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Draft Application Forms – Not for Implementation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This document is being distributed for comment purposes only.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 existing manufacturing, commercial, mining, 

and silvicultural facility that currently discharges process wastewater. 

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Paperwork Reduction Act Notice 

The U.S. Environmental Protection Agency estimates the average burden to collect information and 

complete Form 2C to be 33 hours. This estimate includes time for reviewing instructions, searching 

existing data sources, gathering and maintaining the needed data, and completing and reviewing the 

collection of information. Send comments regarding the burden estimate or any other aspect of this 

collection of information to the Chief, Information Policy Branch (PM-223), U.S. Environmental 

Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460 and to the Office of 

Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, 

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

For Comment Only
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Draft Application Forms – Not for Implementation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, using a format consistent with the 

form. 

Provide your EPA Identification Number from the Federal Registry 

Service, NPDES Permit Number, and facility name at the top of 

each page of Form 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. Additionally, for Tables A through E, provide 

the applicable Outfall Number at the top of each page. 

Do not leave any response areas blank unless the form directs you 

to skip 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 will consider your application 

complete when it and any supplementary material are received and 

completed according to the authority’s satisfaction. The NPDES 

permitting authority will judge the completeness of any application 

independently of the status of any other permit application or permit 

for the same facility or activity. 

Definitions 

Definitions of all significant terms 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 require 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 19th

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.

For Comment Only
2C-2 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation Applicable 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 use your best estimate. If you are 

unable to determine a water balance for your activities (such as 

mining activities), provide a pictorial description of the nature and 

amount of any sources of water and any collection and treatment 

measures. An example of an acceptable line drawing is provided in 

Exhibit 2C–1 at the end of these Instructions. 

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. Otherwise, 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 

For Comment Only
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 limits 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 schedule 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 order, 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 addition 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 All applicants from all outfalls 

unless a waiver is obtained from 

the NPDES permitting authority. 

B Toxic Metals, Cyanide, Total 

Phenols, and Organic Toxic 

Pollutants 

Applicants in the Primary Industry 

Categories listed in Exhibit 2C-3 

located at the end of these 

Instructions. 

C Certain Conventional and 

Non-Conventional Pollutants 

Applicants 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 

Applicants who believe 

pollutants may be present in 

their facility’s discharge. 

E 2,3,7,8-Tetrachlorodibenzo-pdioxin Applicants 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 categories listed in Exhibit 2C-3. If you are 

applying for a permit for a privately owned treatment works, 

determine your testing requirements based on the industrial 

categories of your contributors. This exercise is simply to determine 

your testing requirements only. You are not giving up your right to 

challenge your inclusion in the category determined for testing (e.g., 

for deciding whether an ELG is applicable) before your permit is 

issued. If “yes”, continue to Item 7.5. If “no”, skip to Item 7.8. 

Complete a separate Table B for each outfall. Section 1 of Table B 

lists toxic metals, cyanide, and total phenols. Sections 2 through 5 

of Table B list the pollutants in each of the 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 

For Comment Only
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 categories, list the primary 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 pollutants in the required fraction in 

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

have completed this task. 

Item 7.8 and Sections 1 through 5 of Table B. For all other cases 

(secondary industries, nonprocess wastewater outfalls, and 

nonrequired GC/MS fractions) and remaining pollutants, check 

“Believed Present” or “Believed Absent” in Sections 1 through 5 of 

Table B to indicate whether you have reason to believe that any of 

the pollutants listed are discharged from your outfalls. Answer “yes” 

to Item 7.8 after you have completed this step. 

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

or have reason to believe is present in your discharge from each 

applicable outfall in concentrations of 10 parts per billion (ppb) or 

greater, you must report quantitative data. For every pollutant 

expected to be discharged in concentrations less than 10 ppb, you 

must submit quantitative data or briefly describe the reasons the 

pollutant is expected to be discharged. For pollutants in intake 

water, see the discussion under “General Instructions for 

Reporting, Sampling, and Analysis” below. Answer “yes” to Item 

7.9 once you have completed Section 1 of Table B.

Item 7.10. This item asks if you qualify as a “small business.” If so, 

you are exempt from submitting quantitative data for the organic 

toxic pollutants on Table B (Sections 2 through 5). You still have to 

indicate whether you believe any of the pollutants listed in Sections 

1 through 5, however, are present in your discharge per the 

Instructions at Item 7.8 above. 

You can qualify as a “small business” in two ways: (1) If your facility 

is a coal mine and if your probable total annual production is less 

than 100,000 tons per year, you may submit past production data or 

estimated future production (such as a schedule of estimated total 

production under 30 CFR § 795.14(c)) instead of conducting 

analyses for the organic toxic pollutants. (2) If your facility is not a 

coal mine and if your gross total annual sales for the most recent 

three years average less than $100,000 per year (in second quarter 

1980 dollars), you may submit sales data for those years instead of 

conducting analyses for the organic toxic pollutants. The production 

or sales data must be for the facility that is the source of the 

discharge. The data should not be limited to production or sales for 

the process or processes that contribute to the discharge, unless 

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

situations involving intra-corporate transfer of goods and services, 

the transfer price per unit should approximate market prices for 

those goods and services as closely as possible. Sales figures for 

years after 1980 should be indexed to the second quarter of 1980 

by using the gross national product price deflator (second quarter of 

1980=100). This index is available online from the U.S. Department 

of Commerce, Bureau of Economic Analysis at 

http://bea.gov/national/pdf/SNTables.pdf. 

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 pollutant 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 either report quantitative data or 

briefly describe the reasons the pollutant is expected to be 

discharged. 

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

Instructions for Reporting, Sampling, and Analysis” 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 

For Comment Only
2C-5 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

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

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

requirements, civil penalties and liability for cleanup costs for spills of oil and 

hazardous substances. A discharge of a particular substance can be 

exempted if the origin, source, and amount of the discharged substances are 

identified in the NDPES permit application or in the permit, if the permit 

contains a requirement for treatment of the discharge, and if the treatment is 

in place. 

Exemptions are allowed from the requirements of CWA Section 311. 

Applications for exemptions must set forth the following information: 

1. The substance and the amount of each substance that may be discharged. 

2. The origin and source of the discharge of the substance. 

3. The treatment to be provided for the discharge by: 

a. An onsite treatment system separate from any treatment system 

treating your normal discharge; 

b. A treatment system designed to treat your normal discharge and that 

is additionally capable of treating the amount of the substance 

identified under paragraph 1 above; or 

c. Any combination of the above. 

See 40 CFR §117.12(a)(2) and (c) or contact your NPDES permitting authority 

for further information on exclusions from CWA Section 311.

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 must briefly describe the reasons 

the pollutant is expected to be discharged and report any 

quantitative data you have for that pollutant. Note that you are not 

required to perform analytical tests for any of the Table D 

pollutants at this time. However, if you have prior test results, you 

must report them. 

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. 

For Comment Only
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 Average 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 characterize your discharges. 

For composite samples, the daily value is the total mass or 

average concentration found in a composite sample taken over the 

operating hours of the facility during a 24-hour period. For grab 

samples, the daily value is the arithmetic or flow-weighted total 

mass or average concentration found in a series of at least four (4) 

grab samples taken over the operating 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 your wastestream, you must report 

them. You must describe your method of testing and data analysis. 

When an applicant has two or more outfalls with substantially 

identical effluents, the NPDES permitting authority may allow the 

applicant to test only one outfall and report that quantitative data as 

applying to the substantially identical outfall. If the permitting 

authority grants your request, attach a separate sheet to the 

application form identifying the outfall tested and describing why the 

other outfall(s) are substantially identical. 

Reporting of Intake Data 

You are not required to report data under the “Intake” columns of 

Tables A through C unless you wish to demonstrate your eligibility 

for a “net” effluent limitation for one or more pollutants in Tables A 

through C (i.e., an effluent limitation adjusted by subtracting the 

average level of the pollutant(s) present in your intake water). 

NPDES regulations allow net limitations only in certain 

circumstances. To demonstrate your eligibility, under the “Intake” 

columns report the average of the results of analyses of your intake 

water and discuss the requirements for a net limitation with your 

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

the water after it has been treated. 

For Comment Only
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 discharges, the NPDES permitting authority 

may waive composite sampling requirements for any outfall for 

which you demonstrate that use of an automatic sampler is 

infeasible and that the minimum of four (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 facility over a 24-hour period. The 

composite must be flow proportional; either the time interval 

between each aliquot or the volume of each aliquot must be 

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

total stream flow since the collection of the previous aliquot. 

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

Fraction—Volatile Compounds in Table B, aliquots must be 

combined in the laboratory immediately before analysis. Four (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 sufficiently 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 pollutant 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. 

For Comment Only
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 provides that “Any person who 

knowingly makes any false statement, representation, or 

certification in any application, ...shall upon conviction, be punished 

by a fine of no more than $10,000 or by imprisonment for not more 

than six months or both.” 

FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS 

APPLICATION TO BE SIGNED AS FOLLOWS: 

A. By a responsible corporate officer. For the purpose of this 

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

secretary, treasurer, or vice-president of the corporation in 

charge of a principal business function, or any 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 proprietorship, by a general partner or 

the proprietor, respectively. 

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

either a principal executive officer or ranking elected official. 

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

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

agency, or (ii) a senior executive officer having responsibility for 

the overall operations of a principal geographic unit of the 

agency (e.g., Regional Administrators of EPA). 

END 

Submit your completed Form 1, Form 2C, and all associated 

attachments (and any other required NPDES application forms) 

to your NPDES permitting authority. 

For Comment Only
2C-9 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Exhibit 2C–1. Example Line Drawing 

For Comment Only
2C-10 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Exhibit 2C–2. Codes for Treatment Units and Disposal 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 

   

For Comment Only
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 FRACTION1 

Volatile Acid 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. 

    For Comment Only
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 dodecylbenzenesulfonate 

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 

For Comment Only
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 

   

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

For Comment Only
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)) Line Drawing 

2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water 

balance? (See Instructions for drawing requirements. See Exhibit 2C-1 at end of Instructions for example.) 

 Yes  No 

For Comment Only
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 average 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 __________ 

For Comment Only
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 

Discharge 

System 

Users 

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 described 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 

Average Duration 

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))

For Comment Only
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 Implementation

Applicable 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 Citation 

 

 

 

Production-Based Limitations 

5.3 Are any of the applicable ELGs expressed in terms 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 environmental 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 pollution control programs (or other environmental projects 

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

 Yes  No  Not applicable 

   

For Comment Only
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 you are required to monitor and, in turn, the tables you must 

complete. Not all applicants need to complete each table. 

Table A. Conventional and Non-Conventional Parameters 

7.1 Are you requesting a waiver from your NPDES permitting authority for one or more 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 waiver request and other required information to the application. 

Outfall Number _____ Outfall Number _____ Outfall Number _____ 

7.3 Have you completed monitoring for all Table A parameters 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 wastewater 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 categories and check the boxes indicating the 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 pollutants in Sections 2 through 5 of Table B for each of the 

GC/MS fractions checked in Item 7.6? 

 Yes  No 

7.8 Have you checked “”Believed Present” or “Believed Absent” for all pollutants listed in Sections 1 through 5 of Table B 

where testing is not required? 

 Yes  No 

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 information 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 exemption 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 Sections 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 “Believed Present” in your discharge? 

 Yes  No 

For Comment Only
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 Implementation

Effluent 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 data for those pollutants that are limited either directly or 

indirectly in an ELG and/or (b) quantitative data or an explanation for those pollutants for which you have indicated 

“Believed Present”? 

 Yes  No 

Table D. Certain Hazardous Substances and Asbestos 

7.14 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed in Table D for

all outfalls? 

 Yes  No 

7.15 Have you completed Table D by (a) describing the reasons 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 the 2,3,7,8-TCDD congeners listed in the Instructions, or do you 

know or have reason to believe that TCDD is or may be present in the effluent? 

 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 Manufactured Toxics 

8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as 

an intermediate or final product or byproduct? 

 Yes  No  SKIP to Section 9. 

8.2 List the pollutants below. 

1. 4. 7. 

2. 5. 8. 

3. 6. 9. 

SECTION 9. BIOLOGICAL 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 

For Comment Only
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 ANALYSES (40 CFR 122.21(g)(12)) Contract Analyses

10.1 Were any of the analyses reported in Section 7 performed 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. 

For Comment Only
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 have completed and are submitting with your application. For each 

section, specify in Column 2 the attachments you are enclosing. 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 privately 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 attachments were prepared under my direction or supervision in 

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

submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly 

responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, 

accurate, and complete. I am aware that there are significant penalties for submitting false information, including the 

possibility of fine and imprisonment for knowing violations. 

Name (first and last) Official Title 

For 

Signature Date Signed 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant 

Waiver 

Requested 

(if applicable) 

Units

(specify)

Effluent 

Maximum 

Daily 

Discharge 

(required) 

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average Daily 

Discharge 

(if available)

Number of 

Analyses 

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

1. Biochemical Oxygen Demand (BOD5)  Concentration Mass 2. Chemical Oxygen Demand (COD)  Concentration Mass 3. Total Organic Carbon (TOC) 

Concentration 

Mass 

4. Total Suspended Solids (TSS) 

Concentration 

Mass 

5. Ammonia (as N) 

Concentration 

Mass 

6. Flow  Rate 7. 

Temperature (winter)  °C °C 

Temperature (summer)  °C °C 

8. 

pH (minimum)  Standard Units s.u. 

pH (maximum)  Standard Units s.u. 

1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136 for the analysis of polluta

required under 40 CFR chapter I, subchapter N 

For 

or O. See Instructions and 40 CFR 122.21(e)(3).

Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

 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 

2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed 

Section 1. Toxic Metals, Cyanide, and Total Phenols 

1.1 Antimony, Total (7440-36-0)    Concentration Mass 1.2 Arsenic, Total (7440-38-2)    Concentration Mass 1.3 Beryllium, Total (7440-41-7)    Concentration Mass 1.4 Cadmium, Total (7440-43-9)    Concentration Mass 1.5 Chromium, Total (7440-47-3)    Concentration Mass 1.6 Copper, Total (7440-50-8)    Concentration Mass 1.7 Lead, Total (7439-92-1)    Concentration Mass 1.8 Mercury, Total (7439-97-6)    Concentration Mass 1.9 Nickel, Total (7440-02-0)    Concentration Mass 

1.10 Selenium, Total (7782-49-2)    Concentration Mass 1.11 Silver, Total (7440-22-4)    Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

1.12 Thallium, Total (7440-28-0)    Concentration Mass 1.13 Zinc, Total (7440-66-6)    Concentration Mass 1.14 Cyanide, Total (57-12-5)    Concentration Mass 1.15 Phenols, Total    Concentration Mass 

Section 2. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)

2.1 Acrolein (107-02-8)    Concentration Mass 2.2 Acrylonitrile (107-13-1)    Concentration Mass 2.3 Benzene (71-43-2)    Concentration Mass 2.4 Bromoform (75-25-2)    Concentration Mass 2.5 Carbon Tetrachloride (56-23-5)    Concentration Mass 2.6 Chlorobenzene (108-90-7)    Concentration Mass 2.7 Chlorodibromomethane (124-48-1)    Concentration Mass 2.8 Chloroethane (75-00-3)    Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

2.9 2-Chloroethylvinyl Ether (110-75-8)    Concentration Mass 

2.10 Chloroform (67-66-3)    Concentration Mass 2.11 Dichlorobromomethane (75-27-4)    Concentration Mass 2.12 1,1-Dichloroethane (75-34-3)    Concentration Mass 2.13 1,2-Dichloroethane (107-06-2)    Concentration Mass 2.14 1,1-Dichloroethylene (75-35-4)    Concentration Mass 2.15 1,2-Dichloropropane (78-87-5)    Concentration Mass 2.16 1,3-Dichloropropylene (542-75-6)    Concentration Mass 2.17 Ethylbenzene (100-41-4)    Concentration Mass 2.18 Methyl Bromide (74-83-9)    Concentration Mass 2.19 Methyl Chloride (74-87-3)    Concentration Mass 2.20 Methylene Chloride (75-09-2)    Concentration Mass 2.21 1,1,2,2- Tetrachloroethane (79-34-5)    Concentration Mass 

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

2.22 Tetrachloroethylene (127-18-4)    Concentration Mass 2.23 Toluene (108-88-3)    Concentration Mass 2.24 1,2-Trans- Dichloroethylene (156-60-5)    Concentration Mass 2.25 1,1,1-Trichloroethane (71-55-6)    Concentration Mass 2.26 1,1,2-Trichloroethane (79-00-5)    Concentration Mass 2.27 Trichloroethylene (79-01-6)    Concentration Mass 2.28 Vinyl Chloride (75-01-4)    Concentration Mass 

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

3.1 2-Chlorophenol (95-57-8)    Concentration Mass 3.2 2,4-Dichlorophenol (120-83-2)    Concentration Mass 3.3 2,4-Dimethylphenol (105-67-9)    Concentration Mass 3.4 4,6-Dinitro-O-Cresol (534-52-1)    Concentration Mass 3.5 2,4-Dinitrophenol (51-28-5)    Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

3.6 2-Nitrophenol (88-75-5)    Concentration Mass 3.7 4-Nitrophenol (100-02-7)    Concentration Mass 3.8 p-Chloro-m-Cresol (59-50-7)    Concentration Mass 3.9 Pentachlorophenol (87-86-5)    Concentration Mass 

3.10 Phenol (108-95-2)    Concentration Mass 3.11 2,4,6-Trichlorophenol (88-05-2)    Concentration Mass 

Section 4. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds) 

4.1 Acenaphthene (83-32-9)    Concentration Mass 4.2 Acenaphtylene (208-96-8)    Concentration Mass 4.3 Anthracene (120-12-7)    Concentration Mass 4.4 Benzidine (92-87-5)    Concentration Mass 4.5 Benzo (a) Anthracene (56-55-3)    Concentration Mass 4.6 Benzo (a) Pyrene (50-32-8)    Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

4.7 3,4-Benzofluoranthene (205-99-2)    Concentration Mass 4.8 Benzo (ghi) Perylene (191-24-2)    Concentration Mass 4.9 Benzo (k) Fluoranthene (207-08-9)    Concentration Mass 

4.10 Bis (2-Chloroethoxy) Methane (111-91-1)    Concentration Mass 4.11 Bis (2-Chloroethyl) Ether (111-44-4)    Concentration Mass 4.12 Bis (2-Chloroisopropyl) Ether (102-80-1)    Concentration Mass 4.13 Bis (2-Ethylhexyl) Phthalate (117-81-7)    Concentration Mass 4.14 4-Bromophenyl Phenyl Ether (101-55-3)    Concentration Mass 4.15 Butyl Benzyl Phthalate (85-68-7)    Concentration Mass 4.16 2-Chloronaphthalene (91-58-7)    Concentration Mass 4.17 4-Chlorophenyl Phenyl Ether (7005-72-3)    Concentration Mass 4.18 Chrysene (218-01-9)    Concentration Mass 4.19 Dibenzo (a,h) Anthracene (53-70-3)    Concentration Mass 

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

4.20 1,2-Dichlorobenzene (95-50-1)    Concentration Mass 4.21 1,3-Dichlorobenzene (541-73-1)    Concentration Mass 4.22 1,4-Dichlorobenzene (106-46-7)    Concentration Mass 4.33 3,3-Dichlorobenzidine (91-94-1)    Concentration Mass 4.34 Diethyl Phthalate (84-66-2)    Concentration Mass 4.35 Dimethyl Phthalate (131-11-3)    Concentration Mass 4.36 Di-N-Butyl Phthalate (84-74-2)    Concentration Mass 4.37 2,4-Dinitrotoluene (121-14-2)    Concentration Mass 4.38 2,6-Dinitrotoluene (606-20-2)    Concentration Mass 4.39 Di-n-Octyl Phthalate (117-84-0)    Concentration Mass 4.40 1,2-Diphenylhydrazine (as Azobenzene) (122-66-7)    Concentration Mass 4.41 Fluoranthene (206-44-0)    Concentration Mass 4.42 Fluorene (86-73-7)    Concentration Mass 

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

4.43 Hexachlorobenzene (118-74-1)    Concentration Mass 4.44 Hexachlorobutadiene (87-68-3)    Concentration Mass 4.45 Hexachlorocyclopentadiene (77-47-4)    Concentration Mass 4.46 Hexachloroethane (67-72-1)    Concentration Mass 

4.47. Indeno (1,2,3-cd) Pyrene (193-39-5)    Concentration Mass 

4.48 Isophorone (78-59-1)    Concentration Mass 4.49 Naphthalene (91-20-3)    Concentration Mass 4.50 Nitrobenzene (98-95-3)    Concentration Mass 4.51 N-Nitrosodimethylamine (62-75-9)    Concentration Mass 4.52 N-Nitrosodi-n-Propylamine (621-64-7)    Concentration Mass 4.53 N-Nitrosodiphenylamine (86-30-6)    Concentration Mass 4.54 Phenanthrene (85-01-8)    Concentration Mass 4.55 Pyrene (129-00-0)    Concentration Mass 

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

4.56 1,2,4-Trichlorobenzene (120-82-1)    Concentration Mass 

Section 5. Organic Toxic Pollutants (GC/MS Fraction—Pesticides) 

5.1 Aldrin (309-00-2)    Concentration Mass 5.2 α-BHC (319-84-6)    Concentration Mass 5.3 β-BHC (319-85-7)    Concentration Mass 5.4 γ-BHC (58-89-9)    Concentration Mass 5.5 δ-BHC (319-86-8)    Concentration Mass 5.6 Chlordane (57-74-9)    Concentration Mass 5.7 4,4’-DDT (50-29-3)    Concentration Mass 5.8 4,4’-DDE (72-55-9)    Concentration Mass5.9 4,4’-DDD (72-54-8)    Concentration Mass 

5.10 Dieldrin (60-57-1)    Concentration Mass 5.11 α-Enosulfan (115-29-7)    Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

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

Pollutant / Parameter 

(and CAS Number, if available)

Testing 

Required 

Presence or Absence 

(check one)

Units 

(specify)

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum 

Daily 

Discharge 

(required)

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average 

Daily 

Discharge 

(if available) 

5.12 β-Endosulfan (115-29-7)    Concentration Mass 5.13 Endosulfan Sulfate (1031-07-8)    Concentration Mass 5.14 Endrin (72-20-8)    Concentration Mass 5.15 Endrin Aldehyde (7421-93-4)    Concentration Mass 5.16 Heptachlor (76-44-8)    Concentration Mass 

1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136 for the analysis of polluta

required under 40 CFR chapter I, subchapter N or O. See Instructions and 40 CFR 122.21(e)(3). 

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1

Pollutant 

Presence or Absence 

(check one)

Units 

(specify) 

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum Daily 

Discharge 

(required) 

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average Daily 

Discharge 

(if available)

Number o

Analyses 

 Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the “Presence or A

each pollutant. 

 Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the “Presence or Ab

each pollutant. 

1. Bromide (24959-67-9)   Concentration Mass 2. Chlorine, Total Residual   Concentration Mass 3. Color   Concentration Mass 4. Fecal Coliform   Concentration Mass 5. Fluoride (16984-48-8)   Concentration Mass 

6 Nitrate-Nitrite   Concentration Mass 

7. Nitrogen, Total Organic (as N)   Concentration Mass 8. Oil and Grease   Concentration Mass 9. 

Phosphorus (as P), Total 

(7723-14-0)

  Concentration Mass 

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

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1

Pollutant 

Presence or Absence 

(check one)

Units 

(specify) 

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum Daily 

Discharge 

(required) 

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average Daily 

Discharge 

(if available)

Number o

Analyses 

11. Sulfide (as S)   Concentration Mass 12. Sulfite (as SO3) (14265-45-3)   Concentration Mass 13. Surfactants   Concentration Mass 14. Aluminum, Total (7429-90-5)   Concentration Mass 15. Barium, Total (7440-39-3)   Concentration Mass 16. Boron, Total (7440-42-8)   Concentration Mass 17. Cobalt, Total (7440-48-4)   Concentration Mass 18. Iron, Total (7439-89-6)   Concentration Mass 19. Magnesium, Total (7439-95-4)   Concentration Mass 20. 

Molybdenum, Total 

(7439-98-7) 

  Concentration Mass 

21. Manganese, Total (7439-96-5)   Concentration Mass 22. Tin, Total (7440-31-5)   Concentration Mass 23. Titanium, Total (7440-32-6)   Concentration 

For 

Mass 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1

Pollutant 

Presence or Absence 

(check one)

Units 

(specify) 

Effluent 

Believed 

Present 

Believed 

Absent 

Maximum Daily 

Discharge 

(required) 

Maximum 

Monthly 

Discharge 

(if available)

Long-Term 

Average Daily 

Discharge 

(if available)

Number o

Analyses 

24. Radioactivity 

 Alpha, Total   Concentration Mass  Beta, Total   Concentration Mass  Radium, Total   Concentration Mass 

Radium 226, Total   Concentration Mass 

1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136 for the analysis of polluta

required under 40 CFR chapter I, subchapter N or O. See Instructions and 40 CFR 122.21(e)(3).

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

1. 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 

For 

 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

20. 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 

For 

 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

39. 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 

For 

 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

58. 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-Trichlorophenoxyacetic acid)  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 

For 

 

Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

77. Vinyl acetate  78. Xylene  79. Xylenol  80. Zirconium  1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136 for the analysis of polluta

required under 40 CFR chapter I, subchapter N or O. See Instructions and 40 CFR 122.21(e)(3). 

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

For Comment Only
EPA Form 3510-2C (Revised <INSERT DATE>) 

EPA Identification Number NPDES Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. 2,3,7,8-TETRACHLORODIBENZO-P-DIOXIN (2,3,7,8-TCDD) (40 CFR 122.21(g)(7)(viii)) 

Pollutant 

TCDD 

Congeners 

Used or 

Manufactured

Presence or 

Absence 

(check one) Results of Screening Procedure 

Believed 

Present 

Believed 

Absent 

2,3,7,8-TCDD   

For Comment Only