossary,” which follows the “General

Instructions” in Form 1.

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, method of

collection, 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. In the column marked “Collection Method

Information”, indicate the following: (a) horizontal collection method,

which is the type of method/device used to identify the coordinates

(e.g., global positioning system or GPS device, census block

centroid, an address, etc.); (b) scale of your source map or photo if

applicable (e.g., the proportional distance on the ground for one unit

of measure typically expressed in ratio form such as 1:24,000); and

(c) horizontal reference datum (i.e., the coordinate reference

system) to which your coordinates relate.

GPS devices are commonly used to electronically record the

latitude and longitude coordinates of a property. It is also possible

to use geographic information systems (e.g., ArcView), online

sources (e.g., U.S. Geological Survey or USGS) to identify

coordinates. The online services r equire that you enter a property

address, the nearest intersection, or zip code. The system then

generates the coordinates. The horizontal collection method for

such sources is “Interpolation–Satellite.” You would not report a

source map scale if you used a GPS device or one of the online

systems. For the horizontal reference datum, you would report one

of the following three options:

1. North American Datum of 1927 (NAD27): This datum was based

on the ground survey in Europe and North America in the 19 th



# century. NAD27 was the standard for many years because the

USGS published its topographic maps in this datum. If you are

reporting a location using a USGS 7.5-minute map, NAD27 is

your default datum.

2. North American Datum of 1983 (NAD83): NAD83 updated

NAD27 with current measurements using radio astronomy and

satellite observations. When the USGS began publishing digital

data, the NAD83 was used which provided a more accurate

representation of the earth’s shape and a more accurate

depiction of the location of objects on the earth.

3. World Geodetic System of 1984 (WGS84): This datum was

developed from the measurements calculated in NAD83. If you

used a GPS to calculate your latitude/longitude coordinates,

WGS84 is the default datum.

If you need further guidance in responding to Item 1.1, refer to

http://www.epa.gov/geospatial/latitudelongitude-data-standard

.

# 2C-2 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for ImplementationApplicable ELGs 

# 5.2 ELG Category ELG

Subcategory Regulatory

Citation

Pulp, Paper,

and

Paperboard

Point Source

Category Secondary Fiber

Non-Deink

Subcategory 40 CFR Part

430, Subpart J 

# FORM 2C—INSTRUCTIONS CONTINUED

Section 2. Line Drawing

Item 2.1. Attach a line drawing depicting 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 us e your best estimate. If you are

unable to determine a water balance fo r your activities (such as

mining activities), provide a pict orial 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.

Section 3. Average Flows and Treatment

Item 3.1. For each outfall identified under Item 1.1, provide the

following information: (a) 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; (b) average flow of wastewater contributed

by each operation in million gallons per day (mgd); (c) a description

of the treatment unit (including size of each treatment unit, flow rate

through each treatment unit, retention time, etc.); (d) the applicable

treatment code(s) from Exhibit 2C

– 2 (see end of Instructions); and

(e) 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

indicate the basis of the rainfall event and the method of estimation.

Add additional pages as necessary.

Item 3.2. Answer whether you are applying for an NPDES permit to

operate a privately owned treatment works. If “yes,” continue to

Item 3.3. If “no,” skip to Section 4.

Item 3.3. Attach a list to your application that includes the identity of

each user of the treatment works and then answer “yes” to Item 3.3.

Section 4. Intermittent Flows

Item 4.1. Answer “yes” or “no” to indicate whether any of the

discharges you described in Sections 1 and 3 of Form 2C are

intermittent or seasonal, except for stormwater runoff, spillage, or

leaks. An intermittent discharge is one that is not continuous. A

continuous discharge is one that occurs without interruption during

the operating hours of the facility, except for infrequent shutdowns

for maintenance, process changes, or other similar activities. A

discharge is seasonal if it occurs only during certain parts of the

year. If “yes”, continue to Item 4.2. If “no”, skip to Section 5. Item 4.2. By relevant outfall number, identify each operation that

has intermittent or seasonal discharges. Indicate the average

frequency (days per week and months per year), the long term

average and maximum daily flow rates in mgd, and the duration of

the intermittent or seasonal discharges. Base your answers on

actual data if available. Otherwi se, provide your best estimate.

Report the average of all daily values measured during days when

the discharge occurred for “Long Term Average Flow Rate,” and

report the highest daily value for the “Maximum Daily Flow Rate”.

Section 5. Production

Item 5.1 Indicate whether any effluent limitation guidelines (ELGs)

promulgated under Section 304 of the Clean Water Act (CWA)

apply to your facility. If “yes”, continue to Item 5.2. If “no”, skip to

Section 6. 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 a Best Practicable

Control Technology Currently Available (BPT), Best Conventional

Pollutant Control Technology (BCT), or Best Available Technology

Economically Achievable (BAT) guideline. If you are unsure

whether you are covered by a promulgated ELG, consult your

NPDES permitting authority (see Exhibit 1

– 1 of the “General

Instructions” of Form 1). 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 5.1 and skip to Section 6.

Item 5.2. Complete Item 5.2 by indicating the applicable ELG

category, ELG subcategory, and corresponding regulatory citation.

See example below.

Item 5.3. Indicate if the limitations in the applicable ELGs are

expressed in terms of production or other measure of operation. For

example, if the limitation is expressed as mass of pollutant per

operational parameter, it is expressed in terms of production (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 “yes”, continue to Item 5.4. If “no”, skip to Section 6.

Item 5.4. Indicate the operations, products, or materials produced

at the facility for each outfall. For each operation, product, or

material produced, denote the quantity produced per day using the

measurement units specified in the applicable ELG. The NPDES

permitting authority will use the production information to apply

ELGs to your facility. You cannot claim that the production

# 2C-3 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED

information you submit is confidential. You do not need to indicate

how you calculated the reported information. The production figures

provided must be based on a reasonable measure of actual daily

production and not on design capacity or on predictions of future

operations. To obtain alternate li mits under 40 CFR 122.45(b)(2)(ii),

you must define your maximum production capability and

demonstrate to the NPDES permitting authority that your actual

production is substantially below maximum production capability

and that there is a reasonable potential for an increase above

actual production during the duration of the permit.

Section 6. Improvements

Item 6.1. 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 your application. The requirements include,

but are not limited to, permit conditions, administrative enforcement

orders, enforcement compliance sc hedule letters, stipulations, court

orders, and grant or loan conditions. If “yes”, continue to Item 6.2. If

“no,” skip to Item 6.3.

Item 6.2. Briefly identify and describe each applicable project (e.g.,

consent decree, enforcement orde r, or permit condition). For each

condition, specify the affected outfall number(s), the source(s) of

the discharge, the projected final compliance date, and the

required final compliance date.

Item 6.3. OPTIONAL ITEM. If desired, attach descriptions of any

additional water pollution control programs (or other environmental

projects that could affect your discharges) that are now underway

or planned. Indicate in your attachments whether each program is

actually underway or is planned, and indicate your actual or

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 addit ion to the criteria for determining

who should complete them. In general, the following conditions

apply:

Table Pollutants/Parameters Who Completes?

A Conventional and NonConventional Pollutants A ll applicants from all outfalls

unless a waiver is obtained from

the NPDES permitting authority.

B Toxic Metals, Cyanide, Total

Phenols, and Organic Toxic

Pollutants A pplicants in the Primary Industry

Categories listed in Exhibit 2C-3

located at the end of these

Instructions.

C Certain Conventional and

Non-Conventional Pollutants A pplicants subject to ELGs that

limit pollutants directly or indirectly

and applicants who believe

pollutants may be present in their

facility’s discharge. Table Pollutants/Parameters Who Completes?

D Certain Hazardous Substances

and Asbestos A pplicants who believe

pollutants may be present in

their facility’s discharge.

E 2,3,7,8-Tetrachlorodibenzo-pdioxin A pplicants that use or

manufacture the pollutant or

believe the pollutant may be

present in the facility’s

discharge.



# IMPORTANT NOTE: Read the “General Instructions for Reporting,

Sampling, and Analysis” on pages 2C-6 and 2C-7 before

completing Section 7.

Item 7.1 and Table A. All applicants are required to report at least

one analysis for each conventional and non-conventional parameter

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 7.2. Specify the outfalls for which you are requesting a waiver.

Next, indicate on Table A for the applicable outfalls the parameters

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 / parameters. See the “General Instructions for

Reporting, Sampling, and Analysis” below 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 categor ies 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 GS/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 7.5. 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 the boxes for “Testing

Required” for all toxic metals, cyanide, and total phenols in

# 2C-4 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED

Section 1 of Table B. Answer “yes” to Item 7.5 once you have

completed this task.

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 categor ies, list the primar y industry categories

applicable to your facility. Next, review Exhibit 2C-3 to determine

whether testing is required and for which GS/MS fraction(s): volatile

compounds, acid compounds, base/neutral compounds, and

pesticides. Check the applicable boxes for each GS/MS fraction

requiring testing.

Item 7.7. For each of the required GC/MS fractions, check “testing

required” for each of the pollut ants in the required fraction in

sections 2 through 5 of Table B. Answer “yes” to Item 7.7 once you

have completed this task.

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 fr om your outfalls. Answer “yes”

to Item 7.8 after you have completed this step.

Item 7.9 and Section 1 of Table B. For each pollutant you know

or have reason to believe is pres ent 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 have to

indicate whether you believe any of the pollutants listed in Sections

1 through 5, however, are presen t 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 to xic 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 co ntribute to the discharge, unless

those are the only processes at your facility. For sales data, in

situations involving intra-corpor ate 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

.

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

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 7.11 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 is

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-4,6-dinitrophenol. 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 the above threshold levels (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 polluta nt is in your discharge.

For pollutants in intake water, see the discussion under “General

Instructions for Reporting, Sampling, and Analysis” below.

Once you have completed the above 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 ei ther 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” below.

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.

Item 7.14 and Table D. For each outfall, indicate if you believe

that any pollutant listed in Table D is “Believed Present” or

# 2C-5 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Under 40 CFR 117.12(a)(2), certain di scharges of hazardous substances

(listed in Exhibit 2C-4 at the end of these Instructions) may be exempted from

the requirements of Section 311 of t he CWA, which establishes reporting

requirements, civil penalties and liabili ty for cleanup costs for spills of oil and

hazardous substances. A discharge of a particular substance can be

exempted if the origin, source, and am ount of the discharged substances are

identified in the NDPES permit applicati on 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 nor mal 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 parag raph 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. 

# FORM 2C—INSTRUCTIONS CONTINUED

“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 mu st 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.

Item 7.15. Answer “yes” to this Item when you have completed

Table D. 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-

dichloro-propionate (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 2.3.7,8-

Tetrachlorodibenzo-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

chromotography 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-6 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

General Instructions for Reporting, Sampling, and Analysis

IMPORTANT NOTICE: Read these instructions prior to completing

Tables A through E and Section 7 of Form 2C.

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 GC/MS analysis

completed under Table B.

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.

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; or,

optionally, you may provide intake data.

Reporting of Effluent Data

Report sampling results for all pollutants in Tables A through C as

concentration and total mass, with the exception of 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

MPN = most probable number kg = kilograms

per 100 milliliters T = tonnes (metric tons) 

# All reporting of values for metals must be in terms of “total

recoverable metal,” unless:

1. An applicable, promulgated ELG specifies the limitation for

the metal in dissolved, valent, or total form;

2. All approved analytical methods for the metal inherently

measure only its dissolved form (e.g., hexavalent chromium);

or

3. The permitting authority has determined that in establishing

case-by-case limitations it is necessary to express the

limitations of the metal in dissolved, valent, or total form to

carry out the provisions of the CWA.

Note that you are not required to complete the “Maximum Monthly

Discharge” and the “Long Term Av erage Daily Discharge” columns

of Tables A through C; however, these fields should be completed

if data are available.

If you measure only one daily value, complete the “Maximum Daily

Discharge” columns of the tables and insert “1” into the “Number of

Analyses” columns. The NPDES permitting authority may require

additional analyses to further c haracterize 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 (4)

grab samples taken over the operat ing hours of the facility during a

24-hour period.

If you measure more than one daily value for a pollutant and those

values are representative of y our 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 that quantitative data as

applying to the substantially identical outfall. If the permitting

authority grants your request, atta ch a separate sheet to the

application form identifying the outfall tested and describing why the

other outfall(s) are subs tantially identical.

Reporting of Intake Data

You are not required to report dat a 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 re sults of analyses of your intake

water and discuss the requirements for a net limitation with your

NPDES permitting authority. If your wa ter is treated before use, test

the water after it has been treated.

# 2C-7 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

General Instructions for Reporting, Sampling, and Analysis Continued

Sampling: 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 contained in the

applicable analytical methods must be followed, including factors

related to sample containers, sample preservation, holding times,

and the collection of duplicate samples.

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. Samples should be

collected 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 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 chemicals.

For all other pollutants a 24-hour composite sample, using a

minimum of four (4) grab samples, must be used unless specified

otherwise at 40 CFR Part 136. However, a minimum of one (1)

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 (1) grab sample must be taken in the first hour (or

less) of discharge, with one (1) additional 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 dischar ges, 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 (4) 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 that

sample integrity is not compromised during compositing. See

Table II at 40 CFR 136.3 for further information.

A

grab sample is defined as an individual sample of at least

100 milliliters collected at a randomly-selected time over a period

not exceeding 15 minutes.

A

composite sample is a combination of at least eight (8) sample

aliquots of at least 100 milliliters, collected at periodic intervals

during the operating hours of a fac ility over a 24-hour period. The

composite must be flow proportional; either the time interval

between each aliquot or the volume of each aliquot must be

proportional to either the stream flow at the time of sampling or the

total stream flow since the collection of the previous aliquot.

Aliquots can be collected manually or automatically. For GC/MS Fraction

— Volatile Compounds in Table B, aliquots must be

combined in the laboratory immedi ately before analysis. Four (4)

(rather than eight) aliquots or grab samples should be collected for

the GC/MS Fraction

— Volatile Compounds. 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.

Use of Historic Data

Existing data may be used, if available, in lieu of sampling

conducted solely for the purposes of this application. All existing

data for pollutants specified in Tables A through E that are collected

within 4.5 years of the application due date must be included in the

pollutant summaries submitted by the applicant. If, however, the

applicant samples for a specific pollutant on a monthly or more

frequent basis, you need only summarize all data collected within

one year of the application due date for the pollutant(s) at issue.

Analysis

Except as specified below, all required quantitative data shall be

collected in accordance with su fficiently sensitive analytical

methods approved under 40 CFR part 136 or required under

40 CFR chapter I, subchapter N or O. A method is “sufficiently

sensitive” when:

(1) The method minimum level (ML) is at or below the level of the

applicable water quality criterion for the measured pollutant or

pollutant parameter;

(2) 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 pollut ant parameter in the discharge.

(3) The method has the lowest ML of the analytical methods

approved under 40 CFR part 136 or required under 40 CFR chapter

I, subchapter N or O for the measured pollutant or pollutant

parameter.

Consistent with 40 CFR part 136, you may provide matrix or sample

specific 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 part 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-8 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

FORM 2C—INSTRUCTIONS CONTINUED

Section 8. Used or Manufactured Toxics

Item 8.1. Indicate if any of the pollutants listed in Table B are 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 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 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.

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.

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.

Section 12. Checklist and Certification Statement

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. Item 12.2. The Clean Water Act provides for severe penalties for

submitting false information on this application form. Section

309(c)(2) of the Clean Water Act pr ovides 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. By a responsible corporate officer. For the purpose of this

section, a responsible corporate officer means: (i) A president,

secretary, treasurer, or vice-p resident of the corporation in

charge of a principal business function, or any 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 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 partnership or sole proprie torship, by a general partner or

the proprietor, respectively.

C. For a municipality, state, federal, or other public facility, by

either a principal executive office r or ranking elected official.

For purposes of this section, a principal executive officer of a

Federal agency includes: (i) the chief executive officer of the

agency, or (ii) a senior executiv e 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 2C, and all associated

attachments (and any other required NPDES application forms)

to your NPDES permitting authority.

# 2C-9 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Exhibit 2C

– 1. Example Line Drawing

# 2C-10 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Exhibit 2C

– 2. Codes for Treatment Units and Di sposal of Wastes Not Discharged

1. PHYSICAL TREATMENT PROCESSES

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 ) 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

2. CHEMICAL TREATMENT PROCESSES

2–A ................ Carbon Adsorption

2–B ................ Chemical Oxidation

2–C ................ Chemical Precipitation

2–D ................ Coagulation

2–E ................ Dechlorination

2–F ................. Disinfection ( Chlorine ) 2–G ................ Disinfection ( Ozone )

2–H ................ Disinfection ( Other )

2–I .................. Electrochemical Treatment

2–J ................. Ion Exchange

2–K ................. Neutralization

2–L ................. Reduction

3. BIOLOGICAL TREATMENT PROCESSES

3–A ................ Activated Sludge

3–B ................ Aerated Lagoons

3–C ................ Anaerobic Treatment

3–D ................ Nitrification–Denitrification 3–E ................. Pre-Aeration

3–F ................. Spray Irrigation/Land Application

3–G ................ Stabilization Ponds

3–H ................ Trickling Filtration

4. WASTEWATER DISPOSAL PROCESSES

4–A ................ Discharge to Surface Water

4-B ................. Ocean Discharge to Outfall 4-C ................. Reuse/Recycle of Treated Effluent

4-D ................. Underground Injection

5. SLUDGE TREATMENT AND DISPOSAL PROCESSES

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 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-11 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Exhibit 2C

– 3. Testing Requirements for Organic Toxic Pollutants Industry Category*

INDUSTRY CATEGORY GC/MS FRACTION 1



# Volatile A cid Base/Neutral Pesticide



# Adhesives and sealants ........................................................ X X X 

Aluminum forming ................................................................. X X X 

Auto and other laundries ....................................................... X X X X

Battery manufacturing ........................................................... X  X 

Coal mining ...........................................................................    

Coil coating ........................................................................... X X X 

Copper forming ..................................................................... X X X 

Electric and electronic compounds ....................................... X X X X

Electroplating ........................................................................ X X X 

Explosives manufacturing .....................................................  X X 

Foundries .............................................................................. X X X 

Gum and wood chemicals (all subparts except D and F) ..... X X  

Gum and wood chemicals, Subpart D (tall oil rosin) ............. X X X 

Gum and wood chemicals, Subpart F (rosin-based

derivatives) ........................................................................... X X X 

Inorganic chemicals manufacturing ...................................... X X X 

Iron and steel manufacturing ................................................ X X X 

Leather tanning and finishing X X X 

Mechanical products manufacturing ..................................... X X X 

Nonferrous metals manufacturing ......................................... X X X X

Ore mining, Subpart B (base and precious metals) ..............  X  

Organic chemicals manufacturing ........................................ X X X X

Paint and ink formulation ...................................................... X X X 

Pesticides ............................................................................. X X X X

Petroleum refining ................................................................. X   

Pharmaceutical preparations ................................................ X X X 

Photographic equipment and supplies .................................. X X X 

Plastic and synthetic materials manufacturing ...................... X X X X

Plastic processing ................................................................. X   

Printing and publishing ......................................................... X X X X

Pulp and paperboard mills .................................................... X X X X

Rubber processing ................................................................ X X X 

Soap and detergent manufacturing ...................................... X X X 

Steam electric power plants .................................................. X X  

Textile mills (except Subpart C, Greige Mills) ....................... X X X 

Timber products processing ................................................. X X X X

* See note at conclusion of 40 CFR Part 122, Appendix D (1983) for explanation of effect of suspensions on testing requirements for

primary industry categories.

1 

# The pollutants in each fraction are listed in Table B.

X = Testing is required.

= Testing is not required.

# 2C-12 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Exhibit 2C

– 4. Hazardous Substances

1. Acetaldehyde

2. Acetic acid

3. Acetic anhydride

4. Acetone cyanohydrin

5. Acetyl bromide

6. Acetyl chloride

7. Acrolein

8. Acrylonitrile

9. Adipic acid

10. Aldrin

11. Allyl alcohol

12. Allyl chloride

13. Aluminum sulfate

14. Ammonia

15. Ammonium acetate

16. Ammonium benzoate

17. Ammonium bicarbonate

18. Ammonium bichromate

19. Ammonium bifluoride

20. Ammonium bisulfite

21. Ammonium carbamate

22. Ammonium carbonate

23. Ammonium chloride

24. Ammonium chromate

25. Ammonium citrate

26. Ammonium fluoroborate

27. Ammonium fluoride

28. Ammonium hydroxide

29. Ammonium oxalate

30. Ammonium silicofluoride

31. Ammonium sulfamate

32. Ammonium sulfide

33. Ammonium sulfite

34. Ammonium tartrate

35. Ammonium thiocyanate

36. Amyl acetate

37. Aniline

38. Antimony pentachloricle

39. Antimony potassium tartrate

40. Antimony tribromide

41. Antimony trichloride

42. Antimony trifluoride

43. Antimony trioxide

44. Arsenic disulfide

45. Arsenic pentoxide

46. Arsenic trichloride

47. Arsenic trioxide

48. Arsenic trisulfide

49. Barium cyanide

50. Benzene

51. Benzoic acid

52. Benzonitrile

53. Benzoyl chloride

54. Benzyl chloride

55. Beryllium chloride

56. Beryllium fluoride

57. Beryllium nitrate

58. Butylacetate

59. n-Butylphthalate

60. Butylamine

61. Butyric acid

62. Cadmium acetate

63. Cadmium bromide

64. Cadmium chloride

65. Calcium arsenate

66. Calcium arsenite

67. Calcium carbide

68. Calcium chromate

69. Calcium cyanide

70. Calcium dodecylbenzenesulfonate

71. Calcium hypochlorite 72. Captan

73. Carbaryl

74. Carbofuran

75. Carbon disulfide

76. Carbon tetrachloride

77. Chlordane

78. Chlorine

79. Chlorobenzene

80. Chloroform

81. Chloropyrifos

82. Chlorosulfonic acid

83. Chromic acetate

84. Chromic acid

85. Chromic sulfate

86. Chromous chloride

87. Cobaltous bromide

88. Cobaltous formate

89. Cobaltous sulfamate

90. Coumaphos

91. Cresol

92. Crotonaldehyde

93. Cupric acetate

94. Cupric acetoarsenite

95. Cupric chloride

96. Cupric nitrate

97. Cupric oxalate

98. Cupric sulfate

99. Cupric sulfate ammoniated

100. Cupric tartrate

101. Cyanogen chloride

102. Cyclohexane

103. 2,4-D acid (2,4- Dichlorophenoxyacetic acid)

104. 2,4-D esters (2,4- Dichlorophenoxyacetic acid esters)

105. DDT

106. Diazinon

107. Dicamba

108. Dichlobenil

109. Dichlone

110. Dichlorobenzene

111. Dichloropropane

112. Dichloropropene

113. Dichloropropene- dichloproropane mix

114. 2,2-Dichloropropionic acid

115. Dichlorvos

116. Dieldrin

117. Diethylamine

118. Dimethylamine

119. Dinitrobenzene

120. Dinitrophenol

121. Dinitrotoluene

122. Diquat

123. Disulfoton

124. Diuron

125. Dodecylbenzesulfonic acid

126. Endosulfan

127. Endrin

128. Epichlorohydrin

129. Ethion

130. Ethylbenzene

131. Ethylenediamine

132. Ethylene dibromide

133. Ethylene dichloride

134. Ethylene diaminetetracetic acid (EDTA)

135. Ferric ammonium citrate

136. Ferric ammonium oxalate

137. Ferric chloride

138. Ferric fluoride

139. Ferric nitrate

140. Ferric sulfate

141. Ferrous ammonium sulfate

142. Ferrous chloride 143. Ferrous sulfate

144. Formaldehyde

145. Formic acid

146. Fumaric acid

147. Furfural

148. Guthion

149. Heptachlor

150. Hexachlorocyclopentadiene

151. Hydrochloric acid

152. Hydrofluoric acid

153. Hydrogen cyanide

154. Hydrogen sulfide

155. Isoprene

156. Isopropanolamine dode cylbenzenesulfonate

157. Kelthane

158. Kepone

159. Lead acetate

160. Lead arsenate

161. Lead chloride

162. Lead fluoborate

163. Lead flourite

164. Lead iodide

165. Lead nitrate

166. Lead stearate

167. Lead sulfate

168. Lead sulfide

169. Lead thiocyanate

170. Lindane

171. Lithium chromate

172. Malathion

173. Maleic acid

174. Maleic anhydride

175. Mercaptodimethur

176. Mercuric cyanide

177. Mercuric nitrate

178. Mercuric sulfate

179. Mercuric thiocyanate

180. Mercurous nitrate

181. Methoxychlor

182. Methyl mercaptan

183. Methyl methacrylate

184. Methyl parathion

185. Mevinphos

186. Mexacarbate

187. Monoethylamine

188. Monomethylamine

189. Naled

190. Naphthalene

191. Naphthenic acid

192. Nickel ammonium sulfate

193. Nickel chloride

194. Nickel hydroxide

195. Nickel nitrate

196. Nickel sulfate

197. Nitric acid

198. Nitrobenzene

199. Nitrogen dioxide

200. Nitrophenol

201. Nitrotoluene

202. Paraformaldehyde

203. Parathion

204. Pentachlorophenol

205. Phenol

206. Phosgene

207. Phosphoric acid

208. Phosphorus

209. Phosphorus oxychloride

210. Phosphorus pentasulfide

211. Phosphorus trichloride

212. Polychlorinated biphenyls (PCB)

213. Potassium arsenate 214. Potassium

arsenite

# 2C-13 

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

Exhibit 2C

– 4. Hazardous Substances

215. Potassium bichromate

216. Potassium chromate

217. Potassium cyanide

218. Potassium hydroxide

219. Potassium permanganate

220. Propargite

221. Propionic acid

222. Propionic anhydride

223. Propylene oxide

224. Pyrethrins

225. Quinoline

226. Resorcinol

227. Selenium oxide

228. Silver nitrate

229. Sodium

230. Sodium arsenate

231. Sodium arsenite

232. Sodium bichromate

233. Sodium bifluoride

234. Sodium bisulfite

235. Sodium chromate

236. Sodium cyanide

237. Sodium dodecylbenzenesulfonate

238. Sodium fluoride

239. Sodium hydrosulfide

240. Sodium hydroxide

241. Sodium hypochlorite

242. Sodium methylate

243. Sodium nitrite 244. Sodium phosphate (dibasic)

245. Sodium phosphate (tribasic)

246. Sodium selenite

247. Strontium chromate

248. Strychnine

249. Styrene

250. Sulfuric acid

251. Sulfur monochloride

252. 2,4,5-T acid (2,4,5-Trichlorophenoxyacetic acid)

253. 2,4,5-T amines (2,4,5-Trichlorophenoxy acetic acid

amines)

254. 2,4,5-T esters (2,4,5 Trichlorophenoxy acetic acid

esters)

255. 2,4,5-T salts (2,4,5-Trichlorophenoxy acetic acid salts)

256. 2,4,5-TP acid (2,4,5-Trichlorophenoxy propanoic acid)

257. 2,4,5-TP acid esters (2,4,5- Trichlorophenoxy propanoic

acid esters)

258. Tetraethyl lead

259. Tetraethyl pyrophosphate

260. Thallium sulfate

261. Toluene

262. Toxaphene

263. Trichlorofon

264. Trichloroethylene

265. Trichlorophenol

266. Triethanolamine dodecylbenzenesulfonate

267. Triethylamine

268. Trimethylamine

269. Uranyl acetate 270. Uranyl nitrate

271. Vanadium penoxide

272. Vanadyl sulfate

273. Vinyl acetate

274. Vinylidene chloride

275. Xylene

276. Xylenol

277. Zinc acetate

278. Zinc ammonium chloride

279. Zinc borate

280. Zinc bromide

281. Zinc carbonate

282. Zinc chloride

283. Zinc cyanide

284. Zinc fluoride

285. Zinc formate

286. Zinc hydrosulfite

287. Zinc nitrate

288. Zinc phenolsulfonate

289. Zinc phosphide

290. Zinc silicofluoride

291. Zinc sulfate

292. Zirconium nitrate

293. Zirconium potassium flouride

294. Zirconium sulfate

295. Zirconium tetrachloride

# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation



# This page intentionally left blank.

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 1 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation Form

2C

NPDES 

# U.S. Environmental Protection Agency

Application for NPDES Permit to Discharge Wastewater

EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS

SECTION 1. OUTFALL LOCATION (40 CFR 122.21(g)(1))Outfall Location 

# 1.1 Provide information on each of the facility’s outfalls in the table below.

Outfall

Number Receiving Water Name Latitude Longitude

Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of

method/device used to identify the coordinates)



# Scale (Proportional distance on the ground for

one unit of measure) 

#  Not Applicable

Horizontal Reference Datum (Coordinate

reference system) 

#  NAD 27  NAD 83  WGS85  Other (specify)

Outfall

Number Receiving Water Name Latitude Longitude

Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of

method/device used to identify the coordinates)



# Scale (Proportional distance on the ground for

one unit of measure) 

#  Not Applicable

Horizontal Reference Datum (Coordinate

reference system) 

#  NAD 27  NAD 83  WGS85  Other (specify)

Outfall

Number Receiving Water Name Latitude Longitude

Degrees Minutes Seconds Degrees Minutes Seconds

Collection Method Information

Horizontal Collection Method (Type of

method/device used to identify the coordinates)



# Scale (Proportional distance on the ground for

one unit of measure) 

#  Not Applicable

Horizontal Reference Datum (Coordinate

reference system) 

#  NAD 27  NAD 83  WGS85  Other (specify)

SECTION 2. LINE DRAWING (40 CFR 122.21(g)(2))LineDrawing 

# 2.1 Have you attached a line drawing to this application that s hows 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.)



#  Yes 

#  No

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 2 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation SECTION 3. AVERAGE FLOWS AND TREATMENT (40 CFR 122.21(g)(3))Average Flows and Treatment 

# 3.1 For each outfall identified under Item 1.1, provide aver age flow and treatment information. Add additional pages, if

necessary.

Outfall Number __________

Operations Contributing to Flow

Operation Average Flow

mgd

mgd

mgd

mgd

mgd

Treatment Units

Description

(Include size, flow rate through each treatment unit,

retention time, etc.) Code from

Table 2C-1 Final Disposal of Solid or

Liquid Wastes Other Than by

Discharge

Outfall Number __________

Operations Contributing to Flow

Operation Average Flow

mgd

mgd

mgd

mgd

mgd

Treatment Units

Description

(Include size, flow rate through each treatment unit,

retention time, etc.) Code from

Table 2C-1 Final Disposal of Solid or

Liquid Wastes Other Than by

Discharge

3.1 Outfall Number __________

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 3 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation cont. Operations Contributing to Flow

Operation Average Flow

mgd

mgd

mgd

mgd

mgd

Treatment Units

Description

(Include size, flow rate through each treatment unit,

retention time, etc.) Code from

Table 2C-1 Final Disposal of Solid or

Liquid Wastes Other Than by

DischargeSystemUsers 

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



#  Yes 

#  No  SKIP to Section 4.

3.3 Have you attached a list that identifies each user of the treatment works?



#  Yes 

#  No

SECTION 4. INTERMITTENT FLOWS (40 CFR 122.21(g)(4))Intermittent Flows 

# 4.1 Except for storm runoff, leaks, or spills, are any discharges de scribed in Sections 1 and 3 intermittent or seasonal?



#  Yes 

#  No  SKIP to Section 5.

4.2 Provide information on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if necessary.

Outfall

Number Operation

(list) Frequency Flow Rate

Duration Average

Days/Week Average

Months/Year Long-term

Average Maximum

Daily

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days

days/week months/year mgd mgd days



# SECTION 5. PRODUCTION (40 CFR 122.21(g)(5))

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 4 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for ImplementationApplicable ELGs 

# 5.1 Do any ELGs promulgated by EPA under Section 304 of the CWA apply to your facility?



#  Yes 

#  No  SKIP to Section 6.

5.2 Provide the following information on applicable ELGs.

ELG Category ELG Subcategory Regulatory CitationProduction-Based Limitations 

# 5.3 Are any of the applicable ELGs expressed in te rms of production (or other measure of operation)?



#  Yes 

#  No  SKIP to Section 6.

5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs.

Outfall

Number Operation, Product, or Material Quantity Per Day Unit of

Measure

SECTION 6. IMPROVEMENTS (40 CFR 122.21(g)(6))Upgrades and Improvements 

# 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 envir onmental programs that could

affect the discharges described in this application?



#  Yes 

#  No  SKIP to Item 6.3.

6.2 Briefly identify each applicable project in the table below.

Brief Identification and Description of

Project Affected

Outfalls

(List Outfall

Number) Source(s) of

Discharge Final Compliance Dates

Required Projected

6.3 Have you attached sheets describing any additional water po llution control programs (or other environmental projects

that may affect your discharges) that you now have underway or planned? (Optional Item)



#  Yes 

#  No 

#  Not applicable

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 5 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation SECTION 7. EFFLUENT AND INTAKE CHARACTERISTICS (40 CFR 122.21(g)(7))Effluent and Intake Characteristics 

# See the Instructions to determine the pollutants and parameters y ou 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 Parameters

7.1 Are you requesting a waiver from y our NPDES permitting authority for one or mo re of the Table A parameters for any

of your outfalls?



#  Yes 

#  No  SKIP to Item 7.3.

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

Outfall Number _____ Outfall Number _____ Outfall Number _____

7.3 Have you completed monitoring for all Table A parameter s at each of your outfalls for which a waiver has not been

requested and attached the results to this application package?



#  Yes 

#  No; A waiver has been requested from my NPDES

permitting authority for all parameters 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 wastew ater fall into one or more of the primary industry categories

listed in Exhibit 2C-3? (See end of Instructions for exhibit.)



#  Yes 

#  No  SKIP to Item 7.8.

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



#  Yes 

#  No

7.6 List the applicable primary industry ca tegories and check the boxes indicating t he required GC/MS fraction(s) identified

in Exhibit 2C-3.

Primary Industry Category Required GC/MS Fraction(s)

(Check applicable boxes.)

 Volatile  Acid  Base/Neutral  Pesticide

 Volatile  Acid  Base/Neutral  Pesticide

 Volatile  Acid  Base/Neutral  Pesticide

7.7 Have you checked “Testing Required” for all required pollu tants 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

7.9 Have you provided (a) quantitative data for those Section 1, Table B pollutants for which you have indicated testing is

required or (b) quantitative data or other required informat ion for those Section 1, Table B pollutants that you have

indicated are “Believed Present” in your discharge?



#  Yes 

#  No

7.10 Does the applicant qualify for a small business exempti on under the criteria specified in the Instructions?



#  Yes  Note that you qualify at the top of Table B

then SKIP to Item 7.12. 

#  No

7.11 Have you provided (a) quantitative data for those Secti ons 2 through 5, Table B pollutants for which you have

determined testing is required or (b) quantitative data or an explanation for those Sections 2 through 5, Table B

pollutants you have indicated are “B elieved Present” in your discharge?



#  Yes 

#  No

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 6 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for ImplementationEffluent and Intake Characteristics Continued 

# 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 (a) quantitative dat a for those pollutants that are limited either directly or

indirectly in an ELG and/or (b) quantitative data or an ex planation 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 (a) describing the r easons the applicable pollutants are expected to be discharged

and (b) 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 t he 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?



#  Yes  Complete Table E. 

#  No  SKIP to Section 8.

7.17 Have you completed Table E by reporting qualitative data for TCDD?



#  Yes 

#  No

SECTION 8. USED OR MANUFACTURED TOXICS (40 CFR 122.21(g)(9))Used or ManufacturedToxics 

# 8.1 Is any pollutant listed in Table B a substance or a com ponent 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. 4. 7.

2. 5. 8.

3. 6. 9.

SECTION 9. BIOLOGICA L TOXICITY TESTS (40 CFR 122.21(g)(11))Biological Toxicity Tests 

# 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 (a) any of your discharges or (b) on a receiving water in relation to your discharge?



#  Yes 

#  No  SKIP to Section 10.

9.2 Identify the tests and their purposes below.

Test(s) Purpose of Test(s) Submitted to NPDES

Permitting Authority? Date Submitted



#  Yes 

#  No



#  Yes 

#  No



#  Yes 

#  No

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 7 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation SECTION 10. CONTRACT ANA LYSES (40 CFR 122.21(g)(12))Contract Analyses 

# 10.1 Were any of the analyses reported in Section 7 perf ormed by a contract laboratory or consulting firm?



#  Yes 

#  No  SKIP to Section 11.

10.2 Provide information for each contract laboratory or consulting firm below.

Laboratory Number 1 Laboratory Number 2 Laboratory Number 3

Name of

Laboratory/Firm

Laboratory Address

Phone Number

Pollutant(s) Analyzed

SECTION 11. ADDITIONAL INFORMATION (40 CFR 122.21(g)(13))Additional Information 

# 11.1 Has the NPDES permitting authority requested additional information?



#  Yes 

#  No  SKIP to Section 12.

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

1. 4.

2. 5.

3. 6.

# EPA Form 3510-2C (Revised <INSERT DATE>) Page 8 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.>

Form Expires <INSERT DATE>



# Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation SECTION 12. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))Checklist and Certification Statement 

# 12.1 In Column 1 below, mark the Form 2C sections you hav e completed and are submitting with your application. For each

section, specify in Column 2 the attachments you are enclosi ng. Note that not all applicants are required to complete all

sections or provide attachments.

Column 1 Column 2



#  Section 1 

#  w/ attachments



#  Section 2 

#  w/ line drawing 

#  w/ additional attachments



#  Section 3 

#  w/ attachments



#  w/ list of each user of priv ately owned treatment works



#  Section 4 

#  w/ attachments



#  Section 5 

#  w/ attachments



#  Section 6 

#  w/ attachments 

#  w/ optional additional

sheets describing any

additional pollution control

plans



#  Section 7 

#  w/ request for a waiver and

supporting information 

#  w/ explanation for identical

outfalls



#  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



#  Section 8 

#  w/ attachments



#  Section 9 

#  w/ attachments



#  Section 10 

#  w/ attachments



#  Section 11 

#  w/ attachments



#  Section 12

12.2 I certify under penalty of law that this document and all atta chments were prepared under my direction or supervision in

accordance with a system designed to assure that qualif ied personnel properly gather and evaluate the information

submitted. Based on my inquiry of the person or per sons 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 (first and last) Official Title

Signature Date SignedEPA Form 3510-2C (Revised <INSERT DATE>)Page 9EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE A. CONVENTIONAL ANDNON-CONVENTIONAL PARAMETERS (40 CFR 122.21(g)(7)(iii))1PollutantWaiverRequested(if applicable)Units(specify)EffluentIntake(Optional)MaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverage DailyDischarge(if available)Number ofAnalysesLong-TermAverage ValueNumber ofAnalysesCheck here if you have applied to your NPDES permitting authority for a waiver forallof the pollutants listed on this table for the noted outfall.1.Biochemical Oxygen Demand(BOD5)ConcentrationMass2.Chemical Oxygen Demand(COD)ConcentrationMass3. Total Organic Carbon (TOC)ConcentrationMass4. Total Suspended Solids (TSS)ConcentrationMass5. Ammonia (as N)ConcentrationMass6. FlowRate7.Temperature (winter)°C °CTemperature (summer)°C °C8.pH (minimum)Standard Units s.u.pH (maximum)Standard Units s.u.1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter Nor O. See Instructions and 40 CFR 122.21(e)(3).ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2C (Revised <INSERT DATE>)Page 11EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses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 Sections2 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 Phenols1.1Antimony, Total(7440-36-0)ConcentrationMass1.2Arsenic, Total(7440-38-2)ConcentrationMass1.3Beryllium, Total(7440-41-7)ConcentrationMass1.4Cadmium, Total(7440-43-9)ConcentrationMass1.5Chromium, Total(7440-47-3)ConcentrationMass1.6Copper, Total(7440-50-8)ConcentrationMass1.7Lead, Total(7439-92-1)ConcentrationMass1.8Mercury, Total(7439-97-6)ConcentrationMass1.9Nickel, Total(7440-02-0)ConcentrationMass1.10Selenium, Total(7782-49-2)ConcentrationMass1.11Silver, Total(7440-22-4)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 12EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses1.12Thallium, Total(7440-28-0)ConcentrationMass1.13Zinc, Total(7440-66-6)ConcentrationMass1.14Cyanide, Total(57-12-5)ConcentrationMass1.15 Phenols, TotalConcentrationMassSection 2. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)2.1Acrolein(107-02-8)ConcentrationMass2.2Acrylonitrile(107-13-1)ConcentrationMass2.3Benzene(71-43-2)ConcentrationMass2.4Bromoform(75-25-2)ConcentrationMass2.5Carbon Tetrachloride(56-23-5)ConcentrationMass2.6Chlorobenzene(108-90-7)ConcentrationMass2.7Chlorodibromomethane(124-48-1)ConcentrationMass2.8Chloroethane(75-00-3)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 13EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses2.92-Chloroethylvinyl Ether(110-75-8)ConcentrationMass2.10 Chloroform (67-66-3)ConcentrationMass2.11Dichlorobromomethane(75-27-4)ConcentrationMass2.121,1-Dichloroethane(75-34-3)ConcentrationMass2.131,2-Dichloroethane(107-06-2)ConcentrationMass2.141,1-Dichloroethylene(75-35-4)ConcentrationMass2.151,2-Dichloropropane(78-87-5)ConcentrationMass2.161,3-Dichloropropylene(542-75-6)ConcentrationMass2.17Ethylbenzene(100-41-4)ConcentrationMass2.18Methyl Bromide(74-83-9)ConcentrationMass2.19Methyl Chloride(74-87-3)ConcentrationMass2.20Methylene Chloride(75-09-2)ConcentrationMass2.211,1,2,2- Tetrachloroethane(79-34-5)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 14EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses2.22Tetrachloroethylene(127-18-4)ConcentrationMass2.23Toluene(108-88-3)ConcentrationMass2.241,2-Trans- Dichloroethylene(156-60-5)ConcentrationMass2.251,1,1-Trichloroethane(71-55-6)ConcentrationMass2.261,1,2-Trichloroethane(79-00-5)ConcentrationMass2.27Trichloroethylene(79-01-6)ConcentrationMass2.28Vinyl Chloride(75-01-4)ConcentrationMassSection 3. Organic Toxic Pollutants (GC/MS Fraction—Acid Compounds)3.12-Chlorophenol(95-57-8)ConcentrationMass3.22,4-Dichlorophenol(120-83-2)ConcentrationMass3.32,4-Dimethylphenol(105-67-9)ConcentrationMass3.44,6-Dinitro-O-Cresol(534-52-1)ConcentrationMass3.52,4-Dinitrophenol(51-28-5)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 15EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses3.62-Nitrophenol(88-75-5)ConcentrationMass3.74-Nitrophenol(100-02-7)ConcentrationMass3.8p-Chloro-m-Cresol(59-50-7)ConcentrationMass3.9Pentachlorophenol(87-86-5)ConcentrationMass3.10Phenol(108-95-2)ConcentrationMass3.112,4,6-Trichlorophenol(88-05-2)ConcentrationMassSection 4. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds)4.1Acenaphthene(83-32-9)ConcentrationMass4.2Acenaphtylene(208-96-8)ConcentrationMass4.3Anthracene(120-12-7)ConcentrationMass4.4Benzidine(92-87-5)ConcentrationMass4.5Benzo (a) Anthracene(56-55-3)ConcentrationMass4.6Benzo (a) Pyrene(50-32-8)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 16EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses4.73,4-Benzofluoranthene(205-99-2)ConcentrationMass4.8Benzo (ghi) Perylene(191-24-2)ConcentrationMass4.9Benzo (k) Fluoranthene(207-08-9)ConcentrationMass4.10Bis (2-Chloroethoxy) Methane(111-91-1)ConcentrationMass4.11Bis (2-Chloroethyl) Ether(111-44-4)ConcentrationMass4.12Bis (2-Chloroisopropyl) Ether(102-80-1)ConcentrationMass4.13Bis (2-Ethylhexyl) Phthalate(117-81-7)ConcentrationMass4.144-Bromophenyl Phenyl Ether(101-55-3)ConcentrationMass4.15Butyl Benzyl Phthalate(85-68-7)ConcentrationMass4.162-Chloronaphthalene(91-58-7)ConcentrationMass4.174-Chlorophenyl Phenyl Ether(7005-72-3)ConcentrationMass4.18Chrysene(218-01-9)ConcentrationMass4.19Dibenzo (a,h) Anthracene(53-70-3)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 17EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses4.201,2-Dichlorobenzene(95-50-1)ConcentrationMass4.211,3-Dichlorobenzene(541-73-1)ConcentrationMass4.221,4-Dichlorobenzene(106-46-7)ConcentrationMass4.333,3-Dichlorobenzidine(91-94-1)ConcentrationMass4.34Diethyl Phthalate(84-66-2)ConcentrationMass4.35Dimethyl Phthalate(131-11-3)ConcentrationMass4.36Di-N-Butyl Phthalate(84-74-2)ConcentrationMass4.372,4-Dinitrotoluene(121-14-2)ConcentrationMass4.382,6-Dinitrotoluene(606-20-2)ConcentrationMass4.39Di-n-Octyl Phthalate(117-84-0)ConcentrationMass4.401,2-Diphenylhydrazine(as Azobenzene) (122-66-7)ConcentrationMass4.41Fluoranthene(206-44-0)ConcentrationMass4.42Fluorene(86-73-7)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 18EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses4.43Hexachlorobenzene(118-74-1)ConcentrationMass4.44Hexachlorobutadiene(87-68-3)ConcentrationMass4.45Hexachlorocyclopentadiene(77-47-4)ConcentrationMass4.46Hexachloroethane(67-72-1)ConcentrationMass4.47.Indeno (1,2,3-cd) Pyrene(193-39-5)ConcentrationMass4.48Isophorone(78-59-1)ConcentrationMass4.49Naphthalene(91-20-3)ConcentrationMass4.50Nitrobenzene(98-95-3)ConcentrationMass4.51N-Nitrosodimethylamine(62-75-9)ConcentrationMass4.52N-Nitrosodi-n-Propylamine(621-64-7)ConcentrationMass4.53N-Nitrosodiphenylamine(86-30-6)ConcentrationMass4.54Phenanthrene(85-01-8)ConcentrationMass4.55Pyrene(129-00-0)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 19EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses4.561,2,4-Trichlorobenzene(120-82-1)ConcentrationMassSection 5. Organic Toxic Pollutants (GC/MS Fraction—Pesticides)5.1Aldrin(309-00-2)ConcentrationMass5.2α-BHC(319-84-6)ConcentrationMass5.3β-BHC(319-85-7)ConcentrationMass5.4γ-BHC(58-89-9)ConcentrationMass5.5δ-BHC(319-86-8)ConcentrationMass5.6Chlordane(57-74-9)ConcentrationMass5.74,4’-DDT(50-29-3)ConcentrationMass5.84,4’-DDE(72-55-9)ConcentrationMass5.94,4’-DDD(72-54-8)ConcentrationMass5.10Dieldrin(60-57-1)ConcentrationMass5.11α-Enosulfan(115-29-7)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 20EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1Pollutant / Parameter(and CAS Number, if available)TestingRequiredPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximumDailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverageDailyDischarge(if available)NumberofAnalysesLongTermAverageValueNumberofAnalyses5.12β-Endosulfan(115-29-7)ConcentrationMass5.13Endosulfan Sulfate(1031-07-8)ConcentrationMass5.14Endrin(72-20-8)ConcentrationMass5.15Endrin Aldehyde(7421-93-4)ConcentrationMass5.16Heptachlor(76-44-8)ConcentrationMass1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter N orO. See Instructions and 40 CFR 122.21(e)(3).EPA Form 3510-2C (Revised <INSERT DATE>)Page 21EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1PollutantPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximum DailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverage DailyDischarge(if available)Number ofAnalysesLong-TermAverageValueNumber ofAnalysesCheck here if you believe all pollutants on Table C to bepresentin your discharge from the noted outfall. You neednotcomplete the “Presence or Absence” column of Table C foreachpollutant.Check here if you believe all pollutants on Table C to beabsentin your discharge from the noted outfall. You neednotcomplete the “Presence or Absence” column of Table C foreachpollutant.1.Bromide(24959-67-9)ConcentrationMass2.Chlorine, TotalResidualConcentrationMass3. ColorConcentrationMass4. Fecal ColiformConcentrationMass5.Fluoride(16984-48-8)ConcentrationMass6 Nitrate-NitriteConcentrationMass7.Nitrogen, TotalOrganic (as N)ConcentrationMass8. Oil and GreaseConcentrationMass9.Phosphorus (asP), Total(7723-14-0)ConcentrationMass10.Sulfate (as SO4)(14808-79-8)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 22EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1PollutantPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximum DailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverage DailyDischarge(if available)Number ofAnalysesLong-TermAverageValueNumber ofAnalyses11. Sulfide (as S)ConcentrationMass12.Sulfite (as SO3)(14265-45-3)ConcentrationMass13. SurfactantsConcentrationMass14.Aluminum, Total(7429-90-5)ConcentrationMass15.Barium, Total(7440-39-3)ConcentrationMass16.Boron, Total(7440-42-8)ConcentrationMass17.Cobalt, Total(7440-48-4)ConcentrationMass18.Iron, Total(7439-89-6)ConcentrationMass19.Magnesium, Total(7439-95-4)ConcentrationMass20.Molybdenum,Total(7439-98-7)ConcentrationMass21.Manganese, Total(7439-96-5)ConcentrationMass22.Tin, Total(7440-31-5)ConcentrationMass23.Titanium, Total(7440-32-6)ConcentrationMassEPA Form 3510-2C (Revised <INSERT DATE>)Page 23EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1PollutantPresence or Absence(check one)Units(specify)EffluentIntake(Optional)BelievedPresentBelievedAbsentMaximum DailyDischarge(required)MaximumMonthlyDischarge(if available)Long-TermAverage DailyDischarge(if available)Number ofAnalysesLong-TermAverageValueNumber ofAnalyses24.RadioactivityAlpha, TotalConcentrationMassBeta, TotalConcentrationMassRadium, TotalConcentrationMassRadium 226,TotalConcentrationMass1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter Nor O. See Instructions and 40 CFR 122.21(e)(3).ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2C (Revised <INSERT DATE>)Page 25EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1PollutantPresence or Absence(check one)Reason Pollutant Believed Present in DischargeAvailable Quantitative Data(specify units)BelievedPresentBelievedAbsent1. Asbestos2. Acetaldehyde3. Allyl alcohol4. Allyl chloride5. Amyl acetate6. Aniline7. Benzonitrile8. Benzyl chloride9. Butyl acetate10. Butylamine11. Captan12. Carbaryl13. Carbofuran14. Carbon disulfide15. Chlorpyrifos16. Coumaphos17. Cresol18. Crotonaldehyde19. CyclohexaneEPA Form 3510-2C (Revised <INSERT DATE>)Page 26EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1PollutantPresence or Absence(check one)Reason Pollutant Believed Present in DischargeAvailable Quantitative Data(specify units)BelievedPresentBelievedAbsent20. 2,4-D (2,4-Dichlorophenoxyacetic acid)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31. Disulfoton32. Diuron33. Epichlorohydrin34. Ethion35. Ethylene diamine36. Ethylene dibromide37. Formaldehyde38. FurfuralEPA Form 3510-2C (Revised <INSERT DATE>)Page 27EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1PollutantPresence or Absence(check one)Reason Pollutant Believed Present in DischargeAvailable Quantitative Data(specify units)BelievedPresentBelievedAbsent39. Guthion40. Isoprene41. Isopropanolamine42. Kelthane43. Kepone44. Malathion45. Mercaptodimethur46. Methoxychlor47. Methyl mercaptan48. Methyl methacrylate49. Methyl parathion50. Mevinphos51. Mexacarbate52. Monoethyl amine53. Monomethyl amine54. Naled55. Napthenic acid56. Nitrotoluene57. ParathionEPA Form 3510-2C (Revised <INSERT DATE>)Page 28EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1PollutantPresence or Absence(check one)Reason Pollutant Believed Present in DischargeAvailable Quantitative Data(specify units)BelievedPresentBelievedAbsent58. Phenolsulfonate59. Phosgene60. Propargite61. Propylene oxide62. Pyrethrins63. Quinoline64. Resorcinol65. Strontium66. Strychnine67. Styrene68.2,4,5-T (2,4,5-Trichlorophenoxyaceticacid)69. TDE (Tetrachlorodiphenyl ethane)70.2,4,5-TP [2-(2,4,5-Trichlorophenoxy)propanoic acid]71. Trichlorofon72. Triethanolamine73. Triethylamine74. Trimethylamine75. Uranium76. VanadiumEPA Form 3510-2C (Revised <INSERT DATE>)Page 29EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1PollutantPresence or Absence(check one)Reason Pollutant Believed Present in DischargeAvailable Quantitative Data(specify units)BelievedPresentBelievedAbsent77. Vinyl acetate78. Xylene79. Xylenol80. Zirconium1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter N orO. See Instructions and 40 CFR 122.21(e)(3).ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2C (Revised <INSERT DATE>)Page 31EPA Identification Number NPDES NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE E. 2,3,7,8-TETRACHLORODIBENZO-P-DIOXIN (2,3,7,8-TCDD) (40 CFR 122.21(g)(7)(viii))PollutantTCDDCongenersUsed orManufacturedPresence orAbsence(check one)Results of Screening ProcedureBelievedPresentBelievedAbsent2,3,7,8-TCDD